BMJ  2007;335:221 (4 August), doi:10.1136/bmj.39289.579375.BE

Letters

Depression in adolescents

Author's reply

Jureidini (previous letter) is correct in reminding readers that our trial is not a test of the efficacy of fluoxetine over psychological treatments. I do not agree with his assertion that it is acceptable to use a placebo arm in a pragmatic effectiveness trial of treatment for adolescent depression.

There is evidence that active treatment involving interventions of a psychological or a pharmacological nature is effective compared with a neutral passive placebo. Active psychological treatment is more successful than placebo in reducing symptoms in the community,¹ and fluoxetine is effective in accelerating the response rate in more moderate to severe depression.² Under current UK ethical guidelines and given the available evidence the use of a neutral placebo could be considered to be exposing depressed adolescents to greater risk than benefit.

I also disagree with Jureidini's negative perspective of the use of fluoxetine and would guard against the implications of not considering drug treatment in depressed adolescents whose condition has proved resistant to psychosocial treatment approaches or not improved 10 weeks after referral. A significant proportion of depressed young people are hard to treat and will become young adults with chronic mental illness.³ We require a substantial improvement in the evidence base for treatment in both community and clinically referred patients before definitive treatment protocols can be fully developed.

Developmental Psychiatry, Douglas House, Cambridge CB2 8AH

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Competing interests: None declared.

References

1. Merry S, McDowell H, Wild CJ, Bir J, Cunliffe R. A randomized placebo-controlled trial of a school-based depression prevention program. J Am Acad Child Adolesc Psychiatry 2004;43:538-47.[CrossRef][ISI][Medline]
2. Kratochvil C, Emslie G, Silva S, McNulty S, Walkup J, Curry J, et al. Acute time to response in the treatment for adolescents with depression study (TADS). J Am Acad Child Adolesc Psychiatry 2006;45:1412-8.[CrossRef][ISI][Medline]
3. Dunn V, Goodyer IM. Longitudinal investigation into childhood- and adolescence-onset depression: psychiatric outcome in early adulthood. Br J Psychiatry 2006;188:216-22.[Abstract/Free Full Text]

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