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Eur Child Adolesc Psychiatry (2007)16:157–167 DOI 10.1007/s00787-006-0584-x ORIGINAL CONTRIBUTION Childhood depression: a place for Ilan JoffeJesse Campbell Carmen ClementeFredrik Almqvist An outcome study comparing individual psychodynamic psychotherapy and family therapy Ulla Koskenranta-AaltoSheila WeintraubGerasimos KolaitisVlassis TomarasDimitris AnastasopoulosKate GraysonJacqueline BarnesJohn Tsiantis j Abstract Background disorder rates were seen for both Accepted: 14 October 2006Published online: 2 January 2007 Although considered clinically Individual Therapy and Family effective, there is little systematic Therapy. A total of 74.3% of cases Original lead researcher: Prof Issy Kolvin research confirming the use of were no longer clinically depressed Individual Psychodynamic Psy- following Individual Therapy and chotherapy or Family Therapy as 75.7% of cases were no longer J. Trowell, MBBS, DCH, DPM, FRCPsych treatments for depression in chil- clinically depressed following (&)Professor of Child Mental Health dren and young adolescents. Aims Family Therapy. This included West Midlands NIMHE/CSIP A clinical trial assessed the effec- cases of Dysthymia and ‘‘Double Honorary Consultant Child & tiveness of these two forms of Depression'' (co-existing Major Adolescent Psychiatrist psychotherapy in treating moder- Depressive Disorder and Dysthy- ate and severe depression in this mia). There was also an overall London NW3 5BA, UK age group. Methods A randomised reduction in co-morbid conditions Tel.: 01707 652205 (UK) control trial was conducted with 72 across the study. The changes in patients aged 9–15 years allocated both treatment groups were per- I. Joffe, MRCPsych to one of two treatment groups.
sistent and there was ongoing Hertfordshire Partnership NHS Trust, Results Significant reductions in improvement. At follow up six Child & Family Clinic months after treatment had ended, Marlowes Health Centre 100% of cases in the Individual Hemel Hempstead HP1 1HE, UK G. Kolaitis, MD Æ D. Anastasopoulos, MDJ. Tsiantis, MD, DPM, FRCPsych Therapy group, and 81% of cases in Department of Child Psychiatry, the Family Therapy group were no Aghia Sophia Children's Hospital longer clinically depressed. Con- Athens University Medical School London NW3 5BA, UK clusions This study provides evi- Thivon & Levadias115 27 Athens, Greece dence supporting the use of focused C. Clemente, MRCPsychRoyal Free Hampstead NHS Trust forms of both Individual Psycho- Department of Child & dynamic Therapy and Family Department of Psychiatry, Adolescent Psychiatry Eginition Hospital Therapy for moderate to severe Royal Free Hospital Athens University Medical School depression in children and young 72 Vas. Sophias Av London NW3 3DP, UK 115 28 Athens, Greece F. Almqvist, MD, PhD K. Grayson, BA, MSc, FRSS j Key words treatment – Statistics By Design U. Koskenranta-Aalto, MD childhood depression – 6 Southampton Close, Blackwater individual psychotherapy – Camberly, Surrey G U17 0HB, UK Department of Child Psychiatry The Hospital for Children & Adolescents, J. Barnes, BSc, MSc, PhD Faculty of Medicine Institute for the Study of Children, Families University of Helsinki and Social Issues, Birkbeck University of London 00250 Helsinki, Finland 7 Bedford Square WC1B 3RA, UK European Child & Adolescent Psychiatry (2007) Vol. 16, No. 3
Steinkopff Verlag 2007 family environment can contribute to childhooddepression Depressed children who live in a Although considered clinically effective, there is little confrontational environment also have higher rates of systematic research into the efficacy of Individual Psychodynamic Psychotherapy or Family Therapy in There is strong evidence of an association between the treatment of depression in children and young depression in children and problems in family adolescents. Most available evidence concerning members, including dysfunctional family relation- psychological treatments is for Cognitive Behavioural ships ]. Factors such as high parental criticism, Therapy (CBT) or Inter-personal Therapy []. While family discord and poor communication between CBT is promising in the short-term, previous studies parent and child have been associated with the onset , ] have found high rates of relapse, suggesting and course of juvenile depressive disorder. Goodyer the need for continuation or booster treatment. Psy- et al. [] concluded that psychosocial interventions chodynamic psychotherapy holds the promise of with first-degree relatives and current close friend- effecting more lasting changes in childhood depres- ships should be considered as part of a treatment sion by improving the capacity to resolve internal and strategy for first episode Major Depressive Disorder in external conflicts over time With the serious nature of childhood/adolescent The aim of this study was to conduct a trial of two depression it is crucial that treatments with efficacy established but as yet unvalidated forms of psycho- and more than transitory effects, and with the po- therapy for major depression in childhood/adoles- tential for a reduction in the cumulative risks, be provided promptly and skilfully.
