Effectiveness of attachment-based family therapy compared to treatment as usual for depressed adolescents in community mental health clinics

Abstract

Background: Major Depressive Disorder (MDD) is a disabling mood disorder, profoundly affecting a large number of adolescent's quality of life. To date, no obvious treatment of choice for MDD in adolescents is available and progress in the treatment of depressed adolescents will have important public health implications. Attachment-Based Family Therapy (ABFT), as the only empirically supported family therapy model designed to treat adolescent depression, aims to repair interpersonal ruptures and rebuild an emotionally protective parent-child relationship.

Objective: To study the effectiveness of ABFT compared with treatment as usual (TAU) delivered within child- and adolescent mental health services (CAMHS) to adolescents with MDD.

Method: Sixty adolescents (86.7% girls), aged 13-18 years (M = 14.9, SD = 1.35), with MDD referred to two CAMHS were randomized to 16 weeks of ABFT or TAU. ABFT consisted of weekly therapy sessions (family/individual or both) according to the treatment manual. TAU was not monitored. Primary outcomes were assessed by blinded evaluators at baseline and post-treatment with the Hamilton Depression Scale (HAMD). Self-reported (Beck Depression Inventory-II, BDI-II) depressive symptoms were assessed at baseline, and after 4, 6, 8, 10,12, 14, and 16 weeks. Analyses were performed according to intent-to-treat principles.

Results: At post-treatment, clinician-rated remission rates on the HAMD (5% in ABFT and 3.33% in TAU, p = 1, OR = 1.54, Fisher's exact test) and self-reported symptoms of depression on the BDI-II did not differ significantly between groups (X2[2, N = 60] = 0.06, p = 0.97). In both treatment groups participants reported significantly reduced depressive symptoms, but the majority (63.3%) of adolescents were still in the clinical range after 16 weeks of treatment.

Conclusion: ABFT was not superior to TAU. Remission and response rates were low in both groups, suggesting none of the treatments were effective in treating MDD in adolescents. Findings must be viewed in the context of the study's small sample size, missing data, and implementation challenges. Continued efforts to improve treatment for MDD in outpatient clinics are warranted. Future research should examine moderators of and mechanisms for individual differences to treatment response, as well as the feasibility and cost-effectiveness of implementing treatment models which may require extensive training and expertise to yield clinically meaningful improvements in non-research settings. Trial registration Clinicaltrials.gov identifier: NCT01830088 https://ichgcp.net/clinical-trials-registry/NCT01830088?term=Villab%C3%B8&draw=2&rank=1 Date of registration: April 12, 2013.

Keywords: Adolescents; Attachment based family therapy; Depression; Efficacy trial.

Conflict of interest statement

The authors have declared that they have no competing or potential conflicts of interest.

Figures

Fig. 1

Consolidated Standards of Reporting Trials (CONSORT) flowchart of participants comparing Attachment Based Family Therapy (ABFT) with Treatment as Usual (TAU)

Fig. 2

Modified Brinley Plot, a scatter plot to visualise individual change on clinician rated depressive symptoms from before and after therapy. When there are no differences pre-and post- treatment scores on GRID-Hamilton Depression Rating Scale (GRID-HAMD), data points are aligned on the 45° line. Points above this line represent depression scores that are higher at week 16 than at baseline (and reversely for points below the 45° line). The shaded symbols represent the uncertainty of the imputed scores. The dashed lines represents clinical cut off points for remission and response

Fig. 3

Self- reported depressive symptoms by treatment at baseline and after 2, 4, 6, 8, 10, 12, 14,16 weeks of of treatment