Child/Adolescent Health

Adding cognitive behavioral therapy to treatment plans reduces depressive symptoms among adolescents

Many depressed adolescents are diagnosed and treated in primary care settings. About 35 to 65 percent fully recover from their depression at the end of acute treatment with a single antidepressant, usually a selective serotonin reuptake inhibitor (SSRI). According to a new study supported in part by the Agency for Healthcare Research and Quality (HS10535 and HS13854), adding cognitive behavior therapy (CBT) to use of a single SSRI only mildly improves symptoms over the antidepressant alone. However, the effect of CBT may have been weakened by reduced use of SSRIs by the adolescents treated with CBT and SSRIs, explains Gregory Clarke, Ph.D., of the Kaiser Permanente Center for Health Research.

Researchers randomized 152 adolescents 12 to 18 years old who had recently been prescribed an SSRI for major depressive disorder to 1 of 2 groups at an HMO primary care clinic: treatment with an SSRI alone (75 adolescents) and treatment with SSRI plus brief CBT (77 adolescents). The CBT program used cognitive restructuring and/or behavioral activation training, with adolescents attending an average of five sessions. An on-site mental health specialist and primary care provider (PCP) collaboratively treated the depressed adolescents.

Adolescents and their parents were interviewed by telephone at 6, 12, 26, and 52 weeks post-randomization. There was significant improvement in moderate depression for those in the CBT plus SSRI group. However, the SSRI control itself proved to be a potent intervention, with nearly 75 percent depression recovery by 12 weeks' followup. Yet, of the 135 adolescents who recovered from their initial depressive episode, about 24 percent in both groups suffered a recurrence within the year. There was no significant difference in other behavioral or emotional symptoms between the two groups. The CBT group had fewer physician visits and an unexpected 20 percent fewer days of SSRI use through the 1-year followup, which may have weakened the impact of CBT. These results parallel other studies that suggest that adolescents with depression only reluctantly take antidepressants and look for opportunities to discontinue them. CBT may be needed longer to yield much improvement beyond use of a single SSRI, note the researchers.

See "A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication," by Dr. Clarke, Lynn Debar, Ph.D., Frances Lynch, Ph.D., and others, in the September 2005 Journal of the American Academy of Child and Adolescent Psychiatry 44(9), pp. 888-898.

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