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Psychotherapy, Pharmacotherapy, and Their Combination for Adolescents with Major Depressive Disorder: A Meta-Analysis

  • Nikita Singh (a1) and John Reece (a1)

Abstract

This meta-analysis aims to inform clinical practice of treatment strategies for adolescents with major depressive disorder (MDD). The efficacy of three empirically validated treatments was compared to determine the most effective treatment. These were: cognitive-behavioural therapy (CBT), selective serotonin reuptake inhibitor (SSRI) pharmacotherapy, and combination CBT and SSRI therapy. Inclusion criteria required studies to report a reliable and valid pre- and post-treatment measure and adequate data for Hedge's g effect size to be calculated. Forty-nine studies meeting the above inclusion criteria were found and included in the analysis. Although all three treatment strategies were found to be effective, analysis revealed no significant difference in treatment outcome among CBT, SSRI, and combination therapy. An investigation of moderator variables revealed months to follow-up to significantly influence the relationship between treatment type and treatment outcome. Given that CBT has no side effects, is more cost effective, and is equally as effective as SSRI therapy and combination therapy, the current study makes a strong case for CBT as a first-line treatment strategy for adolescents with MDD.

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Corresponding author

Address for correspondence: Nikita Singh. Email: nikita_s@hotmail.com

References

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References marked with an asterisk indicate studies included in the analysis.