Psychotherapy (‘‘Individual Therapy'') with a focus There is some evidence to support the use of on interpersonal relationships, life stresses and dys- antidepressant medication in the treatment of child- functional attachments based on the model of Malan hood depression. Previous placebo-controlled studies ] and Davenloo who provide guidelines about have reported response rates to Fluoxetine mono- psychodynamics, training and techniques in brief therapy of 52% and 56% [in cases of major dynamic psychotherapy. (ii) Systems Integrative depression. The TADS study reported a response Family Therapy (‘‘Family Therapy'') with a focus on rate of 60.6% to Fluoxetine monotherapy for Major family dysfunction, but without specific attention to Depressive Disorder, and 71% when Fluoxetine was unresolved intra-psychic conflicts and early child- combined with CBT. However, the use of Selective hood These treatments were compared in Serotonin Re-uptake Inhibitors in the under 18 pop- three culturally diverse settings, using a manualised ulation is becoming more restricted because of the risk/benefit ratio [It is therefore important to It was hypothesised that Individual Therapy would identify alternative treatment modalities for depres- be an effective treatment for depression and that sion in children and young adolescents.
improvement would be maintained and ongoing.
While CBT has been found to be superior to Family therapy could also be effective in the treatment comparison interventions in the treatment of Major of depression. Based on the findings of Brent et al. [ Depressive Disorder (MDD) in children/adolescents which demonstrated a 37.9% response rate for in 4 out of 6 randomised trials [], some limitations depression with Family Therapy, it was hypothesised have been identified: severe cases of depression that Family Therapy might not be as effective as have not been included, nor were cases with many co- Individual Therapy in the treatment of depression.
morbid problems such as conduct disorder or Further hypotheses were made with regard to the repeated self-harm. A number of methodological sequence of response (internal change vs social limitations in the existing research to date were also interaction) and predictors of response between the identified in a review of the treatment research two therapy groups using other measures as well as Muratori et al. [] have shown that psychody- changes of psychosocial functioning based on the namic psychotherapy is effective in treating inter- Social Adjustment Scale for Children and the Family nalising disorders in routine outpatient care; the Assessment Device. These will be reported in sub- benefits of such treatment were manifest both sequent papers.
immediately and with delayed onset (‘‘sleeper effect'').
A number of factors suggest a place for Family Therapy in the treatment of depression in children.
Parents can be important agents for behaviouralchange, as a positive parental attitude may be a A randomised control trial was conducted in London powerful contributor to self-worth in childhood/ado- (Tavistock Clinic), Athens (Aghia Sophia Children's lescence There is now much evidence that the Hospital) and Helsinki (Children's Hospital), with 72 J. Trowell et al.
Childhood depression: a place for psychotheraphy patients aged 9–15 years allocated to either Individual Kiddie-SADS ], a standardised semi-structured Therapy (FIPP) or Family Therapy (SIFT), based on standard randomisation methods. Caseness was the Children had to be living with at least one bio- only factor considered at randomisation. Patients in logical parent, and any antidepressants or other psy- each centre were randomly allocated to one of the two chotropic medication had to have been stopped at least 4 weeks prior to commencement of therapy, to Ethical approval for the study was obtained locally ensure the exclusion of confounding variables.
in each of the three centres. The use of placebo con- Exclusion criteria included: depressive disorders trols was ruled out on ethical grounds [, meriting urgent hospitalisation, Bipolar and Schizo- Based on previous studies of therapy with malad- affective disorder, severe conduct disorder (consid- justed children [, a power calculation was done ered likely to respond only moderately to psycho- to detect a difference in outcome of 30% between the therapy) and parents with psychotic disorder or two treatment groups. Accordingly, it was expected severe personality disorder.
that 44 patients per group would be required to detect Following screening, 24 cases entered into therapy a 30% difference with 80% power, using a 5% test of in each country, divided equally between therapy significance. Following difficulties with recruitment, a types in London and Helsinki, with 11 in Individual further power calculation was carried out based on therapy and 13 in Family therapy in Athens.
another review of the literature; using the Brent et al.
