Behavior Therapy Plus Medication May Help Teens with Depression and Substance Use Disorders

Newswise — New research from the University of Colorado Denver School of Medicine has found that a common antidepressant is showing promising success when combined with cognitive behavior therapy to treat adolescents with depression and substance use disorders. The report was published in the November issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals. The landmark study titled "A Randomized Control Trial of Fluoxetine and Cognitive Behavioral Therapy in Adolescents with Major Depression, Behavior Problems and Substance Use Disorders" is the first randomized controlled trial of combined pharmacotherapy for depression and behavioral intervention for substance use disorders in adolescents.

Research has shown that depression among adolescents with substance use disorders is three to four times greater than in adolescents without substance abuse and is associated with more severe substance abuse, poorer treatment outcomes and higher relapse rates. However, little is known about the safety and efficacy of medications in adolescents with substance abuse since such youths have been systematically excluded from pharmacotherapy studies. As a result, clinicians have been reluctant to treat depression (and other common co-occurring disorders) in adolescents with substance use disorders.

To bridge this clinical and research gap, Paula Riggs, MD, and colleagues at the UC Denver School of Medicine conducted a 16-week randomized controlled trial of the antidepressant fluoxetine in 126 teens (average age 17) who met diagnostic criteria for major depressive disorder, lifetime conduct disorder and at least one substance abuse disorder other than tobacco.

"The primary aims of the study were to evaluate the safety and efficacy of fluoxetine for depression and the impact on substance use, conduct problems and other substance treatment outcomes," said Riggs.

The adolescents were randomly assigned to receive either 20 milligrams of fluoxetine daily or a placebo, along with cognitive behavioral therapy (CBT) focused on substance abuse rather than depression.

"The weekly, individual cognitive behavioral therapy helps adolescents improve their decision-making skills as well as their coping, communication, and drug-refusal skills, added Riggs. "It also helps adolescents learn ways to avoid high-risk situations and increase their motivation and involvement in pro-social activities that are incompatible with drug use."

The study found fluoxetine combined with CBT was well-tolerated and had greater efficacy than the placebo with CBT on the Childhood Depression Rating Scale-Revised but not on the Clinical Global Impression Improvement measure of treatment response. Drug use and conduct disorder symptoms decreased significantly in both the fluoxetine and placebo treatment groups but there was no difference between fluoxetine and placebo treatment on either variable. The rate of treatment retention/completion (84 percent) was higher and reduction in drug use similar to that reported for other evidence-based substance treatment modalities in adolescents with less psychopathology.

The higher than expected rate of treatment response (CGI-I) in the placebo + CBT (67 percent) as well as the fluoxetine + CBT (76 percent) treatment group may indicate that CBT contributed to depression treatment response, despite its focus on substance abuse. Adolescents whose depressions remitted (regardless of medication group assignment) significantly decreased their drug use whereas drug use did not decrease in those whose depressions did not remit.

"An important clinical implication of these results may be that in the context of cognitive behavior therapy (substance abuse treatment), co-occurring depression may significantly improve or remit without antidepressant pharmacotherapy," said Riggs. "However, if depression does not appear to be improving early in the course of substance treatment, fluoxetine should be considered even if adolescents are not yet abstinent, with weekly monitoring of treatment adherence, substance use, adverse effects and target symptom response.

The results (Arch Pediatr Adolesc Med. 2007;161(11):1026-1034) are available at http://www.jamamedia.org.

This study was supported by a grant from the National Institute on Drug Abuse, National Institutes of Health. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

The School of Medicine faculty work to advance science and improve care as the physicians, educators and scientists at University of Colorado Hospital, The Children's Hospital, Denver Health, National Jewish Medical and Research Center and the Veterans Administration Medical Center. The School is part of the University of Colorado Denver, one of three universities in the University of Colorado system.