*Alderman, J., Wolkow, R., & Fogel, I.M. (2006). Drug concentration monitoring with tolerability and efficacy assessments during open-label, long-term sertraline treatment and adolescents. Journal of Child and Adolescent Psychopharmacology, 16, 117129. doi:10.1089/cap.2006.16.117
*Ambrosini, P., Wagner, K.D., Biederman, J., Glick, I., Tan, C., Elia, J., . . . Geller, D. (1999). Multicenter open-label sertraline study in adolescent outpatients with major depression. Journal of the American Academy Child and Adolescent Psychiatry, 38, 566572. doi:10.1097/00004583-199905000_00018
American Psychiatric Association (APA). (2005). Lets talk about teen suicide. Arlington, VA: Author.
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. doi:10.1176/appi.books.9780890425596.910646
Angold, A., Costello, E.J., & Worthman, C.M. (1998). Puberty and depression: The role of age, pubertal status, and pubertal timing. Psychological Medicine, 28, 5161.
Australian Research Council. (2010). Excellence in Research Australia (ERA) journal list. Canberra, Australia: Author. Retrieved from http://arc.gov.au/era/era_2010/era_2010.htm
Beautris, A.L. (2000). Risk factors for suicide and attempted suicide among young people. The Australian and New Zealand Journal of Psychiatry, 34, 420436. doi:10.1046/j.1440-1614.2000.00691.x
*Berard, R., Fong, R., Carpenter, D.J., Thomason, C., & Wilkinson, C. (2006). An international, multicenter, placebo-controlled trial of paroxetine in adolescents with major depressive disorder. Journal of Child and Adolescent Psychopharmacology, 16, 5975. doi:10.1089/cap.2006.16.59
Birmaher, B., Arbelaez, C., & Brent, D. (2002). Clinical outcomes after short-term psychotherapy for adolescents with major depressive disorder. Archives of General Psychiatry, 57, 619637
Birmaher, B., Brent, D., Bernet, W., Bukstein, O., Walter, H., Benson, S.R., . . . Stock, S. (2007). Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Children and Adolescent Psychiatry, 46, 15031526. doi:10.1097/chi.0b013e318145aelc
*Birmaher, B., Brent, D., Kolko, D., Baugher, M., Bridge, J., Holder, D., . . . Ulloa, R.E. (2000). Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder. Archives of General Psychiatry, 57, 2936. doi:10.001/archpsych.57.1.29
Borenstein, M., Hedges, L.V., Higgins, J.P.T., & Rothstein, H.R. (2009). Introduction to meta-analysis. West Sussex, UK: John Wiley & Sons.
Borenstein, M., Hedges, L.V., Higgins, J.P.T., & Rothstein, H.R. (2005). Comprehensive meta-analysis (Version 2) [Computer software]. Englewood, NJ: Biostat
*Bostic, J.Q., Prince, J., Brown, K., & Place, S. (2001). A retrospective study of citalopram in adolescents with depression. Journal of Child and Adolescent Psychopharmacology, 11, 159166. doi: 1089/104454601750284063
*Boulos, C., Kutcher, S.P., Gardner, D., & Young, E. (1992). An open naturalistic trial of fluoxetine in adolescents and young adults with treatment-resistant major depression. Journal of Child and Adolescent Psychopharmacology, 2, 103113. doi:10.1089/cap.1992.2.103
*Braconnier, A., Le Coent, R., & Cohen, D. (2002). Paroxetine versus clomipramine in adolescents with severe depression: A double-blind randomised, multi-center trial. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 2229. doi:10.1097/00064583-200301000-00007
*Brent, D., Emslie, G.J., Clarke, G., Wagner, K.D., Asarnow, J.R., Keller, M.B., . . . Zelazny, J. (2008). Switching to another selective serotonin reuptake inhibitor or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI resistant depression. American Medical Association, 299 (8), 901913.
*Brent, D., Holder, D., Kolko, D., Birmaher, B., Baugher, M., Roth, C., & Johnson, B. (1997). A clinical psychotherapy trial for adolescent depression comparing cognitive, family and supportive treatment. Archives of General Psychiatry, 54, 877–855. doi:10.1001/archpsyc.1997.0183021025017
Calati, R., Pedrini, L., Alighieri, S., Alvarez, M.I., Desideri, L., Durante, D., . . . De Girolamo, G. (2011). Is cognitive behavioural therapy an effective complement to antidepressants in adolescents? A meta‐analysis. Acta Neuropsychiatrica, 23, 263271. doi:10.1111/j.1601-5215.2011.00595.x
