NIHR Signal Three psychological therapies are effective for adolescent depression

Published on 4 July 2017

For adolescents with unipolar major depression, there was no difference in self-reported depressive symptoms or cost-effectiveness after 18 months for cognitive behavioural therapy (CBT), short-term psychoanalytic psychotherapy and brief psychological intervention.

This was a large NIHR funded trial of three evidence-based psychological therapies often used in the NHS alongside medication or without it. 

Teenagers from various sites in the UK were randomly allocated to one of the three therapy types and some also given antidepressants if indicated. Uptake and attendance proved difficult, which may be an element for further research.

Around a quarter had indication of unipolar major depression 18 months after treatment started, indicating current interventions are not as effective as they could be at sustaining reductions in depression.  

The cost of treatment did not differ significantly between the three so thinking about which is the more practical option and preferred by the adolescent should be the main consideration. This may help improve attendance and adherence to treatment.

Three psychological therapies are effective for adolescent depression

Share your views on the research.

Why was this study needed?

Depression occurs in 1 to 3% of children and young people in the UK. It increases the risk of suicide and failure to achieve expected educational and occupational attainment. It is also associated with chronic mental health problems in adulthood. Therefore there is a need to ensure treatments are not only effective in the short-term but also in the longer term, to prevent continuance into adulthood.

This study aimed to assess whether there was any difference in outcomes up to a year and a half after finishing one of three therapies: CBT, short-term psychoanalytic psychotherapy or a brief intervention. The latter is a fairly new option that incorporates elements of the other two in a practical way, such as problem solving, agenda setting and helping with relationship difficulties.  

All are delivered by highly trained staff, from child and adolescent psychiatrists, psychotherapists, mental health nurses or clinical psychologists. Extra specialist training lasted from one day, for the brief psychological intervention and CBT, to four years for the short-term psychoanalytic psychotherapy. There is a lack of evidence on cost effectiveness of these interventions.

What did this study do?

This randomised controlled trial (IMPACT) compared three psychological therapies for adolescents who had moderate to severe unipolar depression.

The researchers recruited 557 participants aged 11 to 17 from 15 NHS clinics in the UK, 465 were included in analysis. They were randomised to receive either: CBT, involving up to 20 individual sessions plus up to four family sessions; psychoanalysis, involving up to 28 individual sessions plus up to seven family sessions; or a brief intervention, involving up to eight individual sessions plus up to four family sessions.

Antidepressants were prescribed for over a third of participants in each group.

Attendance was a problem. Only between 8% and 27% of participants actually attended the recommended number of sessions. Nearly a quarter either did not attend or went to one or two sessions.

What did it find?

According to the Mood and Feelings Questionnaire, a scale of 0 to 66 with higher scores indicating more severe depression:

  • All three groups had an overall improvement in depression scores from a baseline score of around 46 to around 22 by 86 weeks.
  • There was no difference in score between CBT or psychoanalysis at 52 weeks (adjusted mean difference [aMD] ‑0.31, 95% confidence interval [CI] ‑3.77 to 3.16) or 86 weeks (aMD 0.58, 95% CI ‑4.10 to 2.95).
  • There was no difference in score between the CBT and the short-term psychoanalysis groups combined compared to the brief intervention at 52 weeks (aMD ‑2.81, 95% CI ‑5.79 to 0.18) or 86 weeks (aMD ‑1.90, 95% CI ‑4.92 to 1.13).

Other important results were:

  • Twenty seven per cent in the brief intervention group, 25% in the CBT group and 15% in the psychoanalysis continued to have presence of symptoms indicating major depressive disorder at 86 weeks. The differences between therapies were not statistically significant as the number of adolescents was too small to provide reliable results.
  • The total costs, when considering levels of service, health, social care, education costs as well as treatment costs over the 86 weeks were £2678.39 for the brief intervention, £2379.01 for CBT and £3081.70 for short-term psychoanalysis. This difference was not statistically significant.

What does current guidance say on this issue?

