Critical Decision Points for Augmenting Interpersonal Psychotherapy for Depressed Adolescents: A Pilot Sequential Multiple Assignment Randomized Trial

Abstract

Objective: Practice parameters recommend systematic assessment of depression symptoms over the course of treatment to inform treatment planning; however, there are currently no guidelines regarding how to use symptom monitoring to guide treatment decisions for psychotherapy. The current study compared two time points (week 4 and week 8) for assessing symptoms during interpersonal psychotherapy for depressed adolescents (IPT-A) and explored four algorithms that use the symptom assessments to select the subsequent treatment.

Method: Forty adolescents (aged 12-17 years) with a depression diagnosis began IPT-A with an initial treatment plan of 12 sessions delivered over 16 weeks. Adolescents were randomized to a week 4 or week 8 decision point for considering a change in treatment. Insufficient responders at either time point were randomized a second time to increased frequency of IPT-A (twice per week) or addition of fluoxetine. Measures were administered at baseline and weeks 4, 8, 12, and 16.

Results: The week 4 decision point for assessing response and implementing treatment augmentation for insufficient responders was more efficacious for reducing depression symptoms than the week 8 decision point. There were significant differences between algorithms in depression and psychosocial functioning outcomes.

Conclusion: Therapists implementing IPT-A should routinely monitor depression symptoms and consider augmenting treatment for insufficient responders as early as week 4 of treatment.

Clinical trial registration information: An Adaptive Treatment Strategy for Adolescent Depression. https://ichgcp.net/clinical-trials-registry/NCT02017535" title="See in ClinicalTrials.gov">NCT02017535.

Keywords: algorithms; depression; fluoxetine; psychotherapy; symptom assessment.

Conflict of interest statement

Disclosure: Dr. Mufson has received royalties from Guilford Press, Inc. for the book, Interpersonal Psychotherapy for Depressed Adolescents. Drs. Gunlicks-Stoessel, Bernstein, Reigstad, Klimes-Dougan, Cullen, Murray, Vock, and Ms. Westervelt report no biomedical financial interests or potential conflicts of interest.

Copyright © 2018 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.

Figures

FIGURE 1. Sequential Multiple Assignment Randomized Trial (SMART) Design

Note: HRSD = Hamilton Rating Scale for Depression; IPT-A = interpersonal psychotherapy for depressed adolescents; R = randomization.

FIGURE 2. CONSORT Diagram

Note: IPT-A = interpersonal psychotherapy for depressed adolescents.

FIGURE 3. Model-Estimated Children’s Depression Rating Scale–Revised (CDRS-R) Scores by Algorithm

Note: FLX = fluoxetine; IPT-A = interpersonal psychotherapy for depressed adolescents.

FIGURE 4. Model-Estimated Children’s Global Assessment Scale (C-GAS) Scores by Algorithm

Note: FLX = fluoxetine; IPT-A = interpersonal psychotherapy for depressed adolescents.

FIGURE 5. Model-Estimated Social Adjustment Scale–Self-Report (SAS-SR) Scores by Algorithm

Note: FLX = fluoxetine; IPT-A = interpersonal psychotherapy for depressed adolescents.