Treatment was conducted over a 9-month period study [] sample size as a guide, where there were 35– and consisted of eight to fourteen 90 min sessions of 37 subjects in each treatment arm, the size of the Family Therapy (mean = 11), or sixteen to thirty treatment groups in this study was adjusted accord- 50 min sessions of Individual Therapy (mean = 24.7) plus Individual Parent sessions (one per 2 sessions of All participants were referred into the study from child's psychotherapy) by a separate case worker.
community Child Mental Health Services. The pa- There were between 4 and 6 individual therapists, and tients' progress within the study is illustrated in the 4 and 6 family therapists in each of the three centres.
CONSORT diagram [in Fig. The therapists in Athens and Helsinki had received Entry to the trial followed screening using the training from the London team prior to the com- Child Depression Inventory a brief self-report mencement of the study. Treatment manuals were measure. Children scoring >13 were included pro- used to ensure comparability across all three centres, vided they subsequently met criteria for Major supplemented by cross-centre training.
Depressive Disorder (MDD) and/or Dysthymia on the Assessment took place prior to treatment (‘‘Base- line''), at the end of therapy (‘‘End of Therapy'', pri-mary endpoint) and again 6 months later (‘‘Followup'', secondary endpoint). Patients ‘‘lost to follow up'' Recruited subjects (CDI>13): 110 were those who did not return for ‘‘End of therapy'' or‘‘Follow up'' assessment. They had attended a variablenumber of therapy sessions.
Baseline assessment:
An extensive battery of instruments was adminis- Met inclusion criteria tered at each time point (full details available from the authors) collecting information about the child, theparents, their families, as well as relevant schoolmeasures. The findings of the following instruments are reported here: 1. The Demography Interview [a semi-structured Individual therapy: 35 Family therapy: 37 2. The Kiddie-SADS [this semi-structured clinical interview provides a measure of Major Depressive End of therapy assessment
End of therapy assessment
Disorder and Dysthymia (based on DSM IV crite- Lost to follow-up: 0 Lost to follow-up: ria), and psychiatric co-morbidity. These includedanxiety disorders (Generalised, Phobias, Separa-tion anxiety and Panic disorder), behavioural dis- Follow-up assessment
Follow-up assessment
orders (ODD, Conduct disorder), OCD, ADHD and Anorexia nervosa.
Lost to follow-up: 0 Lost to follow-up: 1 3. The Childhood Depression Inventory (CDI) this 27 item self-report questionnaire indicates the Fig. 1 CONSORT diagram European Child & Adolescent Psychiatry (2007) Vol. 16, No. 3
Steinkopff Verlag 2007 number of depressive symptoms and has a cut off factors related to improvement in each of the therapy indicating the presence of depression. A score of 13 was used as the threshold for entry into the study,based on research by Garvin et al. [] for use ofthe CDI in clinical settings.
4. Moods & Feelings Questionnaire (MFQ, 1): this 16 item self-report questionnaire provides a measure j Characteristics of the sample of depression. A threshold of 8 or more defineshigh scorers.
The mean age of participants was 12 years, almost 5. The Children's Global Assessment Scale (C-GAS, two thirds (62%) were male, the majority were white []): this clinician rated scale provides a measure and they represented all social class groups (see Ta- of overall impairment of child functioning (range ble Almost two thirds (62%) came from two-par- of scores: 0 (lowest) to 100 (highest)).
ent families (although not necessarily both biologicalparents). Just under half (44%) had a history ofmaternal psychiatric illness while 15% had a historyof depression in their extended family (siblings, j Statistical analysis grandparents, aunts and uncles). Three quarters(76%) had been depressed for more than 6 months.
Mixed Model Repeated Measures ANOVA was used to Overall, the sample characteristics were similar in examine the extent of depression (as measured by the each therapy type, except for a significantly higher continuous instruments CDI, MFQ and C-GAS) at percentage of males in the Individual therapy group each of the three time points. v2 and Exact tests were (v2 = 4.036; df = 1; P < 0.05) and a significant higher used for the comparison of the presence/absence of prevalence of paternal psychiatric history in the depression using cut-offs and the Kiddie-SADS.
