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Sunday, July 22, 2007

For Adolescents no additional benefit of cognitive behavioural therapy with an antidepressant

There was no evidence of a protective effect on suicidal thinking or action with the addition of CBT to an antidepressant in depressed adolescents. In contrast to an earlier study in the United States cognitive behavioural therapy (CBT) does not improve outcome of treatment with a selective serotonin reuptake inhibitor (SSRI). On second look the US study also did not show additional benefit of CBT added to a SSRI (fluoxetine). Moreover the results of the US trial limits generalisability since it excluded adolescents with active suicidal intent, self harm, severe conduct disorder, and active substance abuse. Certainly suicidality is a core feature of severe depression. More than half of the participants were recruited from advertisement.
This trial in Great Britain is of more importance since it includes moderate to severely depressed adolescents and this randomised controlled trial had a follow-up of 28 weeks and it did not exclude suicidal adolescents nor psychotic depressed patients. They were all outpatients. CBT was offered weekly for 12 weeks, then fortnightly for 12 weeks with a final session at 28 weeks (total 19 sessions). The focus of usual care was an explanation of depression and attention to recent family or peer group conflicts. Comorbidity problems were also attended to when required, including liaison with schools and other agencies.
Overall outcome on the long term (28 weeks) was not bad at all: 7/94 (61%) of those in the SSRI alone group and 52/98 (53%) of the CBT plus SSRI group were much or very much improved. Again no significant difference but a good response for adolescents with a severe depression.

One weakness is the absence of a placebo arm, which we considered to be unethical in such ill patients, so we cannot draw any conclusions regarding overall effectiveness of treatment.
Now this is the most regrettable remark in this article about this excellent trial. Since there is such difficulty in deciding what is the best treatment for adolescents with depression as well as so much uncertainty about the benefit or harm from the use of antidepressants it is most unethical not to include a placebo arm in this kind of randomised controlled trials. If we want to get any further in the treatment of a sever illness we shouldn't choose for the easy way out.

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