Combined treatment with cognitive–behavioural therapy in adolescent depression: meta-analysis

Dubicka, Bernadka; Elvins, Rachel; Roberts, Chris; Chick, Greg; Wilkinson, Paul; Goodyer, Ian

doi:10.1192/bjp.bp.109.075853

Cited by 97 publications

(56 citation statements)

References 22 publications

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“…20 There were no significant group differences on most outcome measures and limited evidence favouring pharmacotherapy or combination treatment (vs. pharmacotherapy) in achieving remission. 20 Similarly, another meta-analysis (5 trials) found that CBT conferred limited additional benefit to pharmacological treatment in depressed adolescents, 21 but the combination did reduce functional impairment in the short term, 21 which is consistent with previous work. 11 Another Cochrane meta-analysis (9 trials, N ¼ 882) assessed the effectiveness of psychological and pharmacological interventions in preventing relapse or recurrence of depression after an initial episode in children and youth up to 25 years of age, and found no difference in outcomes with either approach.…”

Section: Is Psychotherapy An Effective Treatment For Depressed Childrsupporting

confidence: 78%

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder

et al. 2016

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Methods: Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. This section on ''Special Populations'' is the sixth of six guidelines articles.Results: Recent studies inform the treatment of MDD in children and adolescents, pregnant and breastfeeding women, women in perimenopause or menopause, and the elderly. Evidence for efficacy of treatments in these populations is more limited than for the general adult population, however, and risks of treatment in these groups are often poorly studied and reported. Conclusions: Despite the limited evidence base, extant data and clinical experience suggest that each of these special populations can benefit from the systematic application of treatment guidelines for treatment of MDD.

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Section: Is Psychotherapy An Effective Treatment For Depressed Childrsupporting

confidence: 78%

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder

et al. 2016

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“…27 A recent meta-analysis noted that, compared with CBT alone, the combination of fluoxetine and CBT may produce greater improvement in psychosocial functions but no greater reduction in residual symptoms. 28 Even for successfully treated cases, there is a high relapse rate in the next 5-10 years. Overall, approximately 50-70% of patients attending a NHS CAMHS clinic may relapse in the 10 years between mid-adolescence and young adulthood, coinciding with some of the largest educational milestones and social changes they may face over their lifetime.…”

Section: Are There Effective Treatments For Depressed Adolescents?mentioning

confidence: 99%

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

Goodyer

Reynolds

Barrett

et al. 2017

Health Technol Assess

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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.

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“…Whereas in adolescence there are a significant number of RCTs of both pharmacological and psychological interventions [7,8,9], literature in younger children (12 and under) is starkly lacking. It is possible that antidepressant medication may have a different level of efficacy in younger children and medication is also less likely to be acceptable to families of younger children.…”

Section: Introductionmentioning

confidence: 99%

Psychological treatments for depression in pre-adolescent children (12 years and younger): systematic review and meta-analysis of randomised controlled trials

Forti-Buratti

Saikia

Wilkinson

et al. 2016

Eur Child Adolesc Psychiatry

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(250 words)Objective: To evaluate the efficacy of psychological treatments for depression in pre-adolescent children, a disorder affecting 1-2% of children in this age-range. Design:Systematic review of studies of psychological interventions to treat depressive disorder in preadolescent children (aged up to 12 years old). The primary outcome was level of depressive symptoms.Data Sources: Studies were found using Medline, PsycINFO, EMBASE and Web of Knowledge databases and selected on several criteria.Eligibility criteria for selecting studies: Only randomised controlled trials were included. Where individual studies covered a broader age range (usually including adolescents up to age 18 years), authors of those studies were contacted and requested to provide individual patient level data for those aged 12 years and younger.Results: 2822 abstracts were reviewed, and from these 124 full text articles were reviewed, yielding 7 studies for which we were able to access appropriate data for this review. 5 of these studies evaluated cognitive behaviour therapy (CBT). Combined results from these studies suggest that there is a lack of evidence that CBT is better than no treatment (Standard Mean Difference -0.342 (95% Confidence Interval -0.961, 0.278), although the number of participants included in the trials was relatively small. The evidence for efficacy of family therapy and psychodynamic therapy is even more limited. Conclusion:The very limited number of participants in randomised controlled trials means that there is inconclusive evidence for the psychological treatment of depression in children aged 12 years and under. Given the prevalence and significant impact of this disorder, there is an urgent need to establish the effectiveness or otherwise of psychological intervention.Final accepted version -Published version is in European of Child and Adolescent Psychiatry, 2016. Please cite as: Forti-Burratti A, Sakhia R, Wilkinson E, Ramchandani PG. Psychological treatments for depression in preadolescent children (12 years and younger): systematic review and meta-analysis of randomised controlled trials. European of Child and Adolescent Psychiatry.

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Combined treatment with cognitive–behavioural therapy in adolescent depression: meta-analysis

Cited by 97 publications

References 22 publications

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder

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

Psychological treatments for depression in pre-adolescent children (12 years and younger): systematic review and meta-analysis of randomised controlled trials

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