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Professor, Department of Psychiatry; University of Texas Southwestern Medical Center, Dallas, TX

First published in Psychiatry Weekly, Volume 10, Issue 1, April 27, 2015

Introduction

Children and adolescents with pediatric depression commonly experience an initial response to acute treatment, and even short-term remission of symptoms. Long-term relapse rates, however, can range from 40%–70% during maintenance treatment,^1-3 highlighting the well-recognized need for depression treatments with greater durability.

Dr. Betsy Kennard, a pediatric depression researcher, followed the lead of related studies from the adult literature to design and conduct a 2008 pilot study of continuation phase treatment for pediatric depression.⁴ In this protocol, acute phase pharmacological treatment was followed with add-on cognitive behavioral therapy (CBT).

“We decided to try this particular approach with children and adolescents thinking that we could get them well quickly—or at least achieve a meaningful response—with medication before adding the CBT component,” says Dr. Kennard. “We hypothesized that the CBT would teach them to better assimilate and practice the cognitive skills that are helpful in maintaining long-term response or remission to depression.”

Study Design

The earlier pilot study randomly assigned 6 months of medication plus CBT continuation therapy to youth (aged 11–17 years; n=46) who responded to 12 weeks of open treatment with fluoxetine. With time to relapse as the primary outcome measure, the medication-only group had 8 times greater risk of relapse than the medication plus CBT group.

Following that pilot study, Kennard and colleagues pursued this line of inquiry further in a larger study,⁵ which expanded both the number of participants included in the randomization (n=144) as well as the age range (8–17 years of age). Its primary goals were also expanded to include greater rates of remission, in addition to lower relapse rates.

The CBT component included mood self-monitoring skills, wellness skills, and behavioral activation, among other aims. Family sessions were included with the goal of teaching participants how to facilitate these skills in the home environment.

Main Findings

Two hundred youths originally received 6 weeks of open treatment with fluoxetine. Participants who demonstrated response to fluoxetine—defined as ≥50% reduction in total Children’s Depression Rating Scale–Revised score—were randomized to medication management-only (N=69) or medication management plus CBT continuation therapy (N=75). All participants continued fluoxetine treatment during the 6-month continuation phase.

Both groups showed strong rates of remission. Of the medication-only group, 84% remitted after ~14 weeks of treatment, compared to 90% of the CBT continuation group after ~11 weeks of treatment. Where the two groups did differ significantly, however, was in probability of relapse: 27% for the medication-only group, and 9% for the CBT continuation group, at 30-week follow-up (approximately 6 weeks after treatment endpoint).⁵

Although not clinically significant, there was a statistically significant difference between both groups’ fluoxetine dosage, with the CBT continuation group receiving less fluoxetine than the medication-only group. “That indicated to us that there was no medication effect between the two groups,” says Dr. Kennard.

Clinical Contact and Family Burdern

The number of medication management visits varied, ranging from 6–16 visits across both groups. The mean number of medication management visits in both groups was, however, virtually identical: 13.2 and 13.3 visits, respectively.

Participants in the CBT continuation group had a mean of 9.8 CBT sessions. This is lower than the number of sessions in comparable studies, says Dr. Kennard, which is closer to 16–20 sessions.

This analysis does not address parent and caregiver burden, but reducing that burden factored heavily in drawing up the treatment protocols. In addition to fewer CBT sessions than the norm, those sessions were timed to coincide with planned medication management visits. Overall, the CBT continuation protocol had only two additional scheduled clinic visits than the medication-only protocol. Roughly half of the CBT sessions were family group sessions.

Conclusions

“This was a sample with fairly severe depression symptoms, and with a degree of symptom severity comparable to that of samples in related studies,” says Dr. Kennard. “Longer-term outcomes of this sample, from weeks 52 through 78, will be published in the future. In the meantime, our results show that CBT continuation therapy is associated with a significantly lower risk of symptom relapse in young people with pediatric depression.”

This interview was conducted on November 11, 2014 by Lonnie Stoltzfoos

Disclosure: Dr. Kennard reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.

References:

1. Emslie GJ, Kennard BD, Mayes TL, et al. Fluoxetine versus placebo in preventing relapse of major depression in children and adolescents. Am J Psychiatry. 2008;165:459-467.

2. Kennard BD, Emslie GJ, Mayes TL, Hughes JL. Relapse and recurrence in pediatric depression. Child Adolesc Psychiatr Clin N Am. 2006;15:1057-1079, xi.

3. Birmaher B, Brent D, Bernet W, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:1503-1526.

4. Kennard BD, Emslie GJ, et al. Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder. J Am Acad Child Adolesc Psychiatry. 2008;47:1395-1404.

5. Kennard BD, Emslie GJ, Mayes TL, et al. Sequential treatment with fluoxetine and relapse--prevention CBT to improve outcomes in pediatric depression. Am J Psychiatry. 2014;171:1083-90.

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