Due to the small sample size in each country, most P < 0.05). A possible explanation for these findings is of the analysis was done for the three countries that demographic factors were not taken into con- sideration at randomisation. These differences may With regards to the Kiddie-SADS data, results have have disappeared had the sample size been larger.
been calculated for separate disorders, but since theyare known to occur together it was deemed appro-priate to adjust the significance level to control for j Prevalence of depressive disorders this association. A significance level of P < 0.01 wasused therefore instead of P < 0.05. Also the associa- The prevalence of cases of MDD and/or Dysthymia, tions between these disorders are stated where only MDD, only Dysthymia and both MDD and applicable, and the significant results using these Dysthymia (‘‘double depression'') have been exam- criteria are reported.
ined. This was done to examine any differences in There were four ‘‘lost to follow up'' cases (1 in treatment effects in these clinically distinct groups of Athens, 3 in London, all in the SIFT group). Inten- tion-to-treat analysis principles were applied for thesecases, with regard to the K-SADS scores, in order not Prevalence of Depression (Major Depressive Disorder to weaken the power of the sample size. Last available and/or Dysthymia) before and after therapy based on scores were carried forward. With regard to the CDI and MFQ, we used a ‘‘mean substitution'' method fordealing with missing data, where feasible and appro- At baseline assessment all the participants were priate. Means were calculated for each instrument diagnosed as depressed, with either MDD and/or splitting by centre, time point and therapy type and Dysthymia, based on the Kiddie-SADS. By the end of imputed. Analysis carried out on the pre- and post therapy, of those receiving Individual Therapy, 74.3% imputed data sets for each instrument confirmed that were no longer diagnosed as depressed and none were this did not change the statistical significance of any diagnosed as depressed at follow up, (see Table ). Of of the findings, other than to maintain the power of those receiving Family Therapy, 75.7% of cases of depression had improved by the end of therapy and at A secondary analysis using Multi-level modelling follow up only 18.9% were still diagnosed as de- (ML-WIN) on the pre-imputed data was also carried out on the CDI, MFQ and C-GAS data. The results of The change in prevalence of depression over the 3 this (not presented here) confirmed the findings of the time points in the Individual Therapy group, was primary analysis. This also allowed us to examine J. Trowell et al.
Childhood depression: a place for psychotheraphy Table 1 Characteristics of thesamplea Individual therapy Standard deviation v2 = 4.036; df = 1; P < 0.05 Socio-economic statusb Parental marital status Married/living with partner Maternal psychiatric history Paternal psychiatric history v2 = 5.449; df = 1; P < 0.05 Depression in extended family (excluding parents) One family member Two family members Duration of depressive illness a Demography interview (Kolvin et al. 1991) b UK Register General's Classification (Social class 1 = highest, Social Class 5 = lowest) P < 0.001). Further 2 · 2 v2 were performed to con- The prevalence of depression in the two groups firm between which times points the significant was similar at the end of therapy. At follow-up there changes had occurred. It was found that there was a were significantly more cases with depression in the statistically significant change in prevalence of Family Therapy group (v2 = 7.335; df = 1; P < 0.01).
depression from Baseline to End of Therapy However, when the ‘‘lost to follow up'' cases were (v2 = 41.364; df = 1; P < 0.001), from Baseline to excluded, the prevalence of depression in the Family Follow up (v2 = 70.00; df = 1; P < 0.001) and also Therapy group at End of Therapy was 13.4%, and at from End of Therapy to Follow up. (v2 = 10.328; Follow up 8.1%. The comparison at Follow up be- df = 1; P < 0.001).
tween the therapy types was not statistically signifi- The change in prevalence of depression over the 3 cant when the ‘‘lost to follow up'' cases were excluded.
time points in the Family Therapy group, was alsostatistically Prevalence of Major Depressive Disorder (MDD) before P < 0.001). The 2 · 2 v2 performed as above found and after therapy based on the Kiddie-SADS that there was a statistically significant change inprevalence of depression from Baseline to End of At the start of therapy more than 90% of the partic- Therapy (v2 = 45.043; df = 1; P < 0.001), from Base- ipants were diagnosed as having Major Depressive line to Follow up (v2 = 50.455; df = 1; P < 0.001) but Disorder (see Table By the end of therapy only 6 not from End of Therapy to Follow up.