According to NICE 2015 guidelines, children and young people with moderate to severe depression should be under the care of tier 2 to 3 of the Child and Adolescent Mental Health Services. Due to the severity, this would be step four in the care pathway. At this point, one of the following psychological therapies is recommended: individual CBT, interpersonal therapy, family therapy, or psychodynamic psychotherapy. NICE guidance recommends brief psychological therapy as an option for moderate to severe depression in their stepped care framework.

For adolescents, combined therapy can be considered using the antidepressant fluoxetine and a psychological therapy. Another suggested option is starting with psychological therapy only and then progressing to combined therapy if the young person is not responding. They advise against the use of antidepressants on their own.

What are the implications?

Any of the three psychological therapies appear equally likely to lead to a sustained reduction in depressive symptoms in the 12 months after therapy has finished. Adolescents and their families can therefore base their decision more on personal preference. This has the potential to improve attendance and adherence to therapy, which was challenging.

Though interpersonal psychotherapy has not been widely available for adolescents in the UK, the Improved Access to Psychological Therapies has been trying to address this.

A quarter of the adolescents still had major depression by 86 weeks. It is not clear whether these were people who had engaged with therapy or not. Looking at barriers and facilitators of adherence should be a future priority regardless of type of therapy.

Citation and Funding

Goodyer IM, Reynolds S, Barrett B, et al. Cognitive-behavioural therapy and short-term psychoanalytic psychotherapy versus brief psychosocial intervention in adolescents with unipolar major depression (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled trial. Health Technol Assess. 2017;21(12):1-94.

This project was funded by the National Institute for Health Research [Health Technology Assessment] (project number 06/05/01).

Bibliography

Barth J, Munder T, Gerger H, et al. Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis. PLoS Med. 2013;10(5):e1001454.

NICE. Depression in children and young people: identification and management. CG28. London: National Institute for Health and Care Excellence; 2015.

Royal College of Psychiatrists. Depression in young people - helping children to cope: information for parents, carers and anyone who works with young people. London: Royal College of Psychiatrists; 2017.

Why was this study needed?

Depression occurs in 1 to 3% of children and young people in the UK. It increases the risk of suicide and failure to achieve expected educational and occupational attainment. It is also associated with chronic mental health problems in adulthood. Therefore there is a need to ensure treatments are not only effective in the short-term but also in the longer term, to prevent continuance into adulthood.

This study aimed to assess whether there was any difference in outcomes up to a year and a half after finishing one of three therapies: CBT, short-term psychoanalytic psychotherapy or a brief intervention. The latter is a fairly new option that incorporates elements of the other two in a practical way, such as problem solving, agenda setting and helping with relationship difficulties.  

All are delivered by highly trained staff, from child and adolescent psychiatrists, psychotherapists, mental health nurses or clinical psychologists. Extra specialist training lasted from one day, for the brief psychological intervention and CBT, to four years for the short-term psychoanalytic psychotherapy. There is a lack of evidence on cost effectiveness of these interventions.

What did this study do?

This randomised controlled trial (IMPACT) compared three psychological therapies for adolescents who had moderate to severe unipolar depression.

The researchers recruited 557 participants aged 11 to 17 from 15 NHS clinics in the UK, 465 were included in analysis. They were randomised to receive either: CBT, involving up to 20 individual sessions plus up to four family sessions; psychoanalysis, involving up to 28 individual sessions plus up to seven family sessions; or a brief intervention, involving up to eight individual sessions plus up to four family sessions.

Antidepressants were prescribed for over a third of participants in each group.

Attendance was a problem. Only between 8% and 27% of participants actually attended the recommended number of sessions. Nearly a quarter either did not attend or went to one or two sessions.

What did it find?

