A Comparison of Cognitive-Behavioral Therapy, Sertraline, and Their Combination for Adolescent Depression

doi:10.1097/01.chi.0000233157.21925.71

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 45, Issue 10, October 2006, Pages 1151-1161

https://doi.org/10.1097/01.chi.0000233157.21925.71 Get rights and content

ABSTRACT

Objective

To evaluate cognitive-behavioral therapy, antidepressant medication alone, and combined CBT and antidepressant medication in the treatment of depressive disorders in adolescents.

Method

Seventy-three adolescents (ages 12-18 years) with a primary diagnosis of DSM-IV major depressive disorder, dysthymic disorder, or depressive disorder not otherwise specified were randomly allocated to one of three treatments. Treatment outcome measures were administered before and after acute treatment, and at a 6-month follow-up. Depression diagnosis was the primary outcome measure; secondary measures were self- and other report and clinician rating of global functioning. The trial was conducted at three community-based clinics between July 2000 and December 2002. Data analyses used an intent-to-treat strategy.

Results

Following acute treatment, all treatment groups demonstrated statistically significant improvement on outcome measures (depressive diagnosis, Reynolds Adolescent Depression Scale, Revised Children's Manifest Anxiety Scale, Suicidal Ideation Questionnaire), and improvement was maintained at follow-up. Combined cognitive-behavioral therapy and antidepressant medication was not found to be superior to either treatment alone. Compared with antidepressant medication alone, participants receiving cognitive-behavioral therapy alone demonstrated a superior acute treatment response (odds ratio = 6.86; 95% confidence interval 1.12-41.82). Although cognitive-behavioral therapy was found to be superior to antidepressant medication alone for the acute treatment of mild to moderate depression among youth, this may have stemmed from the relatively low dose of sertraline used.

Conclusions

All treatments led to a reduction in depression, but the advantages of a combined approach were not evident.

Section snippets

Subjects

Between July 2000 and December 2002, 168 adolescents were referred by physicians or school counselors for assessment of possible depression to one of three clinics (two in suburban Melbourne and one in a regional city of Victoria) colocated with public child and adolescent mental health services. Recruitment was achieved by providing information to physicians and school counselors and inviting them to refer. Telephone screening excluded 66 participants. One hundred two young people and their

Pretreatment Comparison of Groups

Pretreatment differences between groups on demographic and outcome variables were tested using X² tests or Fisher exact test for categorical variables, and one-way ANOVAs for continuous variables. No difference between treatment groups was detected on any of the variables, suggesting that the randomization procedure was effective.

Diagnostic Status.

The proportions of adolescents with MDD who responded to each treatment over time are presented in Figure 2A. The greatest proportion responding to treatment by

DISCUSSION

The “Time for a Future” program was designed to evaluate CBT, sertraline, and their combination in the community-based treatment of adolescent depression. The sample was experiencing mild to moderate levels of depression and high levels of comorbidity. The depressed youths were clinical referrals who have previously been found to be less responsive to treatment than study participants recruited by advertisement (Brent et al., 1998). Therefore, it is likely that the findings of this study can be

REFERENCES (37)

PJ Ambrosini
Historical development and present status of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS)
J Am Acad Child Adolesc Psychiatry
(2000)
PJ Ambrosini et al.
Multicenter open-label sertraline study in adolescent outpatients with major depression
J Am Acad Child Adolesc Psychiatry
(1999)
DA Brent et al.
Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression
J Am Acad Child Adolesc Psychiatry
(1998)
GN Clarke et al.
Cognitive-behavioral treatment of adolescent depression: efficacy of acute group treatment and booster sessions
J Am Acad Child Adolesc Psychiatry
(1999)
EB Foa et al.
Context in the clinic: how well do cognitive-behavioral therapies and medications work in combination?
Biol Psychiatry
(2002)
MB Keller et al.
Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial
J Am Acad Child Adolesc Psychiatry
(2001)
PM Lewinsohn et al.
Cognitive-behavioral treatment for depressed adolescents
Behav Ther
(1990)
PM Lewinsohn et al.
Major depressive disorder in older adolescents: prevalence, risk factors, and clinical implications
Clin Psychol Rev
(1998)
WM Reynolds et al.
Reliability and validity of the Reynolds Adolescent Depression Scale with young adolescents
J School Psychol
(1998)
TM Achenbach
Manual for the Child Behavior Checklist/4–18 and 1991 Profile Burlington
(1991)

American Psychiatric Association

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)

(1994)

DA Brent et al.

A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy

Arch Gen Psychiatry

(1997)

J Byles et al.

Ontario child health study: reliability and validity of the general functioning subscale of the McMaster family assessment device

Fam Process

(1988)

GN Clarke et al.

Adolescent Coping With Depression Course: Leader's Manual for Adolescent Groups

(1990)

GJ Emslie et al.

A double-blind, randomized, placebo controlled trial of fluoxetine in children and adolescents with depression

Arch Gen Psychiatry

(1997)

GJ Emslie et al.

Fluoxetine in child and adolescent depression: acute and maintenance treatment

Depress Anxiety

(1998)

GJ Emslie et al.

Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled randomized clinical trial

J Am Acad Child Adolesc Psychiatry

(2002)

NB Epstein et al.

