Major depression affects 5% to 10% of older adults who visit a primary care provider46-48 and has negative implications for the prognosis of almost all co-occurring medical illnesses with which such patients may present. Treatment of child and adolescent depression Drug treatment for children or adolescents with depression is primarily dependent on SSRIs as first-line

acute treatment. Efficacy Inhibitors,research,lifescience,medical trials have been conducted with fluoxetine, paroxetine, and citalopram.49-51 The recommended practice is to start at half the usual dose of an SSRI (eg, 10 mg/day fluoxetine, paroxetine, or citalopram) for 1 week for adjustment purposes and then increase the dose to the equivalent of 20 mg/day Nutlin-3a clinical trial fluoxetine for another 3 weeks.45 It takes up to 4 weeks at steady state to determine whether a given dose will be helpful Thus, further increases should be made at 4-week intervals. Because children and adolescents metabolize SSRI more rapidly than adults, they often require Inhibitors,research,lifescience,medical doses above the equivalent of 20 mg fluoxetine to attain a clinical response.52 The large National Institute

of Mental Health (NIMH) multicenter contract, Treatment for Adolescents With Depression Study (TADS),53 Inhibitors,research,lifescience,medical for the treatment of depression in adolescents has been recently completed, and perhaps will provide more definitive data for this population. In a sample of 439 adolescents (aged 12 to 17 years) with major depression, four randomly assigned interventions were utilized: fluoxetine (10 to 40 mg/day) with cognitive behavioral therapy (CBT); fluoxetine alone; Inhibitors,research,lifescience,medical CBT alone; and placebo. As noted in Table VI, 71% responded to the combined treatment, with 60.6% to fluoxetine alone, 43.2% to CBT alone, and 34.8% to placebo. A clinically useful manner to review these findings is to calculate number needed to treat (NNT; calculated as 1/risk difference). NNT represents the number of subjects Inhibitors,research,lifescience,medical who would have to be treated with active

treatment to obtain one success that would not be obtained with the control treatment. Referring to Table VI, NNT for the combination treatment is 3, fluoxetine alone 4, and CBT alone 12, suggesting a medium effect size for the combination treatment and for fluoxetine alone. In addition, clinically significant suicidal thinking present in 29% of the sample at baseline improved significantly. Seven (1.6%) of ever 439 patients attempted suicide, but there were no completed suicides. Table VI. Treatment for Adolescents with Depression Study (TADS) randomized controlled trial.53 NNT, number needed to treat; CBT, cognitive behavioral therapy. Treatment of geriatric depression In a similar fashion, SSRIs have now largely replaced TCAs and MAOIs as first-line acute treatments for latelife depression.54 SSRIs are administered in older patients with initial dosing at half the usual effective dose and doubled after 1 week.