*Clarke, G.N., Hornbrook, M., Lynchm, F., Polen, M., Gale, J., O'Connor, E., . . . Seeley, J.R. (2002). Group cognitive-behavioural treatment for depressed adolescent offspring of depressed parents in health maintenance organisation. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 305313. doi:10.1097/00004583-200203000-00010
*Clarke, G., Rohde, P., Lewinsohn, P.M., Hops, H., & Seeley, J.R. (1999). Cognitive-behavioural treatment of adolescent depression: Efficacy of acute group treatment and booster sessions. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 272280. doi:10.1097/00004583-199903000-00014
*Colle, L.M., Belair, J., DiFeo, M., Weiss, J., & LaRouche, C. (1994). Extended open-label fluoxetine treatment of adolescents with major depression. Journal of Child and Adolescent Psychopharmacology, 4, 225232. doi:10.1089/cap.1994.4.225
*Cornelius, J.R., Bukstein, O.G., Wood, S., Kirisci, L., Douaihy, A., & Clarke, D.B. (2009). Double-blind placebo-controlled trial of fluoxetine in adolescents with comorbid major depression and an alcohol use disorder. Addictive Behaviours, 34, 905909. doi:org/10/1016/j.addbeh.2009.03.008
*Curry, J.F., Wells, K.C., Lochman, J.E., Craighead, E.W., & Nagy, P.D. (2003). Cognitive-behavioural intervention for depressed, substance-abusing adolescents: Development and pilot testing. Journal of the American Academy of Child and Adolescent Psychiatry. doi:10.1097/01.chi.0000046861.56865.6c
Dubicka, B., Elvins, R., Roberts, C., Chick, G., Wilkinson, P., & Goodyer, I.M. (2010). Combined treatment with cognitive–behavioural therapy in adolescent depression: Meta-analysis. British Journal of Psychiatry, 197, 433440. doi:10.1097/01.chi.0000233157.21925.71.2006-12846-
*Emslie, G.J., Heiligenstein, J.H., Hoog, S.L., Wagner, K.D., Findling, R.L., McCracken, J.T., . . . Jacobson, J.G. (2004). Fluoxetine treatment for prevention of relapse of depression in children and adolescents: A double-blind, placebo-controlled study. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 13971405. doi:10.1097/01.chi.0000140453.89323.57
*Emslie, G.J., Heiligenstein, J.H., Wagner, K.D., Hoog, S.L., Ernest, D.E., Brown, E., . . . Jacobson, J.G. (2002). Fluoxetine for acute treatment of depression in children and adolescents: A placebo- controlled randomised clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 12051215. doi:org/10.1097/00004583-20021000-0010
*Emslie, G.J., Kennard, B., Mayes, T., Nightingale-Teresi, J., Carmody, T., Hughes, C.W., . . . Rintelman, J.W. (2008). Fluoxetine versus placebo in preventing relapse of major depression in children and adolescents. The American Journal of Psychiatry, 165 (4), 459547.
*Emslie, G.J., Ventura, D., Korotzer, A., & Tourkodimitris, S. (2009). Escitalopram in the treatment of adolescent depression: A randomised placebo-controlled multisite trial. Journal of American Academy of Child and Adolescent Psychiatry, 48, 721729. doi:10.1097/CHI.0b013e3181a2b304
*Emslie, G.J., Rush, J., Weinberg, W.A., Kowatch, R.A., Hughes, C., Carmody, T., & Rintelman, J. (1997). A double-blind, randomised, placebo-controlled trial of fluoxetine in children and adolescents with depression. Archives of General Psychiatry, 54, 10311037. doi:10.1001/archpsyc.1997.01830230069010
*Emslie, G.J., Wagner, K.D., Kutcher, S.P., Krulewicz, S., Fong, R., Carpenter, D.J., . . . Wilkinson, P. (2006). Paroxetine treatment in children and adolescents with major depressive disorder: A randomised, multicenter, double-blind, placebo-controlled trial. Journal of American Academy of Child and Adolescent Psychiatry, 45, 709719. doi:10.1097/01.chi.0000138356.29099.f1
*Farnum, J.C. (2004). Acute SSRI treatment response in children and adolescents with major depressive disorder and comorbid anxiety disorder. (Unpublished doctoral dissertation). University of Hartford, CT.
*GlaxoSmithKline, Biostatistics and Data Sciences Department. (2001). A randomised, multicenter, 8-week, double-blind, placebo-controlled flexible-dose study to evaluate the efficacy and safety of paroxetine in children and adolescents with major depressive disorder. Retrieved from http://www.gsk.com/media/paroxetine.htm
