Sequential treatment with fluoxetine and relapse--prevention CBT to improve outcomes in pediatric depression

Abstract

Objective: The authors evaluated a sequential treatment strategy of fluoxetine and relapse-prevention cognitive-behavioral therapy (CBT) to determine effects on remission and relapse in youths with major depressive disorder.

Method: Youths 8-17 years of age with major depression were treated openly with fluoxetine for 6 weeks. Those with an adequate response (defined as a reduction of 50% or more on the Children's Depression Rating Scale-Revised [CDRS-R]) were randomly assigned to receive continued medication management alone or continued medication management plus CBT for an additional 6 months. The CBT was modified to address residual symptoms and was supplemented by well-being therapy. Primary outcome measures were time to remission (with remission defined as a CDRS-R score of 28 or less) and rate of relapse (with relapse defined as either a CDRS-R score of 40 or more with a history of 2 weeks of symptom worsening, or clinical deterioration).

Results: Of the 200 participants enrolled in acute-phase treatment, 144 were assigned to continuation treatment with medication management alone (N=69) or medication management plus CBT (N=75). During the 30-week continuation treatment period, time to remission did not differ significantly between treatment groups (hazard ratio=1.26, 95% CI=0.87, 1.82). However, the medication management plus CBT group had a significantly lower risk of relapse than the medication management only group (hazard ratio=0.31, 95% CI=0.13, 0.75). The estimated probability of relapse by week 30 was lower with medication management plus CBT than with medication management only (9% compared with 26.5%).

Conclusions: Continuation-phase relapse-prevention CBT was effective in reducing the risk of relapse but not in accelerating time to remission in children and adolescents with major depressive disorder.

Conflict of interest statement

Disclosures

The other authors report no conflict of interests or financial disclosures.

Figures

Figure 1

Consort diagram NOTE: Reason for discontinuing study assessments and reason for discontinuing treatment may have been different for an individual patient due to timing (i.e. one could discontinue treatment early in the study due to needing additional treatment, but later discontinue assessments due to withdrawing consent).

Figure 2

Remission Survival Curve at Week 30 Note. Survival Probability on y-axis= Probability of not Remitting

Figure 3

Relapse Survival Curve at Week 30 Note. Survival Probability on y-axis= Probability of not Relapsing