Dynamic interpersonal therapy for moderate to severe depression: a pilot randomized controlled and feasibility trial.

BACKGROUND: Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated. METHODS: 147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion. RESULTS: The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes. CONCLUSIONS: DIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs.

Trajectories of depression symptom change during and following treatment in adolescents with unipolar major depression.

OBJECTIVE: To classify a cohort of depressed adolescents recruited to the UK IMPACT trial, according to trajectories of symptom change. We examined for predictors and compared the data-driven categories of patients with a priori operational definitions of treatment response. METHOD: Secondary data analysis using growth mixture modelling (GMM). Missing data were imputed. Trajectories of self-reported depressive symptoms were plotted using scores taken at six nominal time points over 86 weeks from randomisation in all 465 patients. RESULTS: A piecewise GMM categorised patients into two classes with initially similar and subsequently distinct trajectories. Both groups had a significant decline in depressive symptoms over the first 18 weeks. Eighty-four per cent (84.1%, n = 391) of patients were classed as 'continued-improvers' with symptoms reducing over the duration of the study. A further class of 15.9% (n = 74) of patients were termed 'halted-improvers' with higher baseline depression scores, faster early recovery but no further improvement after 18 weeks. Presence of baseline comorbidity somewhat increased membership to the halted-improvers class (OR = 1.40, CI: 1.00-1.96). By end of study, compared with classes, a clinical remission cut-off score (≤27) and a symptom reduction score (≥50%) indexing treatment response misclassified 15% and 31% of cases, respectively. CONCLUSIONS: A fast reduction in depressive symptoms in the first few weeks of treatment may not indicate a good prognosis. Halted improvement is only seen after 18 weeks of treatment. Longitudinal modelling may improve the precision of revealing differential responses to treatment. Improvement in depressive symptoms may be somewhat better in the year after treatment than previously considered.

20/20 Hindsight: A 25-year programme at the Anna Freud Centre of efficacy and effectiveness research on child psychoanalytic psychotherapy.

OBJECTIVE: This paper describes the evolution of methods of enquiry-through 25 years of work, with Professor Peter Fonagy and many other colleagues-of research and theorizing about child and adolescent therapy outcomes. METHOD: The work has focused on measuring psychoanalytic outcomes, but with an increasing interest in discovering therapeutic elements across treatment modalities. RESULTS: Headline findings are described, with lessons from the ups and downs of developing (a) retrospective, follow-up, and prospective outcome studies, and (b) measures of child and family functioning. Issues of manualizing and measuring treatment process are discussed, together with the fruitfulness of mixed-method (quantitative and qualitative) process and outcome research with young people and families. CONCLUSIONS: Using the dilemmas, experiences, and findings ||of our group as examples, growing points and well as growing pains for the field are suggested.

"Did I bring it on myself?" An exploratory study of the beliefs that adolescents referred to mental health services have about the causes of their depression.

The causal beliefs which adults have regarding their mental health difficulties have been linked to help-seeking behaviour, treatment preferences, and the outcome of therapy; yet, the topic remains a relatively unexplored one in the adolescent literature. This exploratory study aims to explore the causal beliefs regarding depression among a sample of clinically referred adolescents. Seventy seven adolescents, aged between 11 and 17, all diagnosed with moderate to severe depression, were interviewed using a semi-structured interview schedule, at the beginning of their participation in a randomised controlled trial. Data were analysed qualitatively using framework analysis. The study identified three themes related to causal beliefs: (1) bewilderment about why they were depressed; (2) depression as a result of rejection, victimisation, and stress; and (3) something inside is to blame. Although some adolescents struggled to identify the causes of their depression, many identified stressful life experiences as the cause of their current depression. They also tended to emphasise their own negative ways of interpreting those events, and some believed that their depression was caused by something inside them. Adolescents' causal beliefs are likely to have implications for the way they seek help and engage in treatment, making it important to understand how adolescents understand their difficulties.

The Journey Through and Beyond Mental Health Services in the United Kingdom: A Typology of Parents' Ways of Managing the Crisis of Their Teenage Child's Depression.

