Nancy C. Winters

Efficacy of Paroxetine in the Treatment of Adolescent Major Depression: A Randomized, Controlled Trial

OBJECTIVE To compare paroxetine with placebo and imipramine with placebo for the treatment of adolescent depression. METHOD After a 7- to 14-day screening period, 275 adolescents with major depression began 8 weeks of double-blind paroxetine (20-40 mg), imipramine (gradual upward titration to 200-300 mg), or placebo. The two primary outcome measures were endpoint response (Hamilton Rating Scale for Depression [HAM-D] score < or = 8 or > or = 50% reduction in baseline HAM-D) and change from baseline HAM-D score. Other depression-related variables were (1) HAM-D depressed mood item; (2) depression item of the Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version (K-SADS-L); (3) Clinical Global Impression (CGI) improvement scores of 1 or 2; (4) nine-item depression subscale of K-SADS-L; and (5) mean CGI improvement scores. RESULTS Paroxetine demonstrated significantly greater improvement compared with placebo in HAM-D total score < or = 8, HAM-D depressed mood item, K-SADS-L depressed mood item, and CGI score of 1 or 2. The response to imipramine was not significantly different from placebo for any measure. Neither paroxetine nor imipramine differed significantly from placebo on parent- or self-rating measures. Withdrawal rates for adverse effects were 9.7% and 6.9% for paroxetine and placebo, respectively. Of 31.5% of subjects stopping imipramine therapy because of adverse effects, nearly one third did so because of adverse cardiovascular effects. CONCLUSIONS Paroxetine is generally well tolerated and effective for major depression in adolescents.

The Evolution of Systems of Care for Children's Mental Health: Forty Years of Community Child and Adolescent Psychiatry

Over the past 20 years, child and adolescent community mental health has evolved conceptually, clinically, and scientifically towards the community-based systems of care model. This model asserts important values and principles, including the centrality of the child and family in the care process, the integration of the efforts of disparate agencies and interveners into a contextual approach, and the importance of serving children with serious disturbances in their homes and communities. The article reviews the evolution of the community-based systems of care model, its evidence-base, its application in practice, and the challenges it faces in todays human services environment

Trends and shifting ecologies: part II

Community-based systems of care offer some promising ecologically based approaches to child psychiatric emergencies. More community-based effectiveness research is needed on child and adolescent mental health crisis services. To meet the needs of real-world children with serious emotional disorders and their families, however, research should include integration of multiple evidence-based modalities (such as psychopharmacology, behavioral, and cognitive approaches) and the effectiveness of single modalities. Funding priorities in mental health systems also should shift significantly to support community-based crisis services over more restrictive approaches that have a less solid evidence base.