Goodyer Ian M, Reynolds Shirley, Barrett Barbara, Byford Sarah, Dubicka Bernadka, Hill Jonathan, Holland Fiona, Kelvin Raphael, Midgley Nick, Roberts Chris, Senior Rob, Target Mary, Widmer Barry, Wilkinson Paul, Fonagy Peter
Department of Psychiatry, University of Cambridge, Cambridge, UK.
Charlie Waller Institute, University of Reading, Reading, UK.
Health Technol Assess. 2017 Mar;21(12):1-94. doi: 10.3310/hta21120.
Although there are effective psychological treatments for unipolar major depression in adolescents, whether or not one or more of the available therapies maintain reduced depressive symptoms 1 year after the end of treatment is not known. This is a non-trivial issue because maintaining lowered depressive symptoms below a clinical threshold level reduces the risk for diagnostic relapse into the adult years.
To determine whether or not either of two specialist psychological treatments, cognitive-behavioural therapy (CBT) or short-term psychoanalytic psychotherapy (STPP), is more effective than a reference brief psychosocial intervention (BPI) in maintaining reduction of depression symptoms in the year after treatment.
Observer-blind, parallel-group, pragmatic superiority randomised controlled trial.
A total of 15 outpatient NHS clinics in the UK from East Anglia, north-west England and North London.
Adolescents aged 11-17 years with -Fourth Edition major depression including those with suicidality, depressive psychosis and conduct disorder. Patients were randomised using stochastic minimisation controlling for age, sex and self-reported depression sum score; 470 patients were randomised and 465 were included in the analyses.
In total, 154 adolescents received CBT, 156 received STPP and 155 received BPI. The trial lasted 86 weeks and study treatments were delivered in the first 36 weeks, with 52 weeks of follow-up.
Mean sum score on self-reported depressive symptoms (primary outcome) at final study assessment (nominally 86 weeks, at least 52 weeks after end of treatment). Secondary measures were change in mean sum scores on self-reported anxiety symptoms and researcher-rated Health of the Nation scales for children and adolescents measuring psychosocial function. Following baseline assessment, there were a further five planned follow-up reassessments at nominal time points of 6, 12, 52 and 86 weeks post randomisation.
There were non-inferiority effects of CBT compared with STPP [treatment effect by final follow-up = -0.578, 95% confidence interval (CI) -2.948 to 4.104; = 0.748]. There were no superiority effects for the two specialist treatments (CBT + STPP) compared with BPI (treatment effect by final follow-up = -1.898, 95% CI -4.922 to 1.126; = 0.219). At final assessment there was no significant difference in the mean depressive symptom score between treatment groups. There was an average 49-52% reduction in depression symptoms by the end of the study. There were no differences in total costs or quality-of-life scores between treatment groups and prescribing a selective serotonin reuptake inhibitor (SSRI) during treatment or follow-up did not differ between the therapy arms and, therefore, did not mediate the outcome.
The three psychological treatments differed markedly in theoretical and clinical approach and are associated with a similar degree of clinical improvement, cost-effectiveness and subsequent maintenance of lowered depressive symptoms. Both STPP and BPI offer an additional patient treatment choice, alongside CBT, for depressed adolescents attending specialist Child and Adolescent Mental Health Services. Further research should focus on psychological mechanisms that are associated with treatment response, the maintenance of positive effects, determinants of non-response and whether or not brief psychotherapies are of use in primary care and community settings.
Neither reason for SSRI prescribing or monitoring of medication compliance was controlled for over the course of the study, and the economic results were limited by missing data.
Current Controlled Trials ISRCTN83033550.
This project was funded by the National Institute for Heath Research Health Technology Assessment programme and will be published in full in ; Vol. 21, No. 12. See the National Institute for Heath Research Journals Library website for further project information. Funding was also provided by the Department of Health. The funders had no role in the study design, patient recruitment, data collection, analysis or writing of the study, any aspect pertinent to the study or the decision to submit to .
虽然有针对青少年单相重度抑郁症的有效心理治疗方法，但在治疗结束1年后，一种或多种现有疗法能否维持抑郁症状减轻尚不清楚。这是一个重要问题，因为将抑郁症状维持在临床阈值水平以下可降低成年后诊断复发的风险。
确定两种专业心理治疗方法，即认知行为疗法（CBT）或短期精神分析心理治疗（STPP），在治疗后一年维持抑郁症状减轻方面是否比参考性简短社会心理干预（BPI）更有效。
观察者盲法、平行组、实用性优势随机对照试验。
来自英国东安格利亚、英格兰西北部和北伦敦的15家国民保健服务门诊诊所。
年龄在11至17岁之间的青少年，患有第四版重度抑郁症，包括有自杀倾向、抑郁性精神病和品行障碍的青少年。患者通过随机化最小化方法进行随机分组，控制年龄、性别和自我报告的抑郁总分；470名患者被随机分组，465名患者纳入分析。
共有154名青少年接受CBT，156名接受STPP，155名接受BPI。试验持续86周，研究治疗在前36周进行，随后进行52周的随访。
最终研究评估时（名义上为86周，至少在治疗结束后52周）自我报告的抑郁症状平均总分（主要结局）。次要指标是自我报告的焦虑症状平均总分的变化以及研究人员评定的用于测量儿童和青少年心理社会功能的国家健康量表。在基线评估之后，在随机分组后的6、12、52和86周名义时间点还进行了另外五次计划好的随访重新评估。
与STPP相比，CBT有非劣效性效应[最终随访时的治疗效应=-0.578，95%置信区间（CI）-2.948至4.104；P=0.748]。与BPI相比，两种专业治疗方法（CBT+STPP）没有优势效应（最终随访时的治疗效应=-1.898，95%CI-4.922至1.126；P=0.219）。在最终评估时，各治疗组之间的平均抑郁症状评分没有显著差异。到研究结束时，抑郁症状平均减少了49%-52%。各治疗组之间的总成本或生活质量评分没有差异，并且在治疗或随访期间开具选择性血清素再摄取抑制剂（SSRI）在各治疗组之间没有差异，因此，没有介导结局。
这三种心理治疗方法在理论和临床方法上有显著差异，但在临床改善程度、成本效益以及随后维持抑郁症状减轻方面相似。对于就诊于专科儿童和青少年心理健康服务机构的抑郁青少年，STPP和BPI与CBT一样，为患者提供了额外的治疗选择。进一步的研究应关注与治疗反应、积极效应维持、无反应决定因素相关的心理机制，以及简短心理治疗在初级保健和社区环境中是否有用。
在研究过程中，未对开具SSRI的原因或药物依从性监测进行控制，经济结果因数据缺失而受限。
当前对照试验ISRCTN83033550。
本项目由英国国家卫生研究院卫生技术评估项目资助，将全文发表于《》；第21卷，第12期。有关更多项目信息，请参见英国国家卫生研究院期刊图书馆网站。卫生部也提供了资助。资助者在研究设计、患者招募、数据收集、分析、撰写研究报告、与研究相关的任何方面或提交发表的决定中均无任何作用。
