Week 9: Treatment of Depression (2)

Question 1

Treatment for Adolescents with Depression (TADS)

Answer 1

State of knowledge at the time of TADS
CBT
-Evidence for CBT in treating youth depression
-10 RCTs suggested CBT was efficacious
-40% of patients did not respond
-Significant relapse rates for those who do improve
-Room to improve treatment

Medication
-One RCT suggesting Prozac was efficacious
-SSRIs were increasingly being used, making it important to examine it’s effectiveness in a
sample of depressed adolescents

Combination

• Clinicians often recommended combined SSRI and CBT
• Not clear how they compare to each other, or if the combination is more beneficial then either alone

Question 2

TADS

Goals

Answer 2

Using a sample of patients representative of those found in clinical practice (comorbidity allowed):

(1) What is the effectiveness of pharmacological treatment for
depression in adolescents?

(2) What is the effectiveness of CBT for the treatment of adolescent depression?
(3) How do these treatments compare?

Question 3

TADS: Design

Answer 3

Participants
– 13 sites
– 439 youths enrolled
– age 12 to 17
– 54% female
– MDD, moderate to severe

Design
– Random assignment
– CBT, SSRI, CBT+SSRI, pill 
placebo
– Treated for 12 weeks

Question 4

TADS: Outcomes at 12 Weeks

Answer 4

Overall, groups with active medication did better in terms of depression symptoms.

But, CBT may be helpful for suicidality.
SSRI + CBT recommended for moderate to severe MDD

Despite suicidality on all groups, suicide events were 2x as common in PTs with prozac alone than combined and with CBT alone

Maybe CBT prevents suicide

Therefore, recommend suicide + pill for moderate to severe depression

Question 5

TADS: Outcomes

Answer 5

Not a lot of support for CBT

CBT on it’s own did not outperform a pill placebo

Contrasts with previous evidence

Why?

Sample characteristics

Some evidence that CBT may not work as well in a more severe sample

TADS sample was very severe

Treatment manual

• Very flexible
• Therapists given a lot of latitude in picking from different “modules”
• May have resulted in participants getting fewer CBT techniques

Question 6

TADS: Follow Up

Answer 6

Initial TADS results for 12 weeks of treatment

• Actually conducted 36 weeks of treatment
• After 12 weeks, SSRI and placebo groups unblinded for clinicians
• Makes it easier to run the study and ethically, it is hard to justify placebo given suicidality
• Placebo non-responders got treatment
• Placebo responders were monitored (some were getting better therefore watch and wait)

At 36 weeks, no difference (CBT caught up)

HOWEVER, depression remits naturally. We do not have a no trial condition so we do not know if this would have happened anyway BUT spontaneous recovery is usually a lot longer than 36 weeks

Question 7

TADS: 1 Year Follow Up

Answer 7

After 36 weeks, treatment no longer provided by TADS team
-Treatment available in the community (so might have had treatment longer)

1 year after end of treatment, participants maintaining gains on all measures of depression and suicidality

Question 8

Summary

Answer 8

CBT for child and adolescent depression can be effective

Results from TADS suggest that CBT alone may not be the best treatment option for more severe depression

TADS authors conclude that CBT in combination with SSRIs may prove protective against suicidality