*GlaxoSmithKline, Biostatistics and Data Science Department. (1998a). A double-blind, multicenter placebo controlled study of paroxetine in adolescents with unipolar major depression. Retrieved from http://www.gsk.com/media/paroxetine.htm
*GlaxoSmithKline, Biostatistics and Data Science Department. (1998b). Multi-center, double-blind, placebo controlled study of paroxetine and imipramine in adolescents with unipolar major depression-acute phase. Retrieved from http://www.gsk.com/media/paroxetine.htm
*Goodyer, I., Dubicka, B., Wilkinson, P., Kelvin, R., Roberts, C., Byford, S., . . . Harrington, R. (2008). A randomised controlled trial of cognitive-behavioural therapy in adolescents with major depression treated with selective serotonin reuptake inhibitors: The ADAPT trial. Health Technology Assessment Journal, 12 (14), iiiiv, ix–60.
*Goodyer, I., Dubicka, B., Wilkinson, P., Kelvin, R., Roberts, C., Byford, S., . . . Harrington, R. (2007). Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: Randomised controlled trial. The British Medical Journal. doi:10.1136/bmj39224.49434055
Haby, M.M., Tonge, B., Littlefield, L., Carter, R., & Vos, T. (2004). Cost-effectiveness of cognitive-behavioural therapy and selective serotonin reuptake inhibitors for major depression in children and adolescents. Australian and New Zealand Journal of Psychiatry, 38, 579591. doi:10.1111/j.1440-1614.2005.01652.x
*Heiligenstein, J.H., Hoog, S.L., Wagner, K.D., Findling, R.L., Galil, N., Kaplan, S., . . . Jacobson, J.G. (2006). Fluoxetine 40–60mg versus fluoxetine 20mg in the treatment of children and adolescents with a less-than-complete-response to nine week-treatment with fluoxetine 10–20mg: A pilot study. Journal of Child and Adolescent Psychopharmacology, 16, 207217. doi:10.1089/cap.2006.16.207
*Hides, L., Carroll, S., Catania, L., Cotton, S.M., Baker, A., Scaffadi, A., & Lubman, D.I. (2010). Outcomes of an integrated cognitive-behaviour therapy (CBT) treatment program for co-occurring depression and substance misuse in young people. Journal of Affective Disorders, 121, 169174. doi:10.1016.j.jad.2009.06.002
Hollon, D.S., Stewart, O.M., & Strunk, D. (2006). Enduring effects for cognitive behaviour therapy in the treatment of depression and anxiety. Annual Review of Psychology, 57, 285315. doi:10.1146/annurev.psych.57.102904.190044
Hopkins, W.G. (2009). A new view of statistics. Retrieved from http://www.sportsci.org/resource/stats/
*Kaufman, N.K., Rohde, P., Seeley, R., Clarke, G.N., & Stice, E. (2005). Potential mediators of cognitive-behavioural therapy for adolescents with comorbid major depression and conduct disorder. Journal of Consulting and Clinical Psychology, 73, 3846. doi:10.1037/0022-006X.73.1.38
Keller, M.B., McCullough, J.P., Klein, D.N., Arnow, B., Dunner, D.L., Gelenberg, A.J., . . . Zajecka, J. (2000). A comparison of nefazodone, the cognitive-behavioural analysis system of psychotherapy, and their combination for the treatment of chronic depression. The New England Journal of Medicine, 342, 14621470. doi:10.1056/NEJM200005183422001
*Keller, M.B., Ryan, N., Strober, M., Klein, R.B., Kutcher, S.P., Birmaher, B., . . . McCaffert, B.S. (2001). Efficacy of paroxetine in the treatment of adolescent major depression: A randomised, controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 762772. doi:org/10.1097/00004583-200107000-00010
*Kennard, B., Emslie, G.J., Mayes, T.I., Nightingale-Teresi, J., Nakonezny, P.A., Hughes, C.W., . . . Jarrett, R.B. (2008). Cognitive-behavioural therapy to prevent relapse in pediatric responders to pharmacotherapy of major depressive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 13951409. doi:10.1097/CHI.ob13e31818914al
Klein, R.B. (2004). Beyond significance testing: Reforming data analysis methods in behavioural research. Washington, DC: American Psychological Association.