OBJECTIVE: Depression is a common mental illness experienced by young people. Yet we know little about how their parents manage their symptoms at home, and how parents may experience their treatment at child and adolescent mental health services (CAMHS). Thus, the aim of our study was to create a typology of parents' experiences over a 2-year period, beginning with their teenage child's referral to CAMHS in the United Kingdom. METHOD: A total of 85 semistructured interviews were conducted with one or both parents of 28 adolescents at 3 time points, and qualitatively analyzed using ideal type analysis. RESULTS: Three distinct types or patterns of parental experience were identified: the learning curve parents, the finding my own solutions parents, the stuck parents. CONCLUSION: These patterns of parental experience could perhaps provide a basis for clinicians working in CAMHS to reflect on the families that they see and to adapt their ways of working accordingly to best support these families.

Clinical characteristics associated with the prescribing of SSRI medication in adolescents with major unipolar depression.

Unipolar major depressions (MD) emerge markedly during adolescence. National Institute for Health and Care Excellence (NICE) UK recommends psychological therapies, with accompanying selective serotonin reuptake inhibitors (SSRIs) prescribed in severe cases only. Here, we seek to determine the extent and rationale of SSRI prescribing in adolescent MD before entering a randomised clinical trial. SSRI prescribing, together with their clinical characteristics was determined in 465 adolescent patients with MD prior to receiving a standardised psychological therapy as part of the Improving mood with psychoanalytic and cognitive therapies (IMPACT) clinical trial. Overall, 88 (19 %) had been prescribed antidepressants prior to psychological treatment. The clinical correlates varied by gender: respectively, depression severity in boys and self-harming behaviours in girls. Prescribing also differed between clinical research centres. Medical practitioners consider severity of depression in boys as an indicator for antidepressant prescribing. Self-injury in girls appears to be utilised as a prescribing aid which is inconsistent with past and current revised UK NICE guidelines.

"Just like talking to someone about like shit in your life and stuff, and they help you": Hopes and expectations for therapy among depressed adolescents.

OBJECTIVE: To explore hopes and expectations for therapy among a clinical population of depressed adolescents. METHOD: As part of a randomized clinical trial, 77 adolescents aged 11-17, with moderate to severe depression, were interviewed using a semi-structured interview schedule. The interviews were analysed qualitatively using framework analysis. RESULTS: The findings are reported around five themes: "the difficulty of imagining what will happen in therapy," "the 'talking cure,'" "the therapist as doctor," "therapy as a relationship," and "regaining the old self or developing new capacities." CONCLUSIONS: Differing expectations are likely to have implications for the way young people engage with treatment, and failure to identify these expectations may lead to a risk of treatment breakdown.

Beyond a diagnosis: The experience of depression among clinically-referred adolescents.

Policy-makers have identified an urgent need to improve our ability to detect and diagnose depression in adolescents. This study aims to explore the lived experience of depression in clinically referred adolescents. 77 adolescents, aged between 11 and 17 with moderate to severe depression, were interviewed as part of a randomised controlled trial, using the Expectations of Therapy Interview. Data were analysed qualitatively using framework analysis, with a focus on how the adolescents spoke about their depression. The study identified five themes: 1) Misery, despair and tears; 2) Anger and violence towards self and others; 3) A bleak view of everything; 4) Isolation and cutting off from the world; and 5) The impact on education. Researchers and policy-makers need to develop an understanding of depression grounded in the experiences of adolescents to improve detection and diagnosis of depression.

Magnetic resonance imaging of a randomized controlled trial investigating predictors of recovery following psychological treatment in adolescents with moderate to severe unipolar depression: study protocol for Magnetic Resonance-Improving Mood with Psychoanalytic and Cognitive Therapies (MR-IMPACT).

