Combined cognitive-behavioural therapy and pharmacotherapy for adolescent depression: Does it improve outcomes compared with monotherapy?

Abstract

Adolescent depression can be effectively treated with selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, or with specific forms of psychotherapy, such as cognitive-behavioural therapy (CBT) and interpersonal therapy. A single course of any of these treatments, however, leaves between one-third and one-half of patients insufficiently improved and still depressed. In an effort to increase effectiveness, medication and CBT have been combined (COMB). A few controlled clinical trials have recently compared COMB with monotherapy. TADS (Treatment for Adolescents with Depression Study) randomly assigned 439 adolescents with major depressive disorder to fluoxetine, CBT, COMB or clinical management with placebo. After 12 weeks of treatment, both fluoxetine and COMB reduced depression more than CBT or placebo did, but only COMB was effective in inducing remission, achieving functional recovery and reducing suicidal ideation. After 36 weeks of treatment, there was no difference in improvement among treatments, but more suicidal events occurred in the medication only group than in the CBT only group. However, in another trial, ADAPT (Adolescent Depression and Psychotherapy Trial), involving 208 youths, no advantages of COMB over usual care with an SSRI could be detected. In a third trial, TORDIA (Treatment of Resistant Depression in Adolescence), which randomized 334 patients with an major depression unresponsive to previous SSRI treatment, COMB produced a greater response rate than medication monotherapy. These and other, smaller trials of COMB in adolescent depression are reviewed in this article. It is concluded that, while there is no univocal support for the superiority of COMB, two controlled trials indicate that COMB has a more favourable benefit/risk balance than monotherapy in adolescent depression. It remains to be determined for which patient subgroups and in which clinical settings COMB may be most advantageous.

Figures

Figure 1. Response Rates in TADS [7, 22]

Response: a score of “much “or very much” improved on the Clinical Global Impression-Improvement Scale. CBT: cognitive-behavioral therapy PBO: placebo FLX: fluoxetine COMB: fluoxetine plus CBT At week 12, COMB and FLX were better than PBO and CBT (p

Figure 2. Remission from Depression in TADS after 12 Weeks of Treatment [20]

Remission: a total score of 28 or lower on the Child Depression Rating Scale-Revised[32] CBT: cognitive-behavioral therapy PBO: placebo FLX: fluoxetine COMB: fluoxetine plus CBT Wald χ2=21.5, df=12, p=.04. Only CBT was significantly different from PBO (p=0.0009) [20]

Figure 3. Level of Functioning in TADS [21]

CGAS: Children's Global Assessment Scale CBT: cognitive-behavioral therapy PBO: placebo FLX: fluoxetine COMB: fluoxetine plus CBT CBT was superior to PBO and CBT (p