A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by selective serotonin reuptake inhibitors. The ADAPT trial. Health Technol Assess
ABSTRACT To determine if, in the short term, depressed adolescents attending routine NHS Child and Adolescent Mental Health Services (CAMHS), and receiving ongoing active clinical care, treatment with selective serotonin reuptake inhibitors (SSRIs) plus cognitive behaviour therapy (CBT) compared with SSRI alone, results in better healthcare outcomes.
A pragmatic randomised controlled trial (RCT) was conducted on depressed adolescents attending CAMHS who had not responded to a psychosocial brief initial intervention (BII) prior to randomisation.
Six English CAMHS participated in the study.
A total of 208 patients aged between 11 and 17 years were recruited and randomised.
All participants received active routine clinical care in a CAMHS outpatient setting and an SSRI and half were offered CBT.
The duration of the trial was a 12-week treatment phase, followed by a 16-week maintenance phase. Follow-up assessments were at 6, 12 and 28 weeks. The primary outcome measure was the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). Secondary outcome measures were self-report depressive symptoms, interviewer-rated depressive signs and symptoms, interviewer-rated psychosocial impairment and clinical global impression of response to treatment. Information on resource use was collected in interview at baseline and at the 12- and 28-week follow-up assessments using the Child and Adolescent Service Use Schedule (CA-SUS).
Of the 208 patients randomised, 200 (96%) completed the trial to the primary end-point at 12 weeks. By the 28-week follow-up, 174 (84%) participants were re-evaluated. Overall, 193 (93%) participants had been assessed at one or more time points. Clinical characteristics indicated that the trial was conducted on a severely depressed group. There was significant recovery at all time points in both arms. The findings demonstrated no difference in treatment effectiveness for SSRI + CBT over SSRI only for the primary or secondary outcome measures at any time point. This lack of difference held when baseline and treatment characteristics where taken into account (age, sex, severity, co-morbid characteristics, quality and quantity of CBT treatment, number of clinic attendances). The SSRI + CBT group was somewhat more expensive over the 28 weeks than the SSRI-only group (p=0.057) and no more cost-effective. Over the trial period there was on average a decrease in suicidal thoughts and self-harm compared with levels recorded at baseline. There was no significant increase in disinhibition, irritability and violence compared with levels at baseline. Around 20% (n=40) of patients in the trial were non-responders. Of these, 17 (43%) showed no improvement by 28 weeks and 23 (57%) were considered minimally (n=10) or moderately to severely worse (n=13).
For moderately to severely depressed adolescents who are non-responsive to a BII, the addition of CBT to fluoxetine plus routine clinical care does not improve outcome or confer protective effects against adverse events and is not cost-effective. SSRIs (mostly fluoxetine) are not likely to result in harmful adverse effects. The findings are broadly consistent with existing guidelines on the treatment of moderate to severe depression. Modification is advised for those presenting with moderate (6-8 symptoms) to severe depressions (>8 symptoms) and in those with either overt suicidal risk and/or high levels of personal impairment. In such cases, the time allowed for response to psychosocial interventions should be no more than 2-4 weeks, after which fluoxetine should be prescribed. Further research should focus on evaluating the efficacy of specific psychological treatments against brief psychological intervention, determining the characteristics of patients with severe depression who are non-responsive to fluoxetine, relapse prevention in severe depression and improving tools for determining treatment responders and non-responders.