BACKGROUND: Major depressive disorders (MDD) are a debilitating and pervasive group of mental illnesses afflicting many millions of people resulting in the loss of 110 million working days and more than 2,500 suicides per annum. Adolescent MDD patients attending NHS clinics show high rates of recurrence into adult life. A meta-analysis of recent research shows that psychological treatments are not as efficacious as previously thought. Modest treatment outcomes of approximately 65% of cases responding suggest that aetiological and clinical heterogeneity may hamper the better use of existing therapies and discovery of more effective treatments. Information with respect to optimal treatment choice for individuals is lacking, with no validated biomarkers to aid therapeutic decision-making. METHODS/DESIGN: Magnetic resonance-Improving Mood with Psychoanalytic and Cognitive Therapies, the MR-IMPACT study, plans to identify brain regions implicated in the pathophysiology of depressions and examine whether there are specific behavioural or neural markers predicting remission and/or subsequent relapse in a subsample of depressed adolescents recruited to the IMPACT randomised controlled trial (Registration # ISRCTN83033550). DISCUSSION: MR-IMPACT is an investigative biomarker component of the IMPACT pragmatic effectiveness trial. The aim of this investigation is to identify neural markers and regional indicators of the pathophysiology of and treatment response for MDD in adolescents. We anticipate that these data may enable more targeted treatment delivery by identifying those patients who may be optimal candidates for therapeutic response. TRIAL REGISTRATION: Adjunctive study to IMPACT trial (Current Controlled Trials: ISRCTN83033550).

Innovations in Practice: Adolescent Mentalization-Based Integrative Therapy (AMBIT) - a new integrated approach to working with the most hard to reach adolescents with severe complex mental health needs.

BACKGROUND: 'Hard to reach' young people are associated by virtue of their serious, multiple, and complex needs, the difficulty of delivering effective help to them, and their poor long-term outcomes. There is a lack of published evidence relating to the effectiveness of interventions directed at this group. METHOD: We review these concerns and the options available to service commissioners and clinicians seeking, if not an evidence-based approach then at least an evidence-oriented one. A mentalization-based multimodal intervention (AMBIT) is briefly described, proposing a new kind of specialist practitioner and taking a radically different approach to treatment manualization. RESULTS: A brief description is given of the different settings in which AMBIT is currently being developed, deployed, and evaluated, and of lessons learned. CONCLUSIONS: AMBIT offers promise as an evolving 'open source' framework supporting development of evidence-based local practice in chaotic complex settings.

Development and criterion validity of a computerized text analysis measure of reflective functioning.

The Reflective Functioning scale (RF) is a narrative-based assessment of the capacity to coherently conceptualize one's own and others' subjective motivations, emotions, beliefs, and desires. We report the preliminary results of an effort to develop a computerized text analysis version (CRF) of the RF assessment system. A sample of 113 clinical and non-clinical Adult Attachment Interviews (AAI) were utilized to develop the CRF measure. Using the Marker Approach (Mergenthaler & Bucci, 1999), 54 linguistic markers of high RF language were identified. The associations between CRF and RF were significant in both a clinical sample of patients diagnosed with Borderline Personality Disorder (BPD) (Spearman rho=.57, p<.0001) and a non-clinical sample of adults (Spearman rho=.57, p=.002). These results suggest that a CRF rating scale is feasible, has preliminary criterion validity, and, therefore, has potential to facilitate the efficient assessment of RF.

Parents' understanding and motivation to take part in a randomized controlled trial in the field of adolescent mental health: a qualitative study.

BACKGROUND: Little is known about why parents agree to take part in randomized controlled trials for adolescent mental health. This study aimed to investigate parents' perspectives on participating in a trial for psychological treatment of depression. The study explored parents' motivations, understanding of the trial and perspectives on the acceptability of the trial. METHODS: Sixty-five parents took part in this qualitative study. Their adolescent children had been randomly allocated to one of three active psychological treatments for depression as part of the IMPACT trial and were interviewed about their experiences of participating in the study. Semi-structured interviews were analysed using framework analysis. RESULTS: For seven of the sixty-five parents, their experience of taking part in the trial was not covered in their interview so they were excluded from the analysis. The analysis was therefore based on the data from the parents of 58 adolescents taking part in the trial. The most commonly cited motivation for taking part in the study reported by parents was a desire to help others going through similar difficulties. Parents generally reported finding trial participation acceptable, although there were aspects that some reported finding less acceptable, including randomization and the burden of research assessments. Others spoke positively about the experience of trial participation and found it enjoyable or even therapeutic. Importantly, some did not appear to have a good understanding of the trial design, including randomization and treatment allocation. CONCLUSIONS: This study indicates that trial participation can be a positive experience for parents, yet it raises concerns about how trialists can ensure that consent is fully informed, given that some parents appeared to have a poor understanding of the trial. Future studies should seek to explore how communication with trial participants can be improved, to ensure that trial participation is fully informed. Patient and public involvement will be crucial in ensuring this communication is accessible to stakeholders. TRIAL REGISTRATION: ISRCTN registry ISRCTN83033550 . Registered on 15 October 2009.