According to the Mood and Feelings Questionnaire, a scale of 0 to 66 with higher scores indicating more severe depression:

  • All three groups had an overall improvement in depression scores from a baseline score of around 46 to around 22 by 86 weeks.
  • There was no difference in score between CBT or psychoanalysis at 52 weeks (adjusted mean difference [aMD] ‑0.31, 95% confidence interval [CI] ‑3.77 to 3.16) or 86 weeks (aMD 0.58, 95% CI ‑4.10 to 2.95).
  • There was no difference in score between the CBT and the short-term psychoanalysis groups combined compared to the brief intervention at 52 weeks (aMD ‑2.81, 95% CI ‑5.79 to 0.18) or 86 weeks (aMD ‑1.90, 95% CI ‑4.92 to 1.13).

Other important results were:

  • Twenty seven per cent in the brief intervention group, 25% in the CBT group and 15% in the psychoanalysis continued to have presence of symptoms indicating major depressive disorder at 86 weeks. The differences between therapies were not statistically significant as the number of adolescents was too small to provide reliable results.
  • The total costs, when considering levels of service, health, social care, education costs as well as treatment costs over the 86 weeks were £2678.39 for the brief intervention, £2379.01 for CBT and £3081.70 for short-term psychoanalysis. This difference was not statistically significant.

What does current guidance say on this issue?

According to NICE 2015 guidelines, children and young people with moderate to severe depression should be under the care of tier 2 to 3 of the Child and Adolescent Mental Health Services. Due to the severity, this would be step four in the care pathway. At this point, one of the following psychological therapies is recommended: individual CBT, interpersonal therapy, family therapy, or psychodynamic psychotherapy. NICE guidance recommends brief psychological therapy as an option for moderate to severe depression in their stepped care framework.

For adolescents, combined therapy can be considered using the antidepressant fluoxetine and a psychological therapy. Another suggested option is starting with psychological therapy only and then progressing to combined therapy if the young person is not responding. They advise against the use of antidepressants on their own.

What are the implications?

Any of the three psychological therapies appear equally likely to lead to a sustained reduction in depressive symptoms in the 12 months after therapy has finished. Adolescents and their families can therefore base their decision more on personal preference. This has the potential to improve attendance and adherence to therapy, which was challenging.

Though interpersonal psychotherapy has not been widely available for adolescents in the UK, the Improved Access to Psychological Therapies has been trying to address this.

A quarter of the adolescents still had major depression by 86 weeks. It is not clear whether these were people who had engaged with therapy or not. Looking at barriers and facilitators of adherence should be a future priority regardless of type of therapy.

Citation and Funding

Goodyer IM, Reynolds S, Barrett B, et al. Cognitive-behavioural therapy and short-term psychoanalytic psychotherapy versus brief psychosocial intervention in adolescents with unipolar major depression (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled trial. Health Technol Assess. 2017;21(12):1-94.

This project was funded by the National Institute for Health Research [Health Technology Assessment] (project number 06/05/01).

Bibliography

Barth J, Munder T, Gerger H, et al. Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis. PLoS Med. 2013;10(5):e1001454.

NICE. Depression in children and young people: identification and management. CG28. London: National Institute for Health and Care Excellence; 2015.

Royal College of Psychiatrists. Depression in young people - helping children to cope: information for parents, carers and anyone who works with young people. London: Royal College of Psychiatrists; 2017.

Cognitive behavioural therapy and short-term psychoanalytic psychotherapy versus brief psychosocial intervention in adolescents with unipolar major depression (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled trial

Published on 7 April 2017

Goodyer I M, Reynolds S, Barrett B, Byford S, Dubicka B, Hill J, Holland F, Kelvin R, Midgley N, Roberts C, Senior R, Target M, Widmer B, Wilkinson P & Fonagy P.

