; Skip to Main Content
Skip Nav Destination

Defining "Treatment as Usual" for Adolescent Depression :

April 27, 2016

A study released this month in Pediatrics, “Cognitive Behavioral Therapy in Primary Care for Youth Declining Antidepressants: A Randomized Trial” by Dr. Gregory Clarke et al. (peds.2015-1851) examines the...


A study released this month in Pediatrics, “Cognitive Behavioral Therapy in Primary Care for Youth Declining Antidepressants: A Randomized Trial” by Dr. Gregory Clarke et al. (peds.2015-1851) examines the effectiveness of cognitive behavioral therapy (CBT) among adolescents who decline to take antidepressants for major depression.


This randomized controlled trial is an important “real world” look at a question with which adolescents, parents and pediatricians may struggle: how to help a depressed teen who does not want medication or whose parents may be opposed to use of medications for mental health problems. The trial included adolescents with a formal (DSM-IV-TR) diagnosis of major depression made using a validated measure (the Children’s Schedule for Affective Disorders and Schizophrenia), who also either recently declined or prematurely (<30 days) discontinued antidepressants. Participants were randomized to “treatment as usual” with CBT as compared to “treatment as usual” without CBT (control group).

You might wonder, as I did, what exactly is “treatment as usual” for adolescent depression? The authors list the following: outpatient mental health care, inpatient mental health or alcohol/drug treatment, school counseling, juvenile court or probation, mental health medications other than antidepressants (used by 11.3% of the control group versus 14.3% of the CBT group in the first year) and, actually, antidepressants (7.6% of the control group versus 9.4% of the CBT group in the first year). I also wondered whether the CBT was delivered by “primary care” providers, but CBT in the study was delivered by trained therapists with at least a Master’s degree and several years of experience with CBT. 

The intervention consisted of 2 – 4 part modules with choice to continue with up to 6 more contacts. The authors report a positive result: the CBT group as compared to the control group did indeed have a better outcome in the first year of the study – please read the paper to understand the very interesting nuances of their findings.

However, this positive report led me to wonder if any trials testing other psychological therapies such as psychotherapy have been performed, so that adolescents (and their parents) who decline antidepressants could have additional options. In fact, meta-analyses have looked at this question, though in populations not limited to adolescents.

 A systematic review comparing interpersonal psychotherapy and cognitive therapy for major depression included 7 trials and 741 participants, and found no significant difference between these interventions, with comparable results at cessation of treatment on the Beck Depression Inventory. However, all trials had high risk of bias leading the authors to encourage further study (Jakobsen JC et al Psychol Med 2012;42:1343). 

A Cochrane review focusing on children with depression and comparing treatment with psychological therapies and antidepressant medication alone and in combination identified 11 randomized controlled trials with over 1,307 participants (Cox GR Cochrane Database Syst Rev 2014), yet due to study design challenges ultimately concluded, “…On the basis of the available evidence, the effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established….” with a call for future appropriately powered studies. 

This seems a very important and fruitful area for future study. If indeed 2.1% of children ages 3-17 years are depressed (cdc.gov/childrensmentalhealth/), and if longer depressive episodes predict future recurrence of depression as Dr. Clarke and colleagues note, then we all should advocate for more excellent studies on effective treatment alternatives for depression in youth beyond antidepressant medications alone.

Close Modal

or Create an Account

Close Modal
Close Modal