Clinical Question

Is cognitive behavior therapy (CBT) effective for adolescents with depression who decline antidepressant drug treatment?

Bottom Line

In adolescents who eschew drug treatment of major depression, short-term CBT is more effective than treatment as usual in inducing recovery, with a number needed to treat of 4 to 10. CBT also produced faster results. (Level of Evidence = 1b)

Synopsis

These researchers identified potential patients by mailing study brochures to parents of adolescents 12 to 18 years of age who had a recent prescription for an antidepressant (from a health maintenance organization in the United States) that went unfilled or was initially dispensed but not refilled. In other words, the patients did not fail antidepressant therapy but simply chose not to begin (or continue) it. The 212 adolescents who had major depressive disorder were randomized (allocation concealment uncertain) to continue treatment as usual (as determined by their primary care clinician) or treatment as usual plus at least four sessions of CBT aimed at addressing unrealistic thinking and increasing pleasant activities (behavioral activation). The patients could continue a second set of four to six sessions, if desired, and most did. Recovery, defined as at least eight weeks of well time as measured by the Children's Depression Rating Scale—Revised, occurred significantly faster in the CBT group and was significantly more likely in the first year but not the second year of follow-up. Quality of life was better with therapy in the first year after therapy but not in the second year. Hospital admissions for psychiatric diagnoses were significantly higher in the control group. Substance use, suicidal behavior, and parent-reported outcomes were not different between the two groups, but the study may not have been long enough to find a difference, if one exists. These results agree with the results of several meta-analyses examining the effect of CBT for adolescents with depression.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Uncertain

Setting: Outpatient (primary care)

Reference: ClarkeGDeBarLLPearsonJAet alCognitive behavioral therapy in primary care for youth declining antidepressants: a randomized trial. Pediatrics2016;137(5):e20151851.