Childhood sexual abuse and attachment insecurity: Associations with child psychological difficulties.

Childhood sexual abuse (CSA) is considered an important public health concern that can derail the developmental course of children. Given that children rely upon their attachment figures when they experience upsetting events, attachment organization may play a critical role in predicting victims' adaptation to CSA. To date, no studies have delineated the unique and interactive contributions of these two risk factors in the prediction of psychopathology. The aims of this study were to examine attachment in CSA victims and a comparison group and to assess the contributions of each risk factor to child psychological difficulties. Participants included 111 children aged 7-13, of whom 43 were CSA victims. Children completed an attachment interview and reported on their depressive symptoms. Their mothers reported on children's externalizing symptoms, internalizing symptoms, dissociation, and sexualized behavior. Our key findings showed that child victims of CSA were more likely to be classified as having insecure and disorganized attachment. Further, insecure attachment was the primary factor associated with higher self-reported depressive symptoms in all children and that CSA was associated with more parent-reported child externalizing problems, sexualizing problems, and dissociation. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

'Interaction structures' between depressed adolescents and their therapists in short-term psychoanalytic psychotherapy and cognitive behavioural therapy.

OBJECTIVE: Identify the core 'interaction structures' between therapists and depressed adolescents within and across two common forms of psychotherapy. METHOD: A total of 70 audio-recorded psychotherapy sessions representing short-term psychoanalytic psychotherapy (STPP) and cognitive behavioural therapy (CBT) with youth aged 12-18 years old were coded with the Adolescent Psychotherapy Q-set (APQ), a newly developed instrument. Data included different therapist-patient dyads and stages in treatment and were analysed with cluster analysis. RESULTS: Three distinct interaction structures between therapists and depressed adolescents: two influenced by the therapists' techniques and one more influenced by the young people's attitude to therapy. CONCLUSION: When there is a collaborative working relationship between therapists and depressed young people, the therapy process is influenced by the therapists' techniques; while when there is a poor working relationship, the techniques used by therapists of different theoretical orientation become more similar with the aim of engaging the young person in the process.

'I Just Stopped Going': A Mixed Methods Investigation Into Types of Therapy Dropout in Adolescents With Depression.

What does it mean to 'drop out' of therapy? Many definitions of 'dropout' have been proposed, but the most widely accepted is the client ending treatment without agreement of their therapist. However, this is in some ways an external criterion that does not take into account the client's experience of therapy, or reasons for ending it prematurely. This study aimed to identify whether there were more meaningful categories of dropout than the existing dropout definition, and to test whether this refined categorization of dropout was associated with clinical outcomes. This mixed-methods study used a subset of data from the IMPACT trial, which investigated psychological therapies for adolescent depression. Adolescents were randomly allocated to a treatment arm (Brief Psychosocial Intervention; Cognitive-Behavioral Therapy; Short-Term Psychoanalytic Psychotherapy). The sample for this study comprised 99 adolescents, aged 11-17 years. Thirty-two were classified as having dropped out of treatment and participated in post-therapy qualitative interviews about their experiences of therapy. For 26 dropout cases, the therapist was also interviewed. Sixty-seven cases classified as having completed treatment were included to compare their outcomes to dropout cases. Interview data for dropout cases were analyzed using ideal type analysis. Three types of dropout were constructed: 'dissatisfied' dropout, 'got-what-they-needed' dropout, and 'troubled' dropout. 'Dissatisfied' dropouts reported stopping therapy because they did not find it helpful. 'Got-what-they-needed' dropouts reported stopping therapy because they felt they had benefitted from therapy. 'Troubled' dropouts reported stopping therapy because of a lack of stability in their lives. The findings indicate the importance of including the perspective of clients in definitions of drop out, as otherwise there is a risk that the heterogeneity of 'dropout' cases may mask more meaningful distinctions. Clinicians should be aware of the range of issues experienced by adolescents in treatment that lead to disengagement. Our typology of dropout may provide a framework for clinical decision-making in managing different types of disengagement from treatment.