(17.1%) still had this diagnosis in the Individual European Child & Adolescent Psychiatry (2007) Vol. 16, No. 3
Steinkopff Verlag 2007 Table 2 Presence of Depression(Major Depressive Disorder and/or Individual therapy N = 35 Family therapy N = 37 Dysthymia), Major DepressiveDisorder (MDD), Dysthymia, and Double Depression (MDD andDysthymia) at three time points by therapy type, based on the Kiddie- SADS (percentages in brackets) Double depression a Including imputed data for 4 ‘‘lost to follow-up'' cases Therapy group and by follow-up none received this lence of MDD in the Individual Therapy group com- diagnosis. In the Family Therapy group, the propor- pared to the Family Therapy group at Follow up was tion with a diagnosis of MDD had dropped from 34 not statistically significant.
(91.9%) at baseline to 8 (21.6%) at the end of therapyand 7 (18.9%) at the follow-up contact.
Prevalence of Dysthymia before and after therapy The reduction in prevalence of MDD over the 3 based on the Kiddie-SADS time points in the Individual Therapy group wasstatistically At the start of therapy more than 50% of the partic- P < 0.001). Further 2 · 2 v2 were performed to con- ipants were diagnosed as having Dysthymia (see Ta- firm between which time points the significant chan- ble By the end of therapy only 6 (17.1%) still ges had occurred. It was found that there was a gained a diagnosis of Dysthymia in the Individual statistically significant change in prevalence of MDD Therapy group and by follow-up none received this from Baseline to End of Therapy (v2 = 38.914; df = 1; diagnosis. In the Family Therapy group, the propor- P < 0.001), from Baseline to Follow up (v2 = 58.947; tion with a diagnosis of Dysthymia had dropped from df = 1; P < 0.001) but not from End of Therapy to 20 (54.1%) at baseline to 7 (18.9%) at the end of therapy and 4 (10.8%) at the follow-up contact.
The change in prevalence of MDD over the 3 time As shown in Table the change in prevalence of points in the Family Therapy group was also statis- Dysthymia over the 3 time points in the Individual tically significant (v2 = 51.371; df = 2; P < 0.001).
The 2 · 2 v2 performed as above found that there was (v2 = 32.308; df = 2; P < 0.001). Further 2 · 2 v2 a statistically significant change in prevalence of MDD were performed to confirm between which time from Baseline to End of Therapy (v2 = 37.220; df = 1; points the significant changes had occurred. It was P < 0.001), from Baseline to Follow up (v2 = 39.871; found that there was a statistically significant change df = 1; P < 0.001) but not from End of Therapy to in prevalence of Dysthymia from Baseline to End of Therapy (v2 = 11.993; df = 1; P < 0.005), from Base- The prevalence of MDD in the Individual Therapy line to Follow up (v2 = 28.00; df = 1; P < 0.001) but group compared to the Family Therapy group at End not from End of Therapy to Follow up.
of Therapy was not statistically significant. The The change in prevalence of Dysthymia over the 3 prevalence of MDD in the Individual Therapy group time points in the Family Therapy group was also compared to the Family Therapy group at Follow up P < 0.001). The 2 · 2 v2 performed as above found P < 0.01). However, this difference resulted from the that there was a statistically significant change in inclusion of the 4 ‘‘lost to follow up'' cases in the prevalence of Dysthymia from Baseline to End of Family Therapy group (there were no ‘‘lost to follow Therapy (v2 = 9.855; df = 1; P < 0.005), from Base- up'' cases in the Individual Therapy group). When the line to Follow up (v2 = 15.787; df = 1; P < 0.001) but ‘‘lost to follow up'' cases were excluded, the preva- not from End of Therapy to Follow up.
J. Trowell et al.
Childhood depression: a place for psychotheraphy The prevalence of Dysthymia in the Individual Table 3 Mean scores for depression based on the Childhood Depression Therapy group compared to the Family Therapy Inventory (CDI) and the Moods & Feelings Questionnaire (MFQ), and Meanscores for the global functioning based on the C-GAS, at three time points by group at End of Therapy was not statistically signifi- cant. This was also the case at Follow up.