Full-textDOI: · Available from: Sarah Byford, Aug 28, 2015
- SourceAvailable from: Cindy C Hagan
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- "If true, then we would predict a significant group × age interaction with younger MDD cases showing the strongest effects of illness on the ACC. We have previously shown a non-depressive comorbidity prevalence of approximately 50% for MDD patients attending UK-NHS Clinics (Goodyer et al., 2008) with the most common comorbid diagnoses being anxiety disorders. Furthermore a general factor of distress appears to underlie the reporting of both depressive and anxiety symptoms in this age range (Brodbeck et al., 2014). "
ABSTRACT: Objective There is little understanding of the neural system abnormalities subserving adolescent major depressive disorder (MDD). In a cross-sectional study we compare currently unipolar depressed with healthy adolescents to determine if group differences in grey matter volume (GMV) were influenced by age and illness severity. Method Structural neuroimaging was performed on 109 adolescents with current MDD and 36 healthy controls, matched for age, gender, and handedness. GMV differences were examined within the anterior cingulate cortex (ACC) and across the whole-brain. The effects of age and self-reported depressive symptoms were also examined in regions showing significant main or interaction effects. Results Whole-brain voxel based morphometry revealed no significant group differences. At the whole-brain level, both groups showed a main effect of age on GMV, although this effect was more pronounced in controls. Significant group-by-age interactions were noted: A significant regional group-by-age interaction was observed in the ACC. GMV in the ACC showed patterns of age-related differences that were dissimilar between adolescents with MDD and healthy controls. GMV in the thalamus showed an opposite pattern of age-related differences in adolescent patients compared to healthy controls. In patients, GMV in the thalamus, but not the ACC, was inversely related with self-reported depressive symptoms. Conclusions The depressed adolescent brain shows dissimilar age-related and symptom-sensitive patterns of GMV differences compared with controls. The thalamus and ACC may comprise neural markers for detecting these effects in youth. Further investigations therefore need to take both age and level of current symptoms into account when disaggregating antecedent neural vulnerabilities for MDD from the effects of MDD on the developing brain.Clinical neuroimaging 01/2015; 7:391-399. DOI:10.1016/j.nicl.2014.12.019 · 2.53 Impact Factor
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- "In a recent meta-regression analysis looking at treatments for depression in adults, Cuijpers et al.  found that more sessions per week led to a larger effect size while every additional week of therapy reduced the effect size, which suggests there may be advantages to interventions that are short and intensive. Goodyer et al.  found that about one-fifth of depressed adolescents responded to a brief initial intervention (mean of 3 sessions). Brief therapies have the advantage that they allow for faster access to treatment and can be offered as a first-line treatment, reserving longer therapies for individuals who fail to respond. "
ABSTRACT: The goal of this pilot study was to examine the feasibility and clinical outcomes of a brief (6-session) group therapy programme in adolescent outpatients with depression. The programme had previously been assessed in in-patients, with positive results. A total of 15 outpatients aged 13 to 18 years took part in the programme between October 2010 and May 2011, in 3 separate groups of 4-6 participants each. The outcomes measured were feasibility of the programme, as assessed by attendance rate, user feedback, fidelity of implementation, and response to treatment, as assessed by pre- and post-intervention measurement of depressive symptoms, quality of life, and suicidal ideation. The programme demonstrated good feasibility, with a mean attendance rate of 5.33 out of 6 sessions, a mean rating by participants on overall satisfaction with the programme of 7.21 out of 10 (SD = 1.89), and a 93% concurrence between the contents of the sessions and the contents of the treatment manual. Compared to baseline scores, depressive symptoms at follow-up test were significantly reduced, as assessed by the Children's Depression Rating Scale Revised (F(1, 12) = 11.76, p < .01) and the Beck Depression Inventory Revision (F(1, 32) = 11.19, p < .01); quality of life improved, as assessed by the Inventory of Quality of Life (F(1, 31) = 5.27, p < .05); and suicidal ideation was reduced. No significant changes were seen on the measures of the Parent Rating Scale for Depression and the Clinical Global Impression scale. Based on the results of this pilot study, it is feasible to further assess this brief outpatient treatment programme in a randomized controlled trial without further modifications.Child and Adolescent Psychiatry and Mental Health 03/2014; 8(1):9. DOI:10.1186/1753-2000-8-9
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- "PCPs should consider a period of active support and monitoring (6–8 weeks) using short validated scales before recommending treatment with antidepressants or psychotherapy in cases of mild depression . Evidence from randomized controlled trials (RCTs) show that up to 20 % of depressive youth respond to non-directive supportive therapy, routine specialist care, and/or regular symptom monitoring [13, 22•]. Furthermore, expert opinion and patient/family preferences indicate that active support and monitoring from family physicians is an important therapeutic strategy [13, 23•]. "
ABSTRACT: Depression is a common condition among children and adolescents, with lasting detrimental effects on health, and social and occupational functioning. Despite being well-positioned to treat depression, primary care providers (PCPs) cite significant barriers. This review aims to summarize recent evidence to provide practical guidance to PCPs on the management of pediatric depression in their practices. Following identification and assessment, PCPs should provide general initial management. Children and adolescents with mild depression can be managed with active support and symptom monitoring, while those with moderate-to-severe depression can be treated with psychotherapy and/or antidepressants, which may involve referral to mental health specialty care. Less is known about the treatment of depression in children under the age of 12 years, who may be candidates for earlier referral to mental health specialty care. PCPs have the potential to improve the recognition and management of depression in young people, having lasting individual and societal benefits.Current Psychiatry Reports 08/2013; 15(8):381. DOI:10.1007/s11920-013-0381-4 · 3.05 Impact Factor