title: Cognitive-behavioural therapy and short-term psychoanalytic psychotherapy versus brief psychosocial intervention in adolescents with unipolar major depression (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled trial.
abstract: 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 withDiagnostic and Statistical Manual of Mental Disorders-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;p= 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;p= 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 inHealth Technology Assessment; 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 toThe Lancet.
authors.affiliation: Department of Psychiatry, University of Cambridge, Cambridge, UK.
authors.forename: Ian M
authors.initials: IM
authors.lastname: Goodyer
authors.affiliation: Charlie Waller Institute, University of Reading, Reading, UK.
authors.forename: Shirley
authors.initials: S
authors.lastname: Reynolds
authors.affiliation: David Goldberg Centre, King's College London, London, UK.
authors.forename: Barbara
authors.initials: B
authors.lastname: Barrett
authors.affiliation: David Goldberg Centre, King's College London, London, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Byford
authors.affiliation: Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK.
authors.forename: Bernadka
authors.initials: B
authors.lastname: Dubicka
authors.affiliation: Child and Adolescent Psychiatry, University of Manchester, Manchester, UK.|School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Hill
authors.affiliation: Centre for Biostatistics, University of Manchester, Manchester, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Holland
authors.affiliation: Department of Psychiatry, University of Cambridge, Cambridge, UK.|Cambridge and Peterborough NHS Foundation Trust, Cambridge, UK.
authors.forename: Raphael
authors.initials: R
authors.lastname: Kelvin
authors.affiliation: Anna Freud National Centre for Children and Families, London, UK.|Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.
authors.forename: Nick
authors.initials: N
authors.lastname: Midgley
authors.affiliation: Centre for Biostatistics, University of Manchester, Manchester, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Roberts
authors.affiliation: Tavistock and Portman NHS Foundation Trust, London, UK.
authors.forename: Rob
authors.initials: R
authors.lastname: Senior
authors.affiliation: Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.
authors.forename: Mary
authors.initials: M
authors.lastname: Target
authors.affiliation: Department of Psychiatry, University of Cambridge, Cambridge, UK.
authors.forename: Barry
authors.initials: B
authors.lastname: Widmer
authors.affiliation: Department of Psychiatry, University of Cambridge, Cambridge, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Wilkinson
authors.affiliation: Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Fonagy
mesh_terms: D000293:Adolescent; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D015928:Cognitive Behavioral Therapy / Q000191:economics / Q000379:methods; D003362:Cost-Benefit Analysis; D003865:Major Depressive Disorder / Q000628:therapy; D011613:Psychotherapy / Q000191:economics / Q000379:methods; D016037:Single-Blind Method; D013222:State Medicine; D006113:United Kingdom