Individual therapy Prevalence of ‘‘Double Depression'' (Major Depressive Disorder and Dysthymia) before and after therapybased on the Kiddie-SADS At the start of therapy 48.6% in the Individual Therapy group and 45.9% in the Family Therapy group were diagnosed as having double depression (see Table ).
By the end of therapy only 3 (8.6%) still gained a diagnosis of double depression in the Individual Therapy group and by follow-up none received this diagnosis. In the Family Therapy group, the propor- tion with a diagnosis of double depression had drop- ped from 17 (45.9%) at baseline to 6 (16.2%) at the endof therapy and 4 (10.8%) at the follow-up contact.
In the Individual Therapy group, the mean drop in As shown in Table , the change in prevalence of CDI score from Baseline to End of Therapy was 7.77, double depression over the 3 time points in the with a further drop of 5.49 from End of Therapy to Individual Therapy group was statistically significant Follow up (Total drop: 13.26). In the Family Therapy (v2 = 30.512; df = 2; P < 0.001). Further 2 · 2 v2 group, the mean drop in CDI score from Baseline to were performed to confirm between which time End of Therapy was 13.08, but with only a further points the significant changes had occurred. It was mean drop of 1.18 from End of Therapy to Follow up.
found that there was a statistically significant change (Total drop: 14.26).
in prevalence of double depression from Baseline to Secondary analysis using ML WIN confirmed the End of Therapy (v2 = 13.720; df = 1; P < 0.001), from above findings.
Baseline to Follow up (v2 = 22.453; df = 1; P < 0.001)but not from End of Therapy to Follow up.
The change in prevalence of double depression Moods & Feelings Questionnaire (MFQ) over the 3 time points in the Family Therapy group There was a significant difference in the mean MFQ was also statistically significant (v2 = 14.389; df = 2; scores for both therapy groups at the different time P = 0.001). The 2 · 2 v2 performed as above found points, with the scores going down for both types of that there was a statistically significant change in therapy (see Table P < 0.001, power > 99%). There prevalence of double depression from Baseline to End was a slightly significant difference between the of Therapy (v2 = 7.633; df = 1; P < 0.01), from Individual Therapy and Family therapy groups by Baseline to Follow up (v2 = 11.236; df = 1; P < 0.005) Follow up (P < 0.05) but at low power (52%). There but not from End of Therapy to Follow up.
was also a slightly significant difference between the 2 The prevalence of double depression in the Indi- therapy groups over time (P < 0.05).
vidual Therapy group compared to the Family Ther- In the Individual Therapy group, the mean drop in apy group at End of Therapy was not statistically MFQ score from Baseline to End of Therapy was 6.21, significant, and this remained the case at Follow up.
with a further drop of 2.34 from End of Therapy toFollow up. (Total drop: 8.55) In the Family Therapy j Additional measures of depression: group, the mean drop in MFQ score from Baseline toEnd of Therapy was 9.95, but with only a further mean Childhood Depression Inventory (CDI) drop of 1.19 from End of Therapy to Follow up. (Totaldrop: 11.14) There was a significant difference in the mean CDIscores for both therapy groups at the different timepoints, with the scores going down for both types of j Measure of impairment/level of functioning therapy (see Table , P < 0.001, power > 99%). Therewas no significant difference between the Individual Children's Global Assessment Scale (C-GAS) Therapy and Family therapy groups by Follow up.
There was a slightly significant difference between the There was a significant difference in the mean C-GAS 2 therapy groups over time (P < 0.05, power < 80%).
scores for both therapy groups at the different time European Child & Adolescent Psychiatry (2007) Vol. 16, No. 3
Steinkopff Verlag 2007 Table 4 Cases with one or more co-morbid conditions at three time points, by therapy type, based on the Kiddie-SADS Individual therapy N = 35 (%) Family therapy N = 37 (%) Double depression No double depression Double depression No double depression Double depression No double depression a including imputed data for 4 ‘‘lost to follow-up'' cases points, with the scores increasing for both types of 6 months following therapy. In addition, all remain- therapy (see Table , P < 0.001, power > 99%). There ing cases of depression (MDD, Dysthymia, and was no significant difference between the Individual ‘‘double depression'') had resolved at the follow-up Therapy and Family therapy groups by Follow up.
