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Addition of CBT to antidepressants (compared to antidepressants alone) for adolescent depression

Children's Mental Health: Depression
  Literature review updated June 2018.

Cognitive behavioral therapy (CBT) for depression includes such elements as cognitive restructuring, scheduling pleasant experiences, emotion regulation, communication skills, and problem-solving. Studies included in this review evaluated the effect of adding CBT to treatment with antidepressants compared to treatment with antidepressants only. Some studies included programming for parents, but children were the focus of interventions. One study occurred in a group modality; all others were individual treatments. Most programs included a shorter acute phase lasting three to four months followed by a longer, less intensive phase; this review analyzes post-acute phase outcomes where possible. On average, participants attended three sessions per month. Participants met clinical criteria for moderate to severe major depressive disorder, dysthymic disorder, or unspecified depressive disorder. Comparison groups received medication management services without CBT. 
 
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META-ANALYSIS
CITATIONS

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the program impacts measured in the research literature (for example, impacts on crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases. See Estimating Program Effects Using Effect Sizes for additional information on how we estimate effect sizes.

The effect size may be adjusted from the unadjusted effect size estimated in the meta-analysis. Historically, WSIPP adjusted effect sizes to some programs based on the methodological characteristics of the study. For programs reviewed in 2024 or later, we do not make additional adjustments, and we use the unadjusted effect size whenever we run a benefit-cost analysis.

Research shows the magnitude of effects may change over time. For those effect sizes, we estimate outcome-based adjustments, which we apply between the first time ES is estimated and the second time ES is estimated. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured No. of effect sizes Treatment N Effect sizes (ES) and standard errors (SE) Unadjusted effect size (random effects model)
ES SE Age ES p-value
Anxiety disorder
Clinical diagnosis of an anxiety disorder (e.g., general anxiety, panic, social anxiety, obsessive compulsive disorder) or symptoms measured on a validated scale.
 15 1 25 0.082 0.288 15 0.082 0.776
Major depressive disorder
Clinical diagnosis of major depression or symptoms measured on a validated scale.
 15 6 486 -0.037 0.078 15 -0.033 0.682
Disruptive behavior disorder symptoms
Clinical diagnosis of a disruptive behavior disorder (e.g., conduct disorder, oppositional defiant disorder) or symptoms measured on a validated scale.
 15 1 107 -0.089 0.136 15 -0.089 0.511
Externalizing behavior symptoms
Symptoms of externalizing behavior (e.g., aggressive, hostile, or disruptive behavior) measured on a validated scale.
 15 2 102 -0.172 0.234 15 -0.172 0.462
Global functioning
How well individuals (typically those who are developmentally disabled or seriously mentally ill) have adapted to activities of daily living.
 15 3 344 0.078 0.091 15 0.078 0.388
Internalizing symptoms
Symptoms of internalizing behavior (e.g., sadness, anxiety, or withdrawal) measured on a validated scale.
 15 2 102 -0.113 0.142 15 -0.113 0.424
Suicide attempts
An attempt to die by suicide resulting in survival.
 15 2 267 0.056 0.143 15 0.056 0.695
Suicidal ideation
Thinking about and/or planning death by suicide.
 15 4 399 -0.112 0.144 15 -0.112 0.436

Citations Used in the Meta-Analysis

Brent, D.A., Emslie, G., Clarke, G., Wagner, K.D., Asarnow, J.R., Keller, M., et al. (2008). Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: The TORDIA randomized controlled trial. JAMA, 299(8), 901-913.

Clarke, G., Debar, L., Lynch, F., Powell, J., Gale, J., O'Connor, E., et al. (2005). A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication. Journal of the American Academy of Child & Adolescent Psychiatry, 44(9), 888-898.

Goodyer, I., Dubicka, B., Wilkinson, P., Kelvin, R., Roberts, C., Byford, S. et al. (2007). Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: Randomised controlled trial. British Medical Journal, 335(7611), 142-146.

Iftene, F., Predescu, E., Stefan, S., & David, D. (2015). Rational-emotive and cognitive-behavior therapy (REBT/CBT) versus pharmacotherapy versus REBT/CBT plus pharmacotherapy in the treatment of major depressive disorder in youth; a randomized clinical trial. Psychiatry Research, 225(3), 687-694.

Kennard, B., Silva, S., Vitiello, B., Curry, J., Kratochvil, C., Simons, A., et al. (2006). Remission and residual symptoms after short-term treatment in the Treatment of Adolescents with Depression Study (TADS). Journal of the American Academy of Child & Adolescent Psychiatry, 45(12), 1404-1411.

Melvin, G.A., Tonge, B.J., King, N.J., Heyne, D., Gordon, M.S., & Klimkeit, E. (2006). A comparison of cognitive-behavioral therapy, sertraline, and their combination for adolescent depression. Journal of the American Academy of Child & Adolescent Psychiatry, 45(10), 1151-1161.

Treatment for Adolescents With Depression Study (TADS) Team. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA, 292(7), 807-820.