|Is cognitive behavioural therapy an effective complement to antidepressants in adolescents? A meta-analysis
|Calati R, Pedrini L, Alighieri S, Alvarez MI, Desideri L, Durante D, Favero F, Iero L, Magnani G, Pericoli V, Polmonari A, Raggini R, Raimondi E, Riboni V, Scaduto MC, Serretti A, De Girolamo G
This review found that combined antidepressants and cognitive-behavioural therapy appeared to be more effective, in improving global functioning and general symptoms, than antidepressants alone, for adolescent patients with major depressive and anxiety disorders. The authors' conclusions are likely to be reliable.
To evaluate the effectiveness of combined antidepressant and cognitive-behavioural therapy, compared with antidepressants alone, for adolescents with major depression, anxiety disorder, or both.
PubMed, PsycINFO, and The Cochrane Library were searched to April 2011 for relevant studies in English; some search terms were reported. The reference lists of the retrieved articles and reviews were checked for additional studies.
Studies that compared combined cognitive-behavioural therapy and antidepressant medication versus antidepressants alone, for adolescents with clinically diagnosed psychiatric disorders, were eligible for inclusion. Eligible studies had to report the results at 12 weeks of follow-up on at least one of the scales most commonly used to assess symptom severity or clinical improvement in the patient population. Studies that had overlapping populations or did not report their results using validated scales were excluded.
Most of the included studies were of patients diagnosed with major depressive disorder; some patients had anxiety disorders. The percentage of patients who were male ranged from 22.1 to 50.4, and their age ranged from seven to 18 years. Antidepressant treatments included fluoxetine, paroxetine, selective serotonin re-uptake inhibitors, citalopram, venlafaxine, and sertraline. Cognitive-behavioural therapy consisted of nine to 19 sessions, lasting 50 to 90 minutes. The primary outcome was the score on the Children's Global Assessment Scale. Secondary outcomes were the Clinical Global Impressions Improvement scale and the Children's Depression Rating Scale.
Fifteen reviewers independently screened the studies for inclusion.
Assessment of study quality
Methodological quality was assessed, using the Jadad scale, for randomisation, blinding and description of withdrawals and dropouts. The authors did not state how many reviewers performed this assessment.
Data were extracted to calculate mean differences for continuous outcomes and odds ratios for dichotomous outcomes, with 95% confidence intervals, for the summary estimates of the differences in scores between groups on the assessment scales. The results were grouped according to the assessment scale used to measure disease and symptom severity. The authors did not state how many reviewers extracted the data.
Methods of synthesis
Weighted mean differences, pooled odds ratios, and 95% confidence intervals for the summary estimates, were calculated using a random-effects model. Statistical heterogeneity across the studies was assessed using Χ² and Ι². Sensitivity analyses were conducted to examine the effects of different diagnoses. The potential for publication bias was evaluated by visual appraisal of funnel plots and using the Egger test.
Results of the review
Five studies (n=1,621) were included in the review. Sample sizes ranged from 152 to 488 patients. Three studies attained Jadad scores of five points, indicating high quality. One study attained a Jadad score of two points and the last study was not assessed because it was a pragmatic randomised superiority trial.
Statistically significant benefits were observed with combined therapy, compared with antidepressants alone, in the scores on the Children's Global Assessment Scale (WMD -2.79, 95% CI -4.10 to -1.48; Ι²=0; five studies), and on the Clinical Global impressions Improvement scale (OR 0.59, 95% CI 0.36 to 0.98; Ι²=73%; four studies). The results for the Children's Depression Rating Scale were not statistically significant (WMD 0.94, 95% CI -1.56 to 3.43; three studies).
After the removal of one study of patients with anxiety disorders, a significant benefit on the Children's Global Assessment Scale continued to be observed. Benefit remained on the Clinical Global Impressions Improvement Scale, but it was no longer statistically significant.
The Egger tests suggested publication bias for the Children's Depression Rating Scale, but not for other scales.
Combined antidepressants and cognitive-behavioural therapy appeared to be more effective than antidepressants alone for patients with major depressive and anxiety disorders, producing improvements in global functioning and general symptoms.
The review addressed a clear question and the criteria for the inclusion of studies were defined and were reproducible. Appropriate databases were searched for relevant studies, but the review was restricted to studies published in English. The authors used validated measures to assess the potential for publication bias, and some evidence of this was identified for one of the outcomes. Steps were taken to minimise errors and bias in the selection of studies, but were not reported for the assessment of methodological quality and for data extraction. The results from the studies were synthesised in appropriate meta-analyses, and appropriate sensitivity analyses were conducted to examine the impact of some clinical factors on the results.
The authors' cautious conclusions are likely to be reliable.
Implications of the review for practice and research
Practice: The authors did not state any implications for practice.
Research: The authors stated that future studies should focus on different psychotherapeutic treatments, such as interpersonal psychotherapy.
Calati R, Pedrini L, Alighieri S, Alvarez MI, Desideri L, Durante D, Favero F, Iero L, Magnani G, Pericoli V, Polmonari A, Raggini R, Raimondi E, Riboni V, Scaduto MC, Serretti A, De Girolamo G. Is cognitive behavioural therapy an effective complement to antidepressants in adolescents? A meta-analysis. Acta Neuropsychiatrica 2011; 23(6): 263-271
Subject indexing assigned by CRD
Adolescent; Antidepressive Agents; Cognitive Therapy; Combined Modality Therapy; Humans
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.