A comparison of add-on cognitive behavioural therapy with antidepressants versus antidepressant monotherapy in adolescents

A. R. Tang, C. John, M. Ardissino. Medicine, Imperial College London, London, United Kingdom.

Background: Adolescent major depressive disorder (MDD) remains a significant contributor to adolescent morbidity, adult depression, poor social functioning, substance abuse, reduced interpersonal relationships and suicide. It is the third leading cause of death in adolescents, but effectively treated with antidepressants and psychotherapies such as cognitive behavioural therapy (CBT), or a combination of both (COMB). Antidepressant monotherapy has been associated with increased suicidality in children leading to an FDA “black box” warning. The comparison of COMB with monotherapy has shown better outcomes for functional recovery and improvement in suicidal ideation in adults.

Methods: Databases were searched for randomised controlled trials (RCTs) comparing COMB with monotherapy using terms such as “fluoxetine”, “CBT”, “childhood”, “depression”, “combination”. A literature review was conducted and 10 studies fit the inclusion criteria. RevMan v5.3 software was used for pooled statistical analysis.

Results: There was a significant amount of heterogeneity between studies, variability in the study methods, CBT techniques used and compliance, reducing the generalisability of results. COMB was significantly better than SSRI for 12-week depression symptom reduction, but no significant difference in suicidal ideation or suicide rates was found between the groups.

Conclusions: COMB was found to be more effective or safer than SSRI alone for 12-week depression score outcomes in adolescents. There was no difference found in suicidality rates between SSRI alone and COMB, and assessment of long term (>2 year) outcomes was not possible due to lack of data in the field. Further investigation with larger populations of children may allow for subgroup analysis and investigation into long-term effects, as well as suicidality rates.

Key terms: depression, fluoxetine, CBT, adolescence