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Treatment of Depression in Adolescents: TADS Results and Future Directions

(PSYCHIATRIC TIMES) - The Treatment for Adolescents With Depression Study (TADS) represents the single largest and potentially most informative clinical trial of adolescents with depressive illness. The overall aim of the study was to investigate the effectiveness of standard interventions for adolescent outpatients with moderate to severe depression. The rationale for the trial, the study design, the clinical characteristics of the sample recruited for the trial, the acute phase treatment results, and a series of secondary analyses of the acute treatment phase have been published in recent papers.1-11 This article summarizes these published reports with the goal of guiding stakeholders in making informed decisions about treatment interventions for youths with depression.
The 4 stages of the study

Funded in 1998 by the NIMH, TADS, a multisite study, was designed to answer questions regarding the short-term and longer-term relative effectiveness and safety of the best evidence-supported interventions available for the treatment of depression in adolescents. The study consisted of 4 stages. In the 12-week acute trial phase (stage 1), 3 active treatments—cognitive-behavioral therapy (CBT), fluoxetine, and a combination of fluoxetine and CBT (COMB)—were compared with placebo.

Patients who were considered responders or partial responders to an active treatment (CBT, fluoxetine, or COMB) in the first stage could continue in their assigned treatment arm for 6 weeks of intensive (for partial responders) or maintenance treatment (for full responders) in stage 2. Treatment responders at the end of the second stage could continue in their assigned treatment arm for 18 weeks of additional maintenance level treatment in stage 3. At the end of stage 3, patients and families received appropriate treatment recommendations and exited the controlled part of the trial.

All adolescents recruited for the trial in all treatment arms, regardless of responder status, were encouraged to participate in all study assessments to track their clinical and functional outcomes. In stage 4, patients were followed naturalistically for a year after completing the initial treatment protocol.

Primary outcome measures included clinician-rated and self-reported depressive symptoms and clinician-rated global improvement in depressive illness since beginning treatment. Because of the importance of eliminating bias from the primary outcome measures, independent evaluators (IE) blinded to treatment assignment followed the adolescents and their families through the course of the trial and provided the primary effectiveness outcome data. The primary measures comparing safety and tolerance of the interventions were clinician-rated adverse-event measures.
Results to date

The data analyses published to date have focused on the baseline characteristics of the recruited sample and primary and secondary analyses of the data collected through stage 1. TADS data suggest that the investigators were successful in recruiting adolescents with moderate to severe depression.3 Some of the pertinent summary statistics of the baseline characteristics of the sample are presented in Table 1. For the most part, generally comparable subsamples were randomly assigned to the 3 active (CBT, fluoxetine, or COMB) and the comparison (placebo) interventions.3

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