Joan Rosenbaum Asarnow1, Graham Emslie2, Greg Clarke2, Karen Dineen Wagner2, Anthony Spirito2, Benedetto Vitiello2, Satish Iyengar2, Wael Shamseddeen2, Louise Ritz2, Boris Birmaher2, Neal Ryan2, Betsy Kennard2, Taryn Mayes2, Lynn DeBar2, James McCracken2, Michael Strober2, Robert Suddath2, Henrietta Leonard2, Giovanna Porta2, Martin Keller2, David Brent2. 1. Drs. Asarnow, McCracken, Strober, and Suddath are with the Department of Psychiatry, University of California-Los Angeles; Drs. Brent, Iyengar, Shamseddeen, Ryan, and Birmaher and Ms. Porta are with the University of Pittsburgh; Drs. Emslie and Kennard and Ms. Mayes are with the University of Texas Southwestern Medical Center at Dallas; Drs. Clarke and DeBar are with the Kaiser Permanente Center for Health Sciences; Dr. Wagner is with the University of Texas Medical Branch; Drs. Spirito and Keller are with the Department of Psychiatry, Brown University; Dr. Vitiello and Ms. Ritz are with the National Institute of Mental Health; and Dr. Leonard, now deceased, was formerly with Brown University. Electronic address: jasarnow@mednet.ucla.edu. 2. Drs. Asarnow, McCracken, Strober, and Suddath are with the Department of Psychiatry, University of California-Los Angeles; Drs. Brent, Iyengar, Shamseddeen, Ryan, and Birmaher and Ms. Porta are with the University of Pittsburgh; Drs. Emslie and Kennard and Ms. Mayes are with the University of Texas Southwestern Medical Center at Dallas; Drs. Clarke and DeBar are with the Kaiser Permanente Center for Health Sciences; Dr. Wagner is with the University of Texas Medical Branch; Drs. Spirito and Keller are with the Department of Psychiatry, Brown University; Dr. Vitiello and Ms. Ritz are with the National Institute of Mental Health; and Dr. Leonard, now deceased, was formerly with Brown University.
Abstract
OBJECTIVE: To advance knowledge regarding strategies for treating selective serotonin reuptake inhibitor (SSRI)-resistant depression in adolescents, we conducted a randomized controlled trial evaluating alternative treatment strategies. In primary analyses, cognitive-behavioral therapy (CBT) combined with medication change was associated with higher rates of positive response to short-term (12-week) treatment than medication alone. This study examines predictors and moderators of treatment response, with the goal of informing efforts to match youths to optimal treatment strategies. METHOD: Youths who had not improved during an adequate SSRI trial (N = 334) were randomized to an alternative SSRI, an alternative SSRI plus CBT, venlafaxine, or venlafaxine plus CBT. Analyses examined predictors and moderators of treatment response. RESULTS: Less severe depression, less family conflict, and absence of nonsuicidal self-injurious behavior predicted better treatment response status. Significant moderators of response to CBT + medication (combined) treatment were number of comorbid disorders and abuse history; hopelessness was marginally significant. The CBT/combined treatment superiority over medication alone was more evident among youths who had more comorbid disorders (particularly attention-deficit/hyperactivity disorder and anxiety disorders), no abuse history, and lower hopelessness. Further analyses revealed a stronger effect of combined CBT + medication treatment among youths who were older and white and had no nonsuicidal self-injurious behavior and longer prestudy pharmacotherapy. CONCLUSIONS: Combined treatment with CBT and antidepressant medication may be more advantageous for adolescents whose depression is comorbid with other disorders. Given the additional costs of adding CBT to medication, consideration of moderators in clinical decision making can contribute to a more personalized and effective approach to treatment.
RCT Entities:
OBJECTIVE: To advance knowledge regarding strategies for treating selective serotonin reuptake inhibitor (SSRI)-resistant depression in adolescents, we conducted a randomized controlled trial evaluating alternative treatment strategies. In primary analyses, cognitive-behavioral therapy (CBT) combined with medication change was associated with higher rates of positive response to short-term (12-week) treatment than medication alone. This study examines predictors and moderators of treatment response, with the goal of informing efforts to match youths to optimal treatment strategies. METHOD: Youths who had not improved during an adequate SSRI trial (N = 334) were randomized to an alternative SSRI, an alternative SSRI plus CBT, venlafaxine, or venlafaxine plus CBT. Analyses examined predictors and moderators of treatment response. RESULTS: Less severe depression, less family conflict, and absence of nonsuicidal self-injurious behavior predicted better treatment response status. Significant moderators of response to CBT + medication (combined) treatment were number of comorbid disorders and abuse history; hopelessness was marginally significant. The CBT/combined treatment superiority over medication alone was more evident among youths who had more comorbid disorders (particularly attention-deficit/hyperactivity disorder and anxiety disorders), no abuse history, and lower hopelessness. Further analyses revealed a stronger effect of combined CBT + medication treatment among youths who were older and white and had no nonsuicidal self-injurious behavior and longer prestudy pharmacotherapy. CONCLUSIONS: Combined treatment with CBT and antidepressant medication may be more advantageous for adolescents whose depression is comorbid with other disorders. Given the additional costs of adding CBT to medication, consideration of moderators in clinical decision making can contribute to a more personalized and effective approach to treatment.
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