The McMaster Family Assessment Device

J Marital Fam Ther

(1983)

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Establishment of CAMHC resulted in significant achievements in diagnosis and management of mental disorders among children and adolescents, healthcare staff capacity building, and awareness-raising about mental disorders. Data obtained in CAMHC offers government, mental health professionals and the community the opportunity of improving mental health in the region.
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There are few available antidepressants for pediatric Major Depressive Disorder (MDD). The objective of this systematic review and meta-analysis was to review industry-funded studies of antidepressants in children and adolescents with MDD, and to better understand the contribution of study design and placebo response to the findings of these studies.
Randomized, double-blind, placebo-controlled clinical trials that compared antidepressant with placebo for the acute treatment of MDD in children and/or adolescents were selected. Estimates of the standardized mean difference (SMD) in change in Children's Depression Rating Scale-Revised scores were pooled, after examining for heterogeneity. A random-effects meta-analysis was completed.
Thirty-four antidepressant-placebo comparisons, involving 6161 subjects, were included. The SMD among all studies was 0.12 (CI 0.08, 0.17; p < 0.001), a very small effect size, lower than that seen in studies of adults with MDD. When the meta-analysis was limited to studies with a low mean placebo response, the SMD increased to 0.19 and further increased to 0.22 when studies with at least a 50% chance of receiving placebo were included.
Many studies focused on older children and younger adolescents. Our findings may not reflect antidepressant efficacy in older adolescents.
The modest SMD identified in this analysis may reflect study design factors and the application of antidepressants developed for adults to pediatric patients. Given the urgent clinical need for more pediatric MDD treatments, the influence of placebo response and the need for drug development tailored to this population should be considered in pediatric MDD trial design.
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Sertraline is a selective serotonin reuptake inhibitor with specific indications in child and adolescent psychiatry. Notwithstanding its frequent use and clinical benefits, the relationship between pharmacokinetics, pharmacodynamics, efficacy, and tolerability of sertraline across indications, particularly in non-adult patients, is not fully understood.
This naturalistic therapeutic drug monitoring (TDM) study was conducted in a transdiagnostic sample of children and adolescents treated with sertraline (n = 78; mean age, 14.22 ± 2.39; range, 7–18 years) within the prospective multicenter “TDM-VIGIL” project. Associations between dose, serum concentration, and medication-specific therapeutic and side effects based on the Clinical Global Impression scale were examined. Tolerability was measured qualitatively with the 56-item Pediatric Adverse Event Rating Scale.
A strong linear positive dose–serum concentration relationship (with dose explaining 45% of the variance in concentration) and significant effects of weight and co-medication were found. Neither dose nor serum concentration were associated with side effects. An overall mild-to-moderate tolerability profile of sertraline was observed. In contrast with the transdiagnostic analysis that did not indicate an effect of concentration, when split into depression (MDD) and obsessive-compulsive disorder (OCD) diagnoses, the probability of clinical improvement significantly increased as both dose and concentration increased for OCD, but not for MDD.
This TDM–flexible-dose study revealed a significant diagnosis-specific effect between sertraline serum concentration and clinical efficacy for pediatric OCD. While TDM already guides clinical decision-making regarding compliance, dose calibration, and drug–drug interactions, combining TDM with other methods, such as pharmacogenetics, may facilitate a personalized medicine approach in psychiatry.
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Conventional treatments for youth depression, such as antidepressants, have modest efficacy, side effects, and ongoing controversies regarding safety. Repetitive transcranial magnetic stimulation (rTMS), specifically theta burst stimulation (TBS), applied to the dorsolateral prefrontal cortex (DLPFC) has demonstrated efficacy for the treatment of depression in adults. However, the feasibility and clinical response to TBS for youth depression has yet to be explored.
Twenty participants between the ages of 16 to 24 years old with MDD were recruited. The intervention consisted of 10 treatment sessions over the course of two weeks, in which participants received intermittent TBS and continuous TBS stimulation to the left and right DLPFC, respectively. Change in the Hamilton Rating Scale for Depression (HRSD-17) score was the primary outcome. Clinical assessments occurred at baseline, after the fifth treatment session, and within a week after treatment completion.
Of the twenty participants, eighteen received all TBS sessions, and seventeen completed all clinical assessments. There was a significant reduction in depressive symptoms following treatment completion (p < 0.001). Four of the twenty patients had more than 50% reduction in their depressive symptoms, two of whom achieved remission. All participants received and tolerated at least six daily TBS treatments with no major adverse events.
Study was an uncontrolled, open-label design.
Ten sessions of TBS was feasible, well tolerated, and appeared to have clinical effects for the treatment of depressed youth. Future sham-controlled randomized trials are warranted to validate these findings in a larger cohort of youth depression.
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This research was supported by grants from beyondblue, Australia's Depression Initiative, Premier's Youth Suicide Taskforce, Department of Human Services Victoria, and Australian Rotary Health Research Fund. Pfizer Pharmaceuticals provided medication free of charge but did not provide other financial support or contribution to the experimental design or study protocol.

Disclosure: The authors have no financial relationships to disclose.

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ARTICLESA Comparison of Cognitive-Behavioral Therapy, Sertraline, and Their Combination for Adolescent Depression

ABSTRACT

Objective

Method

Results

Conclusions

Section snippets

Subjects

Pretreatment Comparison of Groups

Diagnostic Status.

DISCUSSION

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Biol Psychiatry

J Am Acad Child Adolesc Psychiatry

Behav Ther

Clin Psychol Rev

J School Psychol

Manual for the Child Behavior Checklist/4–18 and 1991 Profile Burlington

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)

A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy

Arch Gen Psychiatry

Ontario child health study: reliability and validity of the general functioning subscale of the McMaster family assessment device

Fam Process

Adolescent Coping With Depression Course: Leader's Manual for Adolescent Groups

A double-blind, randomized, placebo controlled trial of fluoxetine in children and adolescents with depression

Arch Gen Psychiatry

Fluoxetine in child and adolescent depression: acute and maintenance treatment

Depress Anxiety

Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled randomized clinical trial

J Am Acad Child Adolesc Psychiatry

The McMaster Family Assessment Device

J Marital Fam Ther

ARTICLES
A Comparison of Cognitive-Behavioral Therapy, Sertraline, and Their Combination for Adolescent Depression