Cognitive–behavioural therapy and short-term psychoanalytic psychotherapy versus brief psychosocial intervention in adolescents with unipolar major depression (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled trial

Abstract

BackgroundAlthough there are effective psychological treatments for unipolar major depression in adolescents, whether or not one or more of the available therapies maintain reduced depressive symptoms 1 year after the end of treatment is not known. This is a non-trivial issue because maintaining lowered depressive symptoms below a clinical threshold level reduces the risk for diagnostic relapse into the adult years.ObjectiveTo determine whether or not either of two specialist psychological treatments, cognitive–behavioural therapy (CBT) or short-term psychoanalytic psychotherapy (STPP), is more effective than a reference brief psychosocial intervention (BPI) in maintaining reduction of depression symptoms in the year after treatment.DesignObserver-blind, parallel-group, pragmatic superiority randomised controlled trial.SettingA total of 15 outpatient NHS clinics in the UK from East Anglia, north-west England and North London.ParticipantsAdolescents aged 11–17 years withDiagnostic and Statistical Manual of Mental Disorders-Fourth Edition major depression including those with suicidality, depressive psychosis and conduct disorder. Patients were randomised using stochastic minimisation controlling for age, sex and self-reported depression sum score; 470 patients were randomised and 465 were included in the analyses.InterventionsIn total, 154 adolescents received CBT, 156 received STPP and 155 received BPI. The trial lasted 86 weeks and study treatments were delivered in the first 36 weeks, with 52 weeks of follow-up.Main outcome measuresMean sum score on self-reported depressive symptoms (primary outcome) at final study assessment (nominally 86 weeks, at least 52 weeks after end of treatment). Secondary measures were change in mean sum scores on self-reported anxiety symptoms and researcher-rated Health of the Nation scales for children and adolescents measuring psychosocial function. Following baseline assessment, there were a further five planned follow-up reassessments at nominal time points of 6, 12, 52 and 86 weeks post randomisation.ResultsThere were non-inferiority effects of CBT compared with STPP [treatment effect by final follow-up = –0.578, 95% confidence interval (CI) –2.948 to 4.104;p = 0.748]. There were no superiority effects for the two specialist treatments (CBT + STPP) compared with BPI (treatment effect by final follow-up = –1.898, 95% CI –4.922 to 1.126;p = 0.219). At final assessment there was no significant difference in the mean depressive symptom score between treatment groups. There was an average 49–52% reduction in depression symptoms by the end of the study. There were no differences in total costs or quality-of-life scores between treatment groups and prescribing a selective serotonin reuptake inhibitor (SSRI) during treatment or follow-up did not differ between the therapy arms and, therefore, did not mediate the outcome.ConclusionsThe three psychological treatments differed markedly in theoretical and clinical approach and are associated with a similar degree of clinical improvement, cost-effectiveness and subsequent maintenance of lowered depressive symptoms. Both STPP and BPI offer an additional patient treatment choice, alongside CBT, for depressed adolescents attending specialist Child and Adolescent Mental Health Services. Further research should focus on psychological mechanisms that are associated with treatment response, the maintenance of positive effects, determinants of non-response and whether or not brief psychotherapies are of use in primary care and community settings.LimitationsNeither reason for SSRI prescribing or monitoring of medication compliance was controlled for over the course of the study, and the economic results were limited by missing data.Trial registrationCurrent Controlled Trials ISRCTN83033550.FundingThis project was funded by the National Institute for Heath Research Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 12. See the National Institute for Heath Research Journals Library website for further project information. Funding was also provided by the Department of Health. The funders had no role in the study design, patient recruitment, data collection, analysis or writing of the study, any aspect pertinent to the study or the decision to submit toThe Lancet.

‘I Am Worthless and Kind’; the specificity of positive and negative self‐evaluation in adolescent depression

“…Negative self‐evaluations are highly prevalent amongst depressed adolescents (Goodyer et al ., ; Orchard et al ., ). Given that young people develop a sense of identity and independence during adolescence (Coleman & Hendry, ), and become highly sensitized to social approval by their peers (Steinberg, ), it is unsurprising that the sense of ‘self’ is heightened during this period.…”

“…Major depression is diagnosed by the presence of at least five of nine symptoms that must have been present for at least 2 weeks (DSM‐5; APA, ). Of these, negative self‐perceptions (worthlessness and guilt) have been found to be one of the most common symptoms of depression in adolescence (Goodyer et al ., ; Orchard, Pass, Marshall, & Reynolds, ). Self‐evaluation is also a central component of the influential cognitive model of depression (Beck, ).…”

Examining parent and child agreement in the diagnosis of adolescent depression

“…The scale has been reported to have good internal consistency and test-retest reliability (Angold et al, 1995;Wood, Kroll, Moore, & Harrington, 1995), and good convergent validity (Angold et al, 1995;Thapar & McGuffin, 1998;Wood et al, 1995). It has also been identified as being able to discriminate those with and without diagnoses of depression (Kent, Vostanis, & Feehan, 1997;Thapar & McGuffin, 1998) with evidence of sensitivity to change in clinical trials (Brooks & Kutcher, 2001;Goodyer et al, 2017).…”

Practitioner Review: Therapeutics of unipolar major depressions in adolescents

“…Alternatively, ‘willingness to pay’ may be acceptable if the cost to the taxpayer or service provider generated by such patients is diminished as a consequence (pay now save later). The IMPACT study reported treatment cost of approximately £1,500 per patient (Goodyer et al., , ). The ADAPT study noted that adding CBT to fluoxetine + specialist clinical care was not cost‐effective (Byford et al., ).…”

“…As a result the major clinical scientific conclusions on treatment of a depressive episode are drawn from the four key randomized controlled trials reporting psychological and pharmacological treatments for depressed adolescents (Brent et al, 2008;Goodyer et al, 2007Goodyer et al, , 2017aGoodyer et al, , 2017bMarch et al, 2004). In addition there are a set of studies on preventing the incident onset of major depression (Brent et al, 2015;Garber et al, 2009;Richardson et al, 2014;Stallard et al, 2012).…”