Maternal and Child Sexual Abuse History: An Intergenerational Exploration of Children's Adjustment and Maternal Trauma-Reflective Functioning.

Objective: The aim of the current study was to investigate associations, unique and interactive, between mothers' and children's histories of childhood sexual abuse (CSA) and children's psychiatric outcomes using an intergenerational perspective. Further, we were particularly interested in examining whether maternal reflective functioning about their own trauma (T-RF) was associated with a lower likelihood of children's abuse exposure (among children of CSA-exposed mothers). Methods: One hundred and eleven children (M age = 9.53 years; 43 sexual abuse victims) and their mothers (M age = 37.99; 63 sexual abuse victims) participated in this study. Mothers completed the Parent Development Interview (PDI), which yielded assessments of RF regarding their own experiences of abuse, and also reported on their children's internalizing and externalizing symptoms. Results: Children of CSA-exposed mothers were more likely to have experienced CSA. A key result was that among CSA-exposed mothers, higher maternal T-RF regarding their own abuse was associated with lower likelihood of child CSA-exposure. Mothers' and children's CSA histories predicted children's internalizing and externalizing symptoms, such that CSA exposure for mother or child was associated with greater symptomatology in children. Conclusion: The findings show that the presence of either maternal or child CSA is associated with more child psychological difficulties. Importantly in terms of identifying potential protective factors, maternal T-RF is associated with lower likelihood of CSA exposure in children of CSA-exposed mothers. We discuss these findings in the context of the need for treatments focusing on increasing T-RF in mothers and children in the context of abuse to facilitate adaptation and reduce the intergenerational risk.

The Child Attachment Interview: a psychometric study of reliability and discriminant validity.

While well-established attachment measures have been developed for infancy, early childhood, and adulthood, a "measurement gap" has been identified in middle childhood, where behavioral or representational measures are not yet sufficiently robust. This article documents the development of a new measure--the Child Attachment Interview (CAI)--which seeks to bridge this gap. The CAI is a semistructured interview, in which children are invited to describe their relationships with their primary caregivers. The coding system is informed by the Adult Attachment Interview and the Strange Situation Procedure, and produces 4 attachment categories along with a continuous measure of attachment security based on ratings of attachment-related dimensions. The main psychometric properties are presented, including interrater reliability, test-retest reliability, and concurrent and discriminant validities, both for normally developing children and for those referred for mental health treatment. The CAI correlates as expected with other attachment measures and predicts independently collected ratings of social functioning. The findings suggest that the CAI is a reliable, valid, and promising measure of child-parent attachment in middle childhood. Directions for improvements to the coding system are discussed.

The rooting of the mind in the body: new links between attachment theory and psychoanalytic thought.

The relationship between psychoanalysis and attachment theory is complex indeed. A brief review of the psychoanalytic literature as it concerns attachment theory and research, and of the attachment literature as it pertains to psychoanalytic ideas, demonstrates an increasing interest in attachment theory within psychoanalysis. Some of the difficulties that attachment theory faces in relation to psychoanalytic ideas are traced to its links to the now dated cognitive science of the 1960s and 1970s. Today, however, a second-generation cognitive neuroscience seeks neurobiologically plausible accounts in which links with brain and body are seen as shaping mind and consciousness, which increasingly are seen as "embodied", as emerging from or serving the needs of a physical being located in a specific time, place, and social context. This idea has also been at the core of much psychoanalytic thinking, which has historically affirmed the rootedness of symbolic thought in sensory, emotional, and enacted experience with objects. Now neurobiological advances supporting the concept of embodied cognition offer an opportunity to forge powerful links between the hitherto separate domains of attachment theory and psychoanalysis. Speculations about the nature of language are presented that emphasize the origin of internal working models (and of representations in general) in early sensorimotor and emotional experiences with a caregiver. It is argued that language and symbolic thought may be phylogenetically and ontogenetically embodied, built on a foundation of gestures and actions, and are thus profoundly influenced by the experience of early physical interaction with the primary object. Finally, the clinical and research implications of these ideas are discussed.

Playing with reality: IV. A theory of external reality rooted in intersubjectivity.

