Results of a recent study offer new hope to depressed teens. Researchers found that adolescents with moderate-to-severe major depressive disorder experienced more than 80% improvement after 36 weeks of treatment with cognitive-behavioral therapy, fluoxetine, or a combination of both treatments. The results at 36 weeks stand in contrast to results after only 12 weeks of treatment, when the response rates were 48% with therapy alone, 62% with fluoxetine, and 73% with combined treatment. All three types of treatment produced continuing improvement over eight months: by week 18, cognitive-behavioral therapy was as effective as fluoxetine, and either therapy or fluoxetine was as effective as their combination after 36 weeks (see figure below).
The study involved 327 adolescents ages 12 to 17 years, nearly all of whom had moderate-to-moderately-severe major depression; the average length of illness was almost a year and a half, and 52% had a second psychiatric diagnosis. Suicidal ideation was present in 28.1% of participants at the beginning of the study.
A decrease in suicidality was seen with all three treatments, but cognitive-behavioral therapy and the combined treatment were associated with significantly greater improvement than fluoxetine alone. Suicidal ideation decreased from 39.6% to 2.5% in the combination-treatment group and from 25.2% to 3.9% in the cognitive-behavioral therapy group, but the decrease in the fluoxetine group was smaller, from 26.4% to 13.7%. During the 36 weeks of treatment, suicidal ideation or suicide attempts occurred in 11% of the fluoxetine group, 4.7% of the combination group, and 4.2% of the cognitive-behavioral therapy group. (Of note, at 36 weeks 243 patients remained in the study and only 178 were still on their original treatment regimens.)
This study appears to show that fluoxetine, cognitive-behavioral therapy, and a combination of the two are effective treatments for major depressive disorder in teens. Improvement in overall depression is faster with fluoxetine, and it should not be withheld because of concerns about suicide: the rate of suicidal ideation was cut almost in half in the fluoxetine group. But combining fluoxetine with cognitive-behavioral therapy results in significantly greater reduction of suicidality, making it a safer treatment in this population than fluoxetine alone.
Fran Mennick, BSN, RN
NewsCAP
Even seemingly healthy teens can suffer heart attacks, according to case reports described in the October 2007 issue of Pediatrics. Over 11 years, eight boys and one girl, ages 12 to 20 years, were diagnosed with myocardial infarction at an Ohio hospital. They came to the ED with chest pains radiating to the left arm or jaw. Eight had abnormal electrocardiograms, all had abnormal cardiac enzyme levels, and three had abnormal echocardiograms. Blood lipid profiles detected no hypercholesterolemia, abnormal coronary arteries, or evidence of coronary thrombosis. The children weren't abusing drugs. They all recovered after initial treatment with nitroglycerin, followed by the calcium channel blocker diltiazem. Although chest pain is rarely related to heart problems in teens, write the authors, "adolescents who present for emergency care with typical chest pain need electrocardiographic and cardiac enzyme workups."
Pediatricians should screen for autism at 18- and 24-month routine visits, according to a clinical report from the American Academy of Pediatrics published by Johnson and colleagues in the November 2007 issue of Pediatrics. The incidence of autism spectrum disorders (ASDs), which include autistic disorder, Asperger's disorder, and "pervasive developmental disorder not otherwise specified," has increased in recent years partly as a result of changes in diagnostic practices. Because early intervention can often be effective, diagnosis should not be delayed. Subtle signs of deficits in social relationships, a central feature of ASDs, may appear in the first year of life. Speech delays usually appear in the second year. Information for parents about signs to bring to the pediatrician's attention is at http://www.cdc.gov/ncbddd/autism/actearly. If two or more risk factors are present, the pediatrician should formally screen for ASDs.
Emotional well-being is not linked to cancer survival, according to a study published in the December 2007 issue of Cancer. The study analyzed data from two clinical trials that enrolled 1,093 patients with stage III or IV head and neck cancer. Factors predictive of death were being older than age 60; being widowed, separated, or divorced; having a tumor classification of T4; having a lymph node classification of N3-N4; being a smoker at enrollment; and having poorer functional status at enrollment. Emotional well-being, on the other hand, was not linked to overall survival. The authors caution against extrapolating findings to patients with other cancers.
Vaccinations are vital for patients with cochlear implants. At least one child with a cochlear implant died from bacterial meningitis in 2007 because of inadequate immunization against Streptococcus pneumoniae, according to the Food and Drug Administration. In 2003 it was first reported that the rate of pneumococcal meningitis in children under age six who'd had cochlear implants was more than 30 times higher than the overall incidence in that age group. It has also been reported that the incidence remains high more than two years after implantation. Implanted devices with positioners, which were discontinued in 2002, carry an especially high risk. The Centers for Disease Control and Prevention notes that all children with implants and all who will receive them should be considered at high risk for invasive pneumococcal disease and Haemophilus influenzae and should be immunized. Also, parents and providers should watch for early signs of meningitis and otitis media; early diagnosis and treatment reduce the risk of death.