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.
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).
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.
Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre