What treatments are helpful for depressed adolescents? A study released today gives a surprising answer: not psychotherapy, or at least not the best-defined forms, cognitive-behavioral therapy and brief psychoanalytic therapy. In a trial funded by the British National Institute for Health Research and conducted by researchers from Cambridge and other British universities, neither psychotherapy outperformed nonspecific psychiatric support.
What distinguished this research was its duration. Patients—470 teens in all—were treated for a half year and followed up for an additional year. In the short and long term, psychotherapy offered no additional benefit. The therapies failed across the board, in raters’ reports and patients’ own accounts. The psychotherapies gave no additional symptomatic relief, made no measurable difference in the youngsters’ quality of life, provided no extra protection from suicidal impulses or gestures, and did nothing to improve the odds that a patient would emerge from depression.
Research on adolescents is difficult. In the teenage years, depression may not be easy to define or identify—although the group in this study was quite ill—and, thankfully, spontaneous remissions are frequent. Some adolescent depression, nearly twenty percent in most studies, is hard to budge. Between treatment-resistant cases and ones that respond readily to Prozac or improve with time alone, there may be little room for psychotherapy to show its stuff. Also, I always wonder whether manualized treatments can match the free-form psychotherapy many clinicians rely on in their offices.
But this trial replicates the results of smaller, briefer, or less tightly controlled prior studies: In the long term, the effects of psychotherapy in adolescents are hard to demonstrate when the comparison is to a vigorous form of routine psychiatric care—a handful of sessions that include education about depression and encouragement of activities like socialization.
Earlier this year, the press gave intense attention to overview research that found minimal or modest efficacy for antidepressants (other than Prozac) for depressed adolescents. It will be interesting to see how the media approach the British psychotherapy study—whether it receives equivalent coverage.
The current trial can be seen as a follow-on to British research from 10 years ago that looked at cognitive-behavioral psychotherapy as a supplement to Prozac, for depressed teens. There, too, the psychotherapy gave no added benefit. The Cambridge researchers mined the earlier trial to see what it was that psychiatrists did in the ordinary care of patients on medication. That “routine specialist care” was the basis for the “brief psychosocial intervention” in the recent trial, and psychiatrists administered the treatment.
The current study does not break out results for medication, but about a fifth of the adolescents were on antidepressants at the start of the study, and about two-fifths had taken them—again, mostly Prozac—by the end. In what might be an understatement, the authors comment, “we cannot exclude the possibility that SSRIs [that is, Prozac and similar drugs] might have contributed to the improvements over time.”
A fair summary of recommendations based on this research (and similar prior trials) might read like this:
• Depressed adolescents should meet regularly with psychiatrists who provide their usual care, including practical advice and encouragement.
• With no additional treatment, adolescent depression will often remit on its own.
• Patients who worsen or who fail to improve spontaneously should be offered medication, probably Prozac. Expect a third or more to need this extra help at some point in the first eighteen months.
Now, I don’t know that we are bound to follow this protocol. There are arguments for avoiding the use of medication in adolescents. And as long as psychiatrists are conducting the care, why shouldn't they offer psychotherapy? I'm a fan of psychoanalytic variants for teens. The therapy may help in other ways. But the outlined course of action has this going for it: it’s buttressed by the formal findings.
As I say, it will be interesting to see how the press responds to this new research. There’s overwhelming enthusiasm for evidence-based medicine—when it confirms what we wanted to believe all along.