Individual research recommendation details

Recommendation ID

NG134/4

Question

What is the clinical and cost effectiveness, post-treatment and at longer-term follow‑up, of a brief psychosocial intervention as reported by the IMPACT trial, but delivered by practitioners other than psychiatrists and in other settings, including primary care, to young people aged 12 to 18 years with mild or moderate to severe depression?

Any explanatory notes
(if applicable)

Making choices about treatments

As for mild depression, the committee agreed that children and young people and their families or carers should be empowered to take part in shared decision making. Healthcare professional should also think about a number of key factors, including history, individual circumstances, comorbidities and developmental level and maturity.

Psychological therapies for 5- to 11‑year‑olds with moderate to severe depression

There was some evidence for psychological therapies for children aged 5 to 11 years with moderate to severe depression, but this included very few interventions. The committee agreed that the child or young person and their family or carers should be made aware of this when making decisions about treatments.

In the analysis of evidence for 5- to 11‑year‑olds with moderate to severe depression, family-based IPT and family therapy were more effective at reducing depression symptoms at the end of treatment than psychodynamic psychotherapy; but psychodynamic psychotherapy was better than family therapy at maintaining remission 6 months later. However, the evidence base was small (3 studies) and none included a control intervention. In other studies that included a control, no interventions were better than the control at reducing depression symptoms after treatment or at later time points.

Despite the limited evidence for 5- to 11‑year‑olds, the committee agreed that treatment was important for these young children. They agreed to recommend the treatments (family therapy, family-based IPT and psychodynamic psychotherapy) for which there was some evidence. They specified the types of family therapy used in the studies (family-focused treatment for childhood depression and systems integrative family therapy). They also included individual CBT in the recommendation because it was the most effective treatment for 12- to 18‑year‑olds with moderate to severe depression and they agreed that more mature children might benefit from this intervention.

Because of the limited evidence for effective treatments for 5- to 11‑year‑olds with depression, the committee made a research recommendation to inform future guidance.

Psychological therapies for 12- to 18‑year‑olds with moderate to severe depression

In an analysis of a large body of evidence for 12- to 18‑year‑olds with moderate to severe depression, individual CBT was better at reducing depression symptoms and improving functional status, quality of life and suicidal ideas compared with waiting list/no treatment, or usual care. It also increased remission at the end of treatment compared with attention control and other therapies (such as family therapy). Based on the size of these effects, the number of outcomes showing improvement and the size of the evidence base, the committee agreed to recommend individual CBT as the first-line treatment for young people with moderate to severe depression.

However, the committee recognised that individual CBT might not be suitable or meet the needs of all young people with moderate to severe depression and so they agreed that other therapies (IPT‑A [IPT for adolescents], family therapy, brief psychosocial intervention [BPI] and psychodynamic psychotherapy) could be considered as second-line options because there was some evidence supporting them, but this was less certain.

IPT-A and family therapy both increased functional status and depression symptoms at the end of treatment compared with waiting list/no treatment, or usual care (4 studies each). Family therapy was also better at inducing remission at the end of treatment than attention control.

The IMPACT trial could not detect a difference between BPI, psychodynamic psychotherapy and individual CBT over a range of outcomes and follow‑up times for 12- to 18‑year‑olds with moderate to severe depression. The committee agreed that BPI could be considered as an option when individual CBT is unsuitable. But they acknowledged that further research would be helpful to determine the effectiveness of BPI when delivered by a wider range of less senior practitioners and in other settings such as primary care.

Psychodynamic psychotherapy increased remission at the end of treatment compared with attention control or family therapy and relaxation. However, there was no evidence for functional status and psychodynamic psychotherapy was not more effective than control at relieving depression symptoms or improving quality of life post treatment. The data for this analysis came from the IMPACT trial^[8], which found no detectable differences between the effectiveness of psychodynamic psychotherapy and individual CBT across a range of outcomes and follow‑up times. However, a second trial of this intervention was identified with participants that spanned both age groups. It was included in the analysis for 5- to 11‑year‑olds. The committee decided not to recommend psychodynamic psychotherapy as a first-line option because it was no better than control at reducing depression symptoms at the end of treatment and there were only 2 studies including this intervention.

The committee recognised that there were fewer studies of family therapy, IPT‑A and psychodynamic psychotherapy than for individual CBT, and the existing studies either lacked data for later follow‑up times or did not cover the full range of outcomes of interest. The committee wanted more evidence to support their use in young people with moderate to severe depression and they therefore made a research recommendation to look at the relative effectiveness of these interventions compared with each other and individual CBT.

The committee agreed that behavioural activation may meet the specific needs of some children and young people with depression. In particular, it might suit those who might struggle with the concepts of CBT and children and young people with learning disabilities or neurodevelopmental disorders. They made a research recommendation to inform future practice.

How the recommendations might affect practice

Individual CBT, family therapy, psychodynamic psychotherapy and IPT‑A are already in widespread use and, as a result, the recommendations are unlikely to change resource use. Brief psychosocial intervention is not commonly delivered in current practice. Although this represents a change in practice, it is a lower intensity intervention than other individual therapies and may therefore reduce overall resource use.

Full details of the evidence and the committee's discussion are in evidence review A: Psychological interventions for the treatment of depression.

Source guidance details

Comes from guidance

Depression in children and young people: identification and management

Number

NG134

Date issued

June 2019

Other details