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Cost-Effectiveness and Clinical-Effectiveness of Combined Therapy versus Medication Only in Adolescents with Resistant Major Depression

Depression in adolescents is a significant issue. Research has focused on treating major depression in adolescents with psychotherapy (CBT), medication (selective serotonin reuptake inhibitors, SSRIs), or a combination of both.  As treatment is not inexpensive, researchers have been looking into the cost-effectiveness of different treatment models.  Previous research has shown that CBT treatment and medication is the most expensive treatment model in the short run.  The least expensive model is medication only.  However, some adolescents do not respond to medication alone.

A recent randomized trial was published in the Archives of General Psychiatry. 334 adolescents with SSRI-resistant depression, were randomly assigned to one of two groups for 24 weeks: a change in medication or a change in medication plus CBT.   Throughout the treatment they were assessed at 6, 12, and 24 weeks for symptom changes, depression-free days, and depression-improvement days.  The researchers also examined the clinical outcomes within certain subgroups of participants: patients with histories of abuse, comorbid disorders, and levels of hopelessness.

The study found that using a combined treatment of CBT and medication led to more depression-free and depression-improved days.  It worked best for patients without a history of abuse or with low levels of helplessness.  While the combined treatment was more costly in the short-run, it may be most cost-efficient in the long run.  This study demonstrates the benefits of further examining the use of combined treatment in adolescents with SSRI-Resistant Depression.

Lynch, F. L., Dickerson, J. F., Clarke, G., Vitiello, B., Porta, G., Wagner, K. D., … Brent, D.  (2011). Incremental cost-effectiveness of combined therapy vs medication only for youth with selective serotonin reuptake inhibitor – resistant depression.  Arch Gen Psychiatry, 68 (3), 253-262.

Child and adolescent Anxiety: Most effective treatments combine CBT and pharmacotherapy

Authors of a new study in the New England Journal of Medicine reported that anxiety disorders in children and adolescents negatively affect school performance, family relations, and social functioning. Despite a high prevalence (10-20%), they are largely “underrecognized and undertreated.” The anxiety disorders evaluated in this study included separation and generalized anxiety and social phobia. Cognitive behavioral therapy (CBT) and selective serotonin-reuptake inhibitors (SSRIs) have already been demonstrated to be effective in this group but a randomized controlled study of the two in combination has been lacking.

To address this, children ranging in age from 7 to 17 received CBT, an SSRI (sertraline/Zoloft) or placebo, or a combination of the CBT and sertraline. The CBT involved fourteen 60-minute sessions and included anxiety-management skills and behavioral exposure to anxiety-provoking situations.

The authors found that improvement was greatest for the combination therapy (80.7%), followed by cognitive behavioral therapy alone (59.7%), then sertraline alone (54.9%), and all therapies were superior to placebo (23.7%). An interesting additional finding was that “there was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline.”

The authors concluded that “all three of the treatment options may be recommended, taking into consideration the family’s treatment preferences, treatment availability, cost, and time burden.”

Study authors: J. T. Walkup, A.M. Albano, J. Piacentini, B. Birmaher, et al.

Adolescents with SSRI-resistant Depression show improved response to treatment that includes CBT

A new study in JAMA reported that approximately 60% of depressed adolescents respond adequately to initial treatments with a selective serotonin reuptake inhibitor (SSRI), but there is a lack of information about subsequent treatment strategies. Four treatment strategies were employed in this study including medication-switching alone (to a different SSRI or to venlafaxine) and medication-switching plus cognitive behavioral therapy (CBT). CBT in this study emphasized cognitive restructuring, behavioral activation, emotion regulation, social skills, and problem solving. Additionally, parent-child sessions emphasized decreasing criticism and improving support, family communication, and problem solving. The authors found that CBT plus a switch to either medication regimen showed a higher response rate than a medication-switch alone (and that there was no difference in response rate between venlafaxine and a second SSRI).

Study authors: D. Brent, G. Emslie, G. Clarke, K. D. Wagner, J. R. Asarnow, M. Keller, et al.

Research Results: CBT plus Medication is Effective for Gambling

An initial randomized, controlled trial shows that Cognitive Behavior Therapy (CBT) plus Selective Serotonin Reuptake Inhibitor (SSRI) can improve pathological gambling. For this study, 34 patients were randomly assigned to either medication alone, CBT plus medication, or CBT plus placebo for 16 weeks. Patients who received CBT plus medication improved the fastest. Further study is needed to assess long-term outcomes and other variables. Results were presented at the November, 2006 Canadian Psychiatric Association’s annual meeting.