Combination can treat depression

Q: Since we moved to a new town, my teenage son has become depressed. The psychiatrist who has been treating him thinks our son would benefit from taking Prozac or another antidepressant. Is this safe? I've heard that these medications can trigger suicide.

A: Your son's doctor probably is recommending medication in addition to therapy, because studies have shown that recovery is more likely — and faster — when these treatments are combined.

One study of 439 teens with major depression found that taking the antidepressant fluoxetine (Prozac) while pursuing cognitive behavioral therapy worked better than either treatment alone. Eighteen weeks after treatment began, 85 percent of those on combination therapy improved, compared with 69 percent of those taking only fluoxetine and 65 percent of those doing only cognitive behavioral therapy. Even after nine months, combination therapy edged out the other treatments.

Experts aren't entirely sure why this is so. But they think therapy and medication may complement each other because they work on different parts of the brain. This may also explain why combination therapy prevents future episodes of depression better than either treatment alone.

Usually, doctors first prescribe fluoxetine or another medication from a class of drugs called selective serotonin reuptake inhibitors, or SSRIs. Although the side effects of each drug vary slightly from person to person, they are about equally likely to help. About 65 percent to 85 percent of patients get some relief.

If your son doesn't start to feel better after taking one drug for several weeks, his doctor may decide to switch to another SSRI or prescribe one of the newer antidepressants listed in the table. Keep in mind that some people need to try a few different medications to find the one that works the best with the fewest side effects.

SSRIs were first introduced in the late 1980s. People taking them began reporting suicidal thoughts, not actual suicides, shortly after that. An FDA committee dismissed any association, and most mental-health professionals accepted the committee's conclusion.

But as the number of children and adolescents receiving prescriptions grew, so did the debate. In 2003, British drug authorities announced a possible connection between the antidepressant paroxetine (Paxil) and suicidal thoughts in some teenagers and children. The FDA performed its own review of these medications, and in 2004, it began requiring that drug manufacturers include a warning on antidepressants. The warning, which applies to children and adults up to age 24, calls attention to the risk of suicidal thoughts, hostility and agitation in both children and adults.

Although results from many subsequent studies have varied, there is a consistent trend. When compared with a placebo (''sugar pill"), all antidepressants, including SSRIs, seem to double the risk of suicidal thinking, from 1 to 2 percent up to 2 to 4 percent, in both children and adults. But the studies did not report any increase in actual suicides.

To date, there is no evidence from controlled research that links suicide to antidepressant use. In fact, studies suggest that the opposite may be true — that antidepressant treatment reduces the risk of suicide. Several studies have found that higher rates of SSRI use coincided with lower suicide rates.

But since the FDA-mandated warning appeared, fewer prescriptions for SSRIs have been given to youths. Before the warning was issued in 2004, SSRIs were given for 59 percent of depressive episodes in children. But by 2005, the rate had sunk to 28 percent. Even more sobering, the youth suicide rate in the United States spiked 8 percent in 2004, the biggest increase in 15 years. There is speculation that the two events, an increase in suicides and a decrease in the use of antidepressants, are linked.

Researchers are trying to understand why antidepressants increase suicidal thoughts in some people, and no single factor seems responsible. Depression itself increases the risk of suicide, and impulsive and self-destructive behavior is common in adolescence. A person's genetic makeup may play a role. And sometimes severely depressed people taking medication recover the energy to act on suicidal thoughts before their mood improves.

Experts recommend that people who are starting an antidepressant or changing their dose be closely monitored. This is particularly important in the first month or two, so be sure to talk openly with your son. Watch for signs that his depression is worsening or that suicidal thoughts or behaviors have emerged. Share any concerns you have with your son's therapist and pediatrician.

You're wise to ask about the possible link between antidepressants and teen suicide, as well as other possible side effects, before giving the medication to your son. However, the consequence of not taking needed medication often is greater than the risk associated with that drug's proper use.

Depression is a serious illness, but it is treatable.

The Harvard Medical School Adviser is researched and written by the faculty and staff of Harvard Medical School. Visit www.health. harvard.edu/adviser.