*Kolko, D.J., Brent, D.A., Baugher, M., Bridge, J., & Birmaher, B. (2000). Cognitive and family therapies for adolescent depression: Treatment specificity, mediation, and moderation. Journal of Consulting and Clinical Psychology, 68, 603614. doi:10.1037/0022-006X.68.4.603
*Kroll, L., Harrington, R., Jayson, D., Fraser, J., & Gowers, S. (1996). Pilot study of continuation cognitive-behavioural therapy for major depression in adolescent psychiatric patients. The American Journal of Child and Adolescent Psychiatry, 35, 11561161. doi:10.1097/00004583-199609000_00013
Lewinsohn, P.M., Rohde, P., & Seeley, J.R. (1998). Major depressive disorder in older adolescents: Prevalence, risk factors, and clinical implications. Clinical Psychology Review, 18, 765794. doi:10.1016/S0272-7358(98)00010-5
*Lusk, P., & Melnyk, B.M. (2011). The brief cognitive-behavioural COPE intervention for depressed adolescents: Outcomes and feasibility of delivery in 30-minutes outpatient visits. Journal of the American Psychiatric Nurses Association, 12, 226236. doi:10.1177/10783911404067
March, J.S., Silva, S., Petrycki, S., Curry, J., Wells, K., Fairbank, J., . . . Severe, J. (2009). The treatment for adolescents with depression study (TADS): Outcomes over 1 year naturalistic follow-up. American Journal of Psychiatry, 166, 11411149.
*March, J.S., Silva, S., Petrycki, S., Curry, J., Wells, K., Fairbank, J., . . . Severe, J. (2007). The treatment for adolescents with depression study (TADS): Long-term effectiveness and safety outcomes. Archives of General Psychiatry, 64 (10), 11321143.
*March, J.S., Silva, S., Petrycki, S., Curry, J., Wells, K., Fairbank, J., . . . McNulty, S. (2004). Fluoxetine, cognitive-behavioural therapy, and their combination for adolescents with depression. The Journal of the American Medical Association, 292 (7), 807820.
McDermott, B., Baigent, M., Chanen, A., Fraser, L., Graetz, B., Hayman, N., . . . Spence, S. (2010). Clinical practice guidelines: Depression in adolescents and young adults. Beyondblue: The National Depression Initiative. Retrieved from http://www.beyondblue.org.au/index.aspx?link_id=6.1247
*Melvin, G.A., Tonge, B.J., King, N.J., Heyne, D., Gordon, M.S., & Klimkeit, S. (2006). A comparison of cognitive-behavioural therapy, sertraline, and their combination for adolescent depression. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 11511161. doi:10.1097/01.chi.0000233157.21925.71
*Nixon, M.K., Milin, R., Simeon, J.G., Cloutier, P., & Spenst, B.A. (2001). Sertraline effects in adolescents major depression and dysthymia: A six-month open trial. Journal of Child and Adolescent Psychopharmacology, 11, 131142. doi:10.1089/104454601750284036
Pampallona, S., Bollini, P., Tibaldi, G., Kupelnick, B., & Munizza, C. (2004). Combined pharmacotherapy and psychological treatment for depression: A systematic review. Archives of General Psychiatry, 61, 714719. doi:10.1001/archpsyc.61.7.714
Reinecke, M.A., & Simons, A. (2005). Vulnerability to depression among adolescents: Implications for cognitive-behavioural treatment. Cognitive and Behavioral Practice, 12, 166176. doi:10.1037/0021-843x.99.1.55.
*Rey-Sanchez, F., & Gutierrez-Casares, J.R. (1997). Paroxetine in children with major depressive disorder: An open trial. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 14431447. doi:10.1097/00004583-19971000-00027
*Riggs, P.D., Mikulich, S.K., Coffman, L.M., & Crowley, T.J. (1997). Fluoxetine in drug-dependent delinquents with major depression: An open trial. Journal of Children and Adolescent Psychopharmacology, 7, 8795. doi:10.1089/cap.1997.7.87
*Rohde, P., Clarke, G.N., Mace, D.E., Jorgensen, J.S., & Seeley, J.R. (2004). An efficacy/effectiveness study of cognitive-behavioural treatment for adolescents with comorbid major depression and conduct disorder. The American Journal of Child and Adolescent Psychiatry, 43, 660–66. doi:10.1097/01.chi.0000121067.29744.41
Rosenthal, R. (1979). The file drawer problem and tolerance for null results. Psychological Bulletin, 86, 638641. doi:10.1037/0033-2909.86.3.638
Rosenthal, R., & DiMatteo, R.R. (2001). Meta-analysis: Recent developments in quantitative methods for literature reviews. Annual Reviews of Psychology, 52, 5982. doi:0066-4308/01/201-0059