Health Technology Assessment Volume 21 Issue 12 , 2017

Background Although there are effective psychological treatments for unipolar major depression in adolescents, whether or not one or more of the available therapies maintain reduced depressive symptoms 1 year after the end of treatment is not known. This is a non-trivial issue because maintaining lowered depressive symptoms below a clinical threshold level reduces the risk for diagnostic relapse into the adult years. Objective To determine whether or not either of two specialist psychological treatments, cognitive–behavioural therapy (CBT) or short-term psychoanalytic psychotherapy (STPP), is more effective than a reference brief psychosocial intervention (BPI) in maintaining reduction of depression symptoms in the year after treatment. Design Observer-blind, parallel-group, pragmatic superiority randomised controlled trial. Setting A total of 15 outpatient NHS clinics in the UK from East Anglia, north-west England and North London. Participants Adolescents aged 11–17 years with Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition major depression including those with suicidality, depressive psychosis and conduct disorder. Patients were randomised using stochastic minimisation controlling for age, sex and self-reported depression sum score; 470 patients were randomised and 465 were included in the analyses. Interventions In total, 154 adolescents received CBT, 156 received STPP and 155 received BPI. The trial lasted 86 weeks and study treatments were delivered in the first 36 weeks, with 52 weeks of follow-up. Main outcome measures Mean sum score on self-reported depressive symptoms (primary outcome) at final study assessment (nominally 86 weeks, at least 52 weeks after end of treatment). Secondary measures were change in mean sum scores on self-reported anxiety symptoms and researcher-rated Health of the Nation scales for children and adolescents measuring psychosocial function. Following baseline assessment, there were a further five planned follow-up reassessments at nominal time points of 6, 12, 52 and 86 weeks post randomisation. Results There were non-inferiority effects of CBT compared with STPP [treatment effect by final follow-up = –0.578, 95% confidence interval (CI) –2.948 to 4.104; p = 0.748]. There were no superiority effects for the two specialist treatments (CBT + STPP) compared with BPI (treatment effect by final follow-up = –1.898, 95% CI –4.922 to 1.126; p = 0.219). At final assessment there was no significant difference in the mean depressive symptom score between treatment groups. There was an average 49–52% reduction in depression symptoms by the end of the study. There were no differences in total costs or quality-of-life scores between treatment groups and prescribing a selective serotonin reuptake inhibitor (SSRI) during treatment or follow-up did not differ between the therapy arms and, therefore, did not mediate the outcome. Conclusions The three psychological treatments differed markedly in theoretical and clinical approach and are associated with a similar degree of clinical improvement, cost-effectiveness and subsequent maintenance of lowered depressive symptoms. Both STPP and BPI offer an additional patient treatment choice, alongside CBT, for depressed adolescents attending specialist Child and Adolescent Mental Health Services. Further research should focus on psychological mechanisms that are associated with treatment response, the maintenance of positive effects, determinants of non-response and whether or not brief psychotherapies are of use in primary care and community settings. Limitations Neither reason for SSRI prescribing or monitoring of medication compliance was controlled for over the course of the study, and the economic results were limited by missing data. Funding This project was funded by the National Institute for Heath Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 12. See the National Institute for Heath Research Journals Library website for further project information. Funding was also provided by the Department of Health. The funders had no role in the study design, patient recruitment, data collection, analysis or writing of the study, any aspect pertinent to the study or the decision to submit to The Lancet.

  • Individual cognitive behavioural therapy: this involves the individual and professional looking at how problems, feelings, thoughts and behaviour all fit together by writing down thoughts and feelings.
  • Short-term psychoanalytic psychotherapy: uses shared therapeutic principles to elaborate and increase coherence of the adolescent’s mental models of attachment relationships, improving their capacity for mode regulation and increasing ability to make and maintain positive relationships with others.
  • Brief psychosocial intervention: A brief structure intervention based on the importance of psychoeducation about depression and action-orientated, goal-focused interpersonal activities. Specific advice given to adolescents on maintaining and improving physical hygiene, engaging in pleasurable activities, school work and peer relations.

Expert commentary

Depression in the teenage years can seriously impede young people’s education, family life and peer relationships. Effective treatment options and rapid recovery is important to minimise the disruption to their lives.

This trial of three psychological approaches (cognitive behavioural therapy, short term psychodynamic psychotherapy and brief psychological intervention) suggests that all three are equally effective and have similar costs, which would offer young people and their family a wider range of choice.

It would be interesting to try and tease out from these data and future research who was most likely to benefit from which approach.

Tamsin Ford, Professor of Child and Adolescent Psychiatry, University of Exeter Medical School