Feb. 27--Teens with major depression who don't respond to their first antidepressant medication are more likely to get well if they switch to a combination therapy, according to a study that included 15 Vancouver-area teenagers.

Those teens are more likely to improve when a different antidepressant is paired with psychotherapy, said a Portland psychologist. Greg Clarke is a senior investigator at the Kaiser Center for Health Research in north Portland and one of the co-authors of the study published this week in the Journal of the American Medical Association. The study was funded by the National Institute of Mental Health.

By the time children reach 18, about 20 percent to 25 percent will have had an episode of major depression, Clarke said.

Among the teens who go in for treatment, about 60 percent find relief through antidepressant medications.

This week's report should be good news to the other 40 percent, the adolescents with depression who do not adequately respond when treated with medication.

"Parents of teens struggling with chronic depression should be reassured by this study," Clarke said. "One message we want to get across: People should not lose hope if they don't respond to the first treatment. There are second and third and fourth treatments that people can benefit from. Don't just think, 'I have to live with this.' "

The 334 teens in the study were living with severe depression; they weren't just going through a bit of a down spell, Clarke emphasized.

"Everybody has periods of feeling sad and down. That's normal," Clarke said.

These teens were suffering from clinical depression.

"They had the classic symptoms: long chronic depression, withdraw from friends, drop out of school. It was the dominant way they felt," Clarke said. "This kind of depression is self-reinforcing: If you stop doing fun stuff, that makes you more sad and down.

"The consequences often leave a lot of things in their lives to deal with: Their friends are no longer available. They've had fights with their parents. They've fallen way behind in school," Clarke said. "It will take a fair amount of effort to reintroduce yourself to life, and you can't generally do it when you're feeling so withdrawn."

Changing medications and adding a course of psychotherapy helped 55 percent of the teens in the study group. Another study group had only a medication switch; 41 percent of them responded.

The extra step in the study was cognitive behavioral therapy, which helped the teens improve their outlooks on life.

"It focuses on what you are struggling with. It doesn't look deep into your life history about root causes. The focus is on getting reintroduced back into ordinary life," Clarke said. "When stuff happens in their lives, (depressed people) interpret it as their fault, and their expectation of success is very low."

The therapist helps the teen adopt a more realistic approach, Clarke said: "What's the proof this will be a disaster? Is there some evidence I might do a reasonable job at this?"

Behavioral activation is another part of the therapy.

"It sounds almost too simple," Clarke said. "We know depressed people withdraw from social situations. They decline invitations to be with friends, and when friends reach out, they turn them down."

Through therapy, "You reintroduce them to things they used to get pleasure from. Steer them to things that are done with other people, things they can see are improving their lives. Find things they can do pretty frequently. It's not, 'If I could go to Disneyland, I'd feel better.' It's taking your dog to the park, small things you can control.

"It seems too good to be true, but people consistently get better. They see that their mood improves, and they're becoming more optimistic. We call it the positive spiral. It makes you more willing to say yes to the next person who calls," Clarke said. "And the therapist points out, you're doing this for yourself."

If you add the 60 percent who benefitted from their initial medication-only treatment with the teens who were helped by the second-stage combination therapy, "you would be getting up to 80 to 85 percent," Clarke said.

"That still leaves some folks who are not responding, and that's another question: What do you do for those people who don't benefit from two rounds of treatment?"

Even with the more intensive treatment program, there were 18 suicide attempts during the 12-week program.

"Nobody committed suicide, thank goodness," Clarke said.

While it focused on teens, the study has lifelong ramifications, Clarke said.

"For most people who have chronic and recurring depression, their first episodes started in either childhood or adolescence. We hope, if can treat them very well as young people, we can stop this course of on-and-off depression," Clarke said. "It can be a pretty heavy life-long burden for someone to carry." liftout 1 For most people who have chronic and recurring depression, their first episodes started in either childhood or adolescence.

Did you know?

About 70 percent of the adolescents in the depression trial were girls. That reflects national statistics, said Kaiser investigator Greg Clarke. Before puberty, rates of depression among boys and girls are about equal, although the numbers are small. "After puberty, the rates are double among girls," he said. "That holds true through adulthood."

At any one time, about 6 percent of girls and 3 percent to 4 percent of boys have clinical depression, Clarke said. Over the course of a year, the numbers are 16 percent of girls and 10 percent of boys.

The other five clinical sites were: Brown University; UCLA; University of Pittsburgh; University of Texas Medical Branch at Galveston; and University of Texas Southwestern Medical Center at Dallas.

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Last updated: 03/28/2008 - 08:46 AM