In Context: Lessons About Adolescent Unipolar Depression From the Improving Mood With Psychoanalytic and Cognitive Therapies Trial.

This paper summarizes the results of the Improving Mood with Psychoanalytic and Cognitive Therapies (IMPACT) study and its implications for psychological treatment of adolescents with moderate to severe unipolar major depression. IMPACT was a pragmatic, superiority, randomized controlled trial conducted in the United Kingdom, which compared the clinical and cost-effectiveness of short-term psychoanalytic therapy (STPP), cognitive-behavioral therapy (CBT), and a brief psychosocial intervention (BPI) in reducing depression symptoms in 465 adolescents with unipolar major depression, aged 11 to 17 years. Although this was a clinically heterogeneous group of adolescents, some symptoms (eg, sleep and concentration difficulties, irritability/anger) were common and disabling. The trial reported no significant difference among the 3 treatments in reducing depression symptoms. One year after treatment, 84% of participants showed improvement in depressive symptoms (<50% of baseline symptoms) and improved psychosocial functioning, achieving this through different symptom reduction trajectories. Although participants attended fewer treatment sessions than planned, the 3 treatments were delivered with fidelity to their respective models. Ending treatment without therapist agreement occurred in 37% of cases. This was not associated with outcomes by treatment group. Adolescents emphasized the importance of the therapeutic relationship in all 3 treatments. Results suggest that although most adolescents respond to time-limited, structured psychological therapy, subgroups of depressed adolescents are likely to need additional treatment or support. These include adolescents who live in complex circumstances and/or who believe that their needs are not met in therapy, some who stop treatment early, and the 16% to 18% of adolescents who do not respond to treatment. CLINICAL TRIAL REGISTRATION INFORMATION: Improving Mood and Preventing Relapse With Psychoanalytic Psychotherapy and Cognitive Behaviour Therapy; https://www.isrctn.com; ISRCTN83033550.

The experience of cognitive behavioural therapy in depressed adolescents who are fatigued.

OBJECTIVE: Fatigue is a common and debilitating symptom of major depressive disorder (MDD). Cognitive behavioural therapy (CBT) is a recommended psychological treatment for adolescents with moderate to severe depression. This study explored the experience of CBT in fatigued adolescents with MDD. DESIGN: A qualitative study was conducted using existing data from the qualitative arm of a large randomized control trial, the IMPACT study. METHODS: Data were obtained from semi-structured interviews conducted after therapy. Participants were 18 adolescents (aged 13-18 years) who reached the clinical threshold for fatigue on diagnostic assessment before starting treatment. The data were analysed using thematic framework analysis. RESULTS: Three themes and seven sub-themes were developed. Adolescents appeared to find taking part in initial sessions, engaging in ongoing sessions and completing homework challenging. Perceiving the therapist as genuine seemed to provide a sense of safety which enabled adolescents to open up in sessions. When the therapist was not perceived as genuine, adolescents appeared to find CBT less helpful. The structure of CBT appeared to enable treatment goals to be set, and facilitated an increase in meaningful activity. Ensuring that tasks were perceived as manageable and goals as achievable seemed important for participation. Cognitive restructuring appeared useful, although some adolescents tended to engage in distraction from thoughts as an alternative strategy. CONCLUSIONS: This study provides an initial insight into how fatigued adolescents with MDD experience CBT. Further research is required to establish whether the themes are pervasive and relatedly, how best to treat depression in fatigued adolescents receiving CBT. PRACTITIONER POINTS: Fatigued adolescents with depression found engaging in CBT sessions and therapeutic homework demanding. Establishing a collaborative therapeutic relationship, where the therapist was perceived as genuine, appeared helpful for participation. The structured approach to therapy, combined with flexibility, was experienced as helpful. Adolescents who perceived the pace of sessions to be manageable and therapeutic goals as achievable seemed to find CBT helpful overall. These findings provide insight into how fatigued adolescents with depression experience CBT and highlight the importance of being aware of fatigue and adapting therapy accordingly.