Major Depressive Disorder (MDD) is a prevalent in 5% of adolescents. This mental disorder impacts adolescents’ health, with greater tendencies to engage in suicidal behavior and completed suicides. MDD also has social effects within the family’s structure and order. According to the World Health Organization, Major Depressive Disorder is the leading cause of disability in the U.S. for ages 15-44 (World Health Organization 2008). As a result, new developments in MDD treatments can benefit public health. In this research, the Treatment for Adolescents with Depression Study or TADS funded by the National Institute of Mental Health evaluated the effectiveness of different types of therapies in adolescents with major depression disorder. There were three different range of therapies used in the treatment: fluoxetine hydrochloride therapy, cognitive behavior therapy (CBT), and the combination of the two. Their initial hypothesis is that that combination therapy would show a larger, more rapid short-term treatment benefit than fluoxetine therapy or CBT. The second tail of the hypothesis’stated that the advantage for combination therapy relative to monotherapies of fluoxetine therapy or CBT would be evident across 9 treatment months. In summary, combination therapy would have a greater therapeutic outcome for short term( 0 to 12 weeks) and mid-range (2-36 weeks) time correlation. The greater advantages of combo therapy would also be visible in the long-run (36 weeks and greater).
The quantitative research was conducted over a span of 26 weeks in a randomized fashion. The participants of the randomized, controlled trial were included three hundred twenty-seven patients aged 12 to 17 years with a primary DSM-IV diagnosis of major depressive disorder. The research study was conducted in 13 academic and community sites across the United States. The administration protocol included that cognitive behavior and combination therapies were not masked, whereas administration of placebo and fluoxetine was double-blind through 12 weeks, after which treatments became open trails. Likewise, patients assigned to placebo were treated openly after week 12. The results from the placebo group are not included in the results and analyses of this research. In these three hundred twenty seven patients, blind independent evaluators measured the response in patients according to two standards: Children’s Depression Rating Scale– Revised (CDRS-R) total score and secondly, the response rate, defined as a Clinical Global Impressions–Improvement score of much or very much improved. Also, suicidal ideation and events will be observed in these participants. Ideation differs from events as ideation are thoughts and feelings and events were recorded as any bodily injuries outside of self-mutilation and.suicide attempts.
Medication protocol involved specific doses at time intervals and a limited amount of time for CBT sessions. Over the span of the 36 weeks, the patients were monitored over a period of 20 to 30 minute visits and offered encouragement about MDD pharmacotherapy effectiveness. Fluoxetine dosages began at 10mg/d and increased if necessary to 40mg/d at week 6. The maximum dosage was administered during the week 12 visit at 60 mg/day. CBT treatment was divided into three separate stages. The first required that patients had fifteen 1-hour sessions during the first 12 weeks of treatment. Patients, who only had a partial response, were then required to have 6 additional weeks of weekly CBT, while the others had biweekly CBT between Stage 2’s Week 12 through 18. Stage 3 patients were provided CBT every 6 weeks on a maintenance visit schedule. The outcomes and measurements were analyzed by an independent evaluator blind to the treatment condition at baseline levels and at weeks 6,12,18, 2, 30 and 36.
Result measurements would include statistical analyses using random coefficients regression (RR) models generalized estimating equations (GEEs) for binary outcomes were used to compare the
probability of treatment response over time in the 3 treatment arms. From the RR and GEE data, researchers were then able evaluate the magnitude of the influence of combination therapy and fluoxetine therapy relative to CBT by calculating the effect size and the number needed to treat (NNT).
The study results indicate a positive correlation with the first metric, the revised total score defined earlier and time treatment (P .001). Rates of response were 73% for combination therapy, 62% for fluoxetine therapy, and 48% for CBT at week 12. Halfway through the study, at week 18 the rates of response were 85% for combination therapy, 69% for fluoxetine therapy, and 65% for CBT. At week 36, the rate responses were 86% for combination therapy, 81% for fluoxetine therapy, and 81% for CBT. Data illustrates that suicidal ideation decreased with treatment, but less so with fluoxetine therapy than with combination therapy or CBT. For those patients receiving fluoxetine therapy, suicidal events were more common (14.7%) than for those receiving combination therapy (8.4%) or CBT (6.3%).