*Rossello, J., Bernal, G., & Rivera-Medina, C. (2008). Individual and group CBT and IPT for Puerto Rican adolescents with depressive symptoms. Cultural Diversity and Ethnic Minority Psychology, 12, 234245. doi:10.1037/1099-9809-14.3.234
Sawyer, M.G., Arney, F.M., Baghurst, P.A., Clark, J.J., Graetz, B.W., . . . Zubrick, S.R. (2000). Mental health of young people in Australia: Child and adolescent component of the National Survey of Mental Health and Wellbeing. Canberra, Australia: Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care.
*Schirman, S., Kronenber, S., Apter, A., Brent, D., Melhem, N., Pick, N., . . . Gothelf, D. (2010). Effectiveness and tolerability of citalopram for the treatment of depression and anxiety disorders in children and adolescents: An open-label study. Journal of Neural Transmissions, 117, 139145. doi:10.1007/s00702-009-0330-x
*Shirazi, E., & Alaghband-Rad, J. (2005). An open trial of citalopram in children and adolescents with depression. Journal of Child and Adolescent Psychopharmacology, 15, 233239. doi:10.1089/cap.2005.15.233
*Shoval, G., Nahshoni, E., Gothelf, D., Manor, I., Golobchik, P., Zemishlany, Z., Weizman, A., & Zalsman, G. (2011). Effectiveness and safety of citalopram in hospitalised adolescents with major depression: A preliminary, 8-week, fixed-dose, open-label, prospective study. Clinical Neuropharmacology, 34, 182185. doi:10.1097/WNF.0b013e31822cb863
Therapeutic Guidelines Australia. (2012). Electronic Therapeutic Guidelines complete. Retrieved from http://etg.tg.com.au.ezproxy.lib.monash.edu.au/conc/tgc.htm?id=27b1fc15b4331af2841f02ef96ddc67b
Smithson, M.J. (2003). Confidence intervals (Sage University Papers Series on Quantitative Applications in the Social Sciences, series no. 07-140). Thousand Oaks, CA: Sage.
United States of America Food and Drugs Administrations. (2009). Public Health Advisory: Suicidality in children and adolescents being treated with anti-depressant medications. Retrieved from http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm155488.htm?utm_campaign=Google2&utm_source=fdaSearch&utm_medium=website&utm_term=SSRI%20adolescents&utm_content=7
Usala, T., Clavenna, A., Zuddas, A., & Bonati, M. (2007). Randomised controlled trial of selective serotonin reuptake inhibitors in treating depression in children and adolescents: A systematic review and meta-analysis. European Neurpsychopharmacology, 18, 6273. doi:10.1016/j.euroneuro.2007.06.001
*von Knorring, A., Olsson, G.I., Thomsen, P.H., Lemming, O.M., & Hulten, A. (2006). A randomised, double-blind, placebo-controlled study of citalopram in adolescents with major depressive disorder. Journal of Clinical Psychopharmacology, 26, 311315. doi:10.1097/01.jcp.000021905/40632.d5
*Vostanis, P., Feehan, C., Grattan, E., & Bickerton, W. (1996a). A randomised controlled out-patient trial of cognitive behavioural treatment for children and adolescents with depression: 9-month follow-up. Journal of Affective Disorders, 40, 105116.
*Vostanis, P., Feehan, C., Grattan, E., & Bickerton, W. (1996b). Treatment for children and adolescents with depression: Lessons from a controlled trial. Clinical Child Psychology and Psychiatry, 1, 199212. doi:10.1177/1359104596012003
*Wagner, K.D., Ambrosini, P., Rynn, M., Wohlberg, C., Yang, R., Greenbaum, M.S., . . . Deas, D. (2003). Efficacy of sertraline in the treatment of children and adolescents with major depressive disorder. Journal of the American Medical Association, 290, 10331041. doi:10.1001/jama,290.8.1033
*Wagner, K.D., Rob, A.S., Findling, R.L., Jin, J., Gutierrez, M.M., & Heydorn, W.E. (2004). A randomised, placebo-controlled trial of citalopram for the treatment of major depression in children and adolescents. The American Journal of Psychiatry, 161, 10791083. doi:10.1176/appi.agp.161.6.1079

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Psychotherapy, Pharmacotherapy, and Their Combination for Adolescents with Major Depressive Disorder: A Meta-Analysis

  • Nikita Singh (a1) and John Reece (a1)

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