1. Treatment for Adolescents With Depression Study (TADS)

2. Fluoxetine, Cognitive Behavioral Therapy, and Their Combination for Adolescents With Depression Treatment for Adolescents With Depression Study (TADS) Team JAMA 2004: Vol 292, No. 7

4. TADS A randomized controlled trial funded by the National Institute of Mental Health Conducted at 13 academic and community centers in the United States To evaluate the effectiveness of treatments for adolescents with MDD

5. Participants 429 patients Age 12 -17 years (mean age 15 years) Primary diagnosis of major depressive disorder (DSM-IV)

6. Inclusion Criteria Outpatient CDRS ≥ 45 IQ ≥ 80 Not taking antidepressants Depressive mood in at least 2 contexts for at least 6 weeks prior to consent

7. Exclusion criteria Bipolar disorder Severe conduct disorder Substance abuse PDD Thought disorder Concurrent psychotropic medications Failed 2 SSRIs or CBT

8. Exclusion criteria Dangerousness to self or others Had been hospitalized for dangerousness within 3 months Suicidal attempt within 6 months Active plan of suicide Suicidal ideation with disorganized family

9. Participants Moderate to severe symptoms Average depressive episode duration - 72 weeks 27% had at least minimal suicidal ideation at baseline

10. Randomization To 1 of 4 treatments for 12 weeks 1. Fluoxetine alone 2. CBT alone 3. Fluoxetine with CBT 4. Placebo

11. Randomization Blinding Independent evaluators

12. Fluoxetine 6 medication visits x 20-30 minutes Dosage adjusted Starting dose 10 mg/d Optimum 20 mg/d Maximum 40 mg/d Mean highest dose 30 mg/d

13. CBT 15 sessions over 12 weeks x 50-60 minutes Psychoeducation Mood monitoring Increasing pleasant activities Social problem solving Cognitive restructuring Parent and family sessions

14. Outcome Assessment Children’s Depression Rating Scale-Revised (CDRS-R) CGI improvement score (much improved or very much improved) Assessed at baseline, week 6, and week12

15. Outcome Assessment Reynolds Adolescent Depression Scale (RADS) Suicidal Ideation Questionnaire-Junior High School Version (SIQ-Jr) All measures reported acceptable psychometric properties

16. Harm-Related Adverse Event Harm to self; e.g. cutting Worsening of suicidal ideation Suicidal attempt Harm to others

17. Suicide-Related Adverse Event Worsening suicidal ideation Suicidal attempt

18. Results Combination of fluoxetine with CBT was significantly superior to placebo fluoxetine alone CBT alone

19. Results Fluoxetine alone was superior to placebo CBT alone was not superior to placebo Fluoxetine alone was significantly better than CBT alone

20. Response Rate Based On CGI 71% in the fluoxetine with CBT 61% in the fluoxetine alone 43% in the CBT alone 35% in the placebo

21. Results Effect size (CDRS-R) Effect size (CGI) NNT Fluoxetine + CBT 0.980.843 Fluoxetine alone 0.680.584 CBT alone-0.030.2012

22. Results “Combination of fluoxetine with CBT is better than fluoxetine alone, which is better than CBT alone, which is equal to placebo”

23. Suicidal Behavior in Children Receiving SSRIs Suicidal ideation decreased in all of the treatment groups 6% of the patients experienced a suicide- related event with no statistically significant difference among the 4 treatment groups Seven patients made a suicide attempt and there were no completed suicides

24. Suicidal Behavior in Children Receiving SSRIs Harm-related adverse events: increased risk (odds ratio = 2.19) for patients receiving fluoxetine compared with those who were not The odds ratio was higher for fluoxetine alone compared with fluoxetine with CBT. Protective effect for CBT for suicidal ideation

25. Summary Combination treatment with fluoxetine and CBT shows highest efficacy CBT is a protective factor for suicide in adolescents receiving fluoxetine