More than two-thirds of adolescents who suffer from depression could see long-term benefits from receiving one of three psychological treatments — of which only one is currently recommended on the NHS – according to research published today in The Lancet Psychiatry.
Depression affects around one in twenty adolescents, causing considerable suffering and potentially affecting relationships and educational performance. Unfortunately recurrence is likely in a half of all cases through into adult life and is associated with increasing personal difficulties and lower educational and employment prospects. However, it may be possible to reduce the risk of recurrence if a treatment for the condition shows enduring effects a year after the end of therapy.
Good evidence exists that psychological treatments are effective — around 70% of adolescents who receive treatment go into clinical remission – but there is very little evidence about whether these effects last. Currently, only cognitive behaviour therapy (CBT) has a sufficient evidence base to be offered on the NHS; CBT focuses on identifying the thoughts, feelings and actions that maintain depression, and then working collaboratively with the patient to change unhelpful thoughts and behaviours and thereby improve social functions.
“Depression can seriously impair people’s lives, and in many cases begins during their teenage years,” explains Professor Ian Goodyer from the Department of Psychiatry at the University of Cambridge. “If we can tackle it early on, evidence suggests we can reduce the chances of severe depression returning. In our study, we wanted to see if in routine NHS clinical settings two new treatments would be as effective as CBT, and, importantly, if their effects of any would last beyond end of treatment.”
Professor Goodyer is part of the ‘Improving mood with psychoanalytic and cognitive therapies’ (IMPACT) research team, which carried out a randomised controlled trial of 465 adolescents referred to 15 NHS clinics across England who received a diagnosis of major depression. The team randomised the patients to receive one of three treatments: CBT, short term psychoanalytic therapy, or a brief psychosocial intervention. The therapies tended to last between six and 11 sessions, delivered over a 25-28 week period.
Brief Psychosocial Intervention is a brief active problem solving intervention for depression that focuses on improving and maintaining mental and physical hygiene, engaging in pleasurable activities, maintaining schoolwork and peer relations, and reducing loneliness.
Short term psychoanalytic therapy, on the other hand, focuses on the patient’s preoccupations, memories, day-dreams, nocturnal dreams and subconscious drivers. The therapy aims to tackle these at an unconscious level and through the therapist-patient relationship.
The researchers found that 70% of the adolescents in the study improved substantially in each of the therapy groups by end of treatment. Follow up over the next 12 months confirmed a continuing decline in depression symptoms – 50% reduction by the end of the study, confirming non-clinical levels were sustained. Furthermore, for all three, the total cost of therapy and subsequent health service use was around the same amount.
Although it was not possible through this particular study to determine the extent to which improvement can be directly attributed to the treatments, the researchers say it demonstrates that these three different psychological therapies may each be employed in NHS child and adolescent mental health services with equal confidence. Furthermore all three can be delivered in 6-11 sessions over a seven month period and be expected to show sustained effects up to a year later. Importantly, although around 40% of the patients in each treatment arm received an antidepressant, this did not influence the effects of each psychological treatment when compared with each other.
“This is very promising and shows that at least two-thirds of teenagers may benefit from these psychiatric treatments, which in theory reduce the risk of recurrence,” says co-author Professor Peter Fonagy of the Anne Freud Centre and UCL. “Of course, this means that there are still a substantial proportion of teenagers who do not benefit and we need to understand why this should be the case and find appropriate treatments to help them, too.”
The researchers believe it is possible that the different psychological treatments have advantages for specific types of adolescent depression, and targeting the treatments more precisely may deliver more efficient therapy and reduce time to remission.
“We currently have a limited arsenal of treatments, but the fact that all three therapies are equally effective – and cost the same to implement – means that we might now be able to offer alternatives,” adds Professor Goodyer. “These therapies are also relatively short, usually involving less than a dozen sessions. Together, these factors could be particularly helpful given that there are often long waiting times for referrals for CBT in the NHS.”
The research was funded by the National Institute for Health Research (NIHR) and the Department of Health.
Goodyer, IM et al. Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial; Lancet Psychiatry; 30 Nov 2016; DOI: 10.1016/S2215-0366(16)30378-9