The sample of the TADS study is an appropriate reflection of the general population, and are useful in clinical and epidemiological evaluations. For MDD pharmacotherapy study, the mean age was 14.6 (1.5) years; 45.0% are male; 74.0% are non-Hispanic white; 11.3% are African American; and 9.8% are Hispanic. CDRS-R raw score at baseline or entry was 59.8 (10.3) which indicates moderate to moderately severe MDD, consistent with consistent with mean Clinical Global Impressions Severity Scale and Clinical Global Assessment Scale scores. Out of the 327 patients, 243 patients (74.3%) remained in the study at week 36. Of the 327 patients, 178 (54.4%) remained in the treatment
condition to which they initially had been randomized (n=68 for combination therapy, n=55 for fluoxetine therapy, and n=55 for CBT) The effect of CBT had a grater significance in combination theory than with Fluoxetine at each time interval. At week 12, .81 for Combination and .9 for Fluoxetine. At week 18, .71 for combination versus .57. The last measurement of magnitude of effect of combination therapy and fluoxetine relative to CBT was .17 to .12. Overall, the increase in the amount of treatment time decreases the magnitude of effect of Combination Therapy and Fluoxetine relative to CBT. This magnitude is correlated to the clinical significance of the treatment leg. Weeks 12 indicates a “large effect” as the data is bounded by .8 as a large effect. Week 18 indicate a “moderate effect” as .5 is the lower limit of effect size. Small effect is indicated by .2 and is above the data from Week 36. Patients with Suicidal Events were recorded in Table . During stages 1-3, those receiving Fluoxetine treatment had a greater percentage of events with 1.7 and 11.0 for the ITT population and OC population, respectively. Next, combination therapy was second with 8.% and 7.5% and finally CBT only with 6.3% and 5.%. Across the three stages and 327 patients, 32 patients were recorded with a suicidal event , with an overall percentage of 8 to 9.8% total.
The results of this review indicate that the scientific evidence base regarding the impact of treatment applications in adolescents with moderate to severe depression. The use of the three hundred twenty seven patients in the randomized,blind trial mimics the diversity within general population. Research results indicate that fluoxetine alone or in combination with CBT shows greater improvement in MDD patients relative to CBT alone. Despite that contrast between fluoxetine or combination therapy with CBT’s overall effect, CBT does provide health care providers and clinicians observable benefits. CBT addition to fluoxetine therapy minimizes persistent suicidal ideation and suicidal events.
These results implicate medication pharmacotherapy and procedures for MDD. The only way to accelerate the response in adolescent depressive patients is to include treatment with fluoxetine alone or in combination with CBT. The addition of CBT to depression treatment enhances the safety of medication. Just as researchers note, future health care decisions must anticipate the expected benefits and expected harms of alternative courses of treatment by taking into account all probabilities in each case. This social utilitarian perspective indicates that the best method for adolescent depression treatment is the combined treatment of fluoxetine and CBT, which appears superior to either monotherapy alone.
In conclusion, public health can benefit from acknowledgement and evidence-based treatment of adolescents with moderate to severe depression. Fluoxetine as an essential part of this treatment, should be encouraged and made available for use in clinical outcomes, especially in the field of psychiatry. This study has provided further literature on evidence-based treatment for adolescent MDD that MDD treatment knowledge is now within “informed consent.” As a result, comprehensive treatment that include the therapy discussed should be used with adolescents with moderate to severe depression.
This quantitative research and the theories associated with it can be used by nurses can use to enhance their nursing practice. One particular nursing implication is that there is solid establishment of the nurse-client, nurse-patient relationship. How a nurse decides to initiate this relationship and the interventions used for ongoing care vary with the presenting behavior. For MDD these presenting behaviors include a depressed mood or marked loss of interest or pleasure activities. In adolescents and children, MDD is visible as irritability instead of sadness. With all patients, especially adolescents, trust is still the primary goal. Above all interventions, the most important to remember are active listening and being fully present with the client. This nurse-patient relationship should also include education and sharing preventative measures. Providing information about hazards as well as benefits of treatment can affect change in the patient’s quality of life. An example of shared information would be the results and benefits provided by TADS recommended treatment for MDD. Finally, these nurses can use their knowledge and skills to set preventive measures in place to prevent future occurrences, in this case, suicidal ideation and suicidal events.
Just as the researches indicates MDD’s impact as family burden, nurses must also be aware of the family who deals with the client. If family members are part of the caregivers staff, they may benefit from supportive interventions to assist them in recognizing and dealing with their feelings as well. In this case, nurses can have a positive roll in providing an emotional and supportive mediator for these adolescents. These interventions are essential in assuring nurses are fulfilling their roles and duties as health care providers.
Works Cited
The TADS Team, Initials. (2007). The treatment for adolescents with depression study (tads). ARCH
GEN PSYCHIATRY, 64(10), Retrieved from 1132-+1144 doi: www.archgenpsychiatry.com
The World Health Organization. The Global Burden of Disease: 2004 update, Table A2: Burden of
disease in DALYs by cause, sex and income group in WHO regions, estimates for 2004.
Geneva, Switzerland: WHO, 2008 < http://www.who.int/healthinfo/global_burden_disease
/GBD_report_2004update_AnnexA.pdf.>
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