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Jureidini (previous letter) is correct in reminding readers that our trial is not a test of the efficacy of fluoxetine over psychological treatments. I do not agree with his assertion that it is acceptable to use a placebo arm in a pragmatic effectiveness trial of treatment for adolescent depression.
There is evidence that active treatment involving interventions of a psychological or a pharmacological nature is effective compared with a neutral passive placebo. Active psychological treatment is more successful than placebo in reducing symptoms in the community,1 and fluoxetine is effective in accelerating the response rate in more moderate to severe depression.2 Under current UK ethical guidelines and given the available evidence the use of a neutral placebo could be considered to be exposing depressed adolescents to greater risk than benefit.
I also disagree with Jureidini's negative perspective of the use of fluoxetine and would guard against the implications of not considering drug treatment in depressed adolescents whose condition has proved resistant to psychosocial treatment approaches or not improved 10 weeks after referral. A significant proportion of depressed young people are hard to treat and will become young adults with chronic mental illness.3 We require a substantial improvement in the evidence base for treatment in both community and clinically referred patients before definitive treatment protocols can be fully developed.
Competing interests: None declared.