The authors explore the interpersonal aspects of the early development of an experience of external reality and the roots of this experience in primary intersubjectivity. They suggest some implications that this has for psychoanalytic work with the patient's experience of external reality. They argue that the external world is not an independently existing 'given', for the infant to discover, as is sometimes implicitly assumed. Infants acquire knowledge about the world not just through their own explorations of it but by using other minds as teachers. The experience of external reality is invariably shaped through subjectivities. The authors argue that at first the infant assumes that his knowledge is knowledge held by all, that what he knows is known by others and that what is known by others is accessible to him. Only slowly does the uniqueness of his own perspective differentiate so that a sense of mental self can develop. In clinical work we frequently observe the undoing of this process of differentiation, and understanding the underlying mechanisms can be helpful in managing the transference and countertransference consequences when the process has been derailed.

Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial.

BACKGROUND: Psychological treatments for adolescents with unipolar major depressive disorder are associated with diagnostic remission within 28 weeks in 65-70% of patients. We aimed to assess the medium-term effects and costs of psychological therapies on maintenance of reduced depression symptoms 12 months after treatment. METHODS: We did this multicentre, pragmatic, observer-blind, randomised controlled superiority trial (IMPACT) at 15 National Health Service child and adolescent mental health service (CAMHS) clinics in three regions in England. Adolescent patients (aged 11-17 years) with a diagnosis of DSM IV major depressive disorder were randomly assigned (1:1:1), via a web-based randomisation service, to receive cognitive behavioural therapy (CBT) or short-term psychoanalytical therapy versus a reference brief psychological intervention. Randomisation was stochastically minimised by age, sex, self-reported depression sum score, and region. Patients and clinicians were aware of group allocation, but allocation was concealed from outcome assessors. Patients were followed up and reassessed at weeks 6, 12, 36, 52, and 86 post-randomisation. The primary outcome was self-reported depression symptoms at weeks 36, 52, and 86, as measured with the self-reported Mood and Feelings Questionnaire (MFQ). Because our aim was to compare the two psychological therapies with the brief psychosocial intervention, we first established whether CBT was inferior to short-term psychoanalytical psychotherapy for the same outcome. Primary analysis was by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN83033550. FINDINGS: Between June 29, 2010, and Jan 17, 2013, we randomly assigned 470 patients to receive the brief psychosocial intervention (n=158), CBT (n=155), or short-term psychoanalytical therapy (n=157); 465 patients comprised the intention-to-treat population. 392 (84%) patients had available data for primary analysis by the end of follow-up. Treatment fidelity and differentiation were established between the three interventions. The median number of treatment sessions differed significantly between patients in the brief psychosocial intervention group (n=6 [IQR 4-11]), CBT group (n=9 [5-14]), and short-term psychoanalytical therapy group (n=11 [5-23]; p<0·0001), but there was no difference between groups in the average duration of treatment (27·5 [SD 21·5], 24·9 [17·7], 27·9 [16·8] weeks, respectively; Kruskal-Wallis p=0·238). Self-reported depression symptoms did not differ significantly between patients given CBT and those given short-term psychoanalytical therapy at weeks 36 (treatment effect 0·179, 95% CI -3·731 to 4·088; p=0·929), 52 (0·307, -3·161 to 3·774; p=0·862), or 86 (0·578, -2·948 to 4·104; p=0·748). These two psychological treatments had no superiority effect compared with brief psychosocial intervention at weeks 36 (treatment effect -3·234, 95% CI -6·611 to 0·143; p=0·061), 52 (-2·806, -5·790 to 0·177; p=0·065), or 86 (-1·898, -4·922 to 1·126; p=0·219). Physical adverse events (self-reported breathing problems, sleep disturbances, drowsiness or tiredness, nausea, sweating, and being restless or overactive) did not differ between the groups. Total costs of the trial interventions did not differ significantly between treatment groups. INTERPRETATION: We found no evidence for the superiority of CBT or short-term psychoanalytical therapy compared with a brief psychosocial intervention in maintenance of reduced depression symptoms 12 months after treatment. Short-term psychoanalytical therapy was as effective as CBT and, together with brief psychosocial intervention, offers additional patient choice for psychological therapy, alongside CBT, for adolescents with moderate to severe depression who are attending routine specialist CAMHS clinics. FUNDING: National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, and the Department of Health.