point. This suggests an ongoing response to therapy There was also no significant difference between the 2 following completion, the sleeper effect.
therapy groups over time, specifically at End of In the Family Therapy group, 75.7% of cases were no longer clinically depressed following therapy, and In the Individual Therapy group, the mean rise in 81% of cases were no longer clinically depressed C-GAS score from Baseline to End of Therapy was 6 months later. Family therapy also appears to have 16.13, with a further rise of 3.84 from End of Therapy been effective in cases of Major Depressive Disorder, to Follow up (Total rise: 19.97). In the Family Therapy Dysthymia and ‘‘double depression''. This effective- group, the mean rise in C-GAS score from Baseline to ness appears to have been persistent, with no relapses End of Therapy was 17.05, with a further rise of 2.03 6 months following therapy. In addition, further from End of Therapy to Follow up (Total rise: 19.08).
improvement in some of the remaining cases of Secondary analysis using ML WIN confirmed the depression (MDD, Dysthymia and ‘‘double depres- above findings.
sion'') was found at the follow-up point, particularlyin cases of Dysthymia and ‘‘double depression''.
Response rates for depression in the Individual Therapy and Family Therapy groups were not sig-nificantly different by End of Therapy. While re- The presence of co-morbid conditions was assessed sponse rates appear to have been approximately 20% using the Kiddie-SADS (based on DSM IV criteria).
greater in the Individual Therapy group, compared to The change in prevalence of cases with co-mor- the Family Therapy group, at Follow up, this is very bidity over the 3 time points in the Individual Ther- largely influenced by the inclusion of the four ‘‘lost to apy group, as depicted in Table was statistically follow up'' cases in the Family Therapy group, who significant (v2 = 19.821; df = 2; P < 0.001). The were considered as unsuccessfully treated cases fol- change in prevalence of cases with co-morbidity over lowing therapy. Without these four cases, the differ- the 3 time points in the Family Therapy group was not ences in response rates between the two groups are statistically significant, because of the absence of any not statistically significant.
decrease from End of Therapy to Follow up. The In addition to improvement as measured by cases prevalence of cases with co-morbidity in the Indi- no longer meeting diagnostic criteria for Major vidual Therapy group compared to the Family Ther- Depressive Disorder or Dysthymia, similar improve- apy group at each of the three time points, however, ment was found in both treatment groups in terms of was not statistically significant.
level of impairment and level of functioning.
While final outcome appears to have been similar in the two groups in many respects, the results from the CDI and MFQ suggest a different pattern of re-sponse or improvement. With regard to the MFQ, the In this study the following was found: Family Therapy group had a lower score at End of In the Individual Therapy group, 74.3% of cases Therapy, despite having had a higher score than were no longer clinically depressed following therapy, the Individual Therapy group at Baseline. While the and 100% of cases were no longer clinically depressed power of this test was low (<80%), it does reflect the 6 months later. Individual therapy appears to have slightly different ‘‘path'' for each of the therapy been effective in cases of Major Depressive Disorder, Dysthymia and ‘‘double depression''. This effective- The Family Therapy group appears to have made ness appears to have been persistent, with no relapses greater improvement, in some respects, by End of J. Trowell et al.
Childhood depression: a place for psychotheraphy Therapy, compared to the Individual Therapy group.
therapy or supportive therapy with regard to rates of These differences, though, had disappeared by Follow remission, recovery, recurrence or level of function- ing. In that study, the median onset of recurrence was By Follow up, many of the Family Therapy trajec- 4 months after recovery, whereas in this study, there tories appear to have plateaued, while the Individual had been no recurrences, and ongoing improvement, Therapy group trajectories suggest the possibility of 6 months post psychotherapy. Further research will further, and possibly more rapid, improvement to explore which components of the therapy were sig- The population groups in the three countries ap- pear to have responded similarly to the treatment.
Although not presented here, virtually no significantdifferences were found when similar analysis was done comparing the three treatment centres (London,Athens, Helsinki), in terms of response rates and Analysis has shown that both Focused Individual Psychodynamic Psychotherapy (with Parent support A significant number of cases in both therapy work) and Systems Integrative Family Therapy were groups had co-morbid conditions. Almost a third of both effective in treating moderate to severe depres- cases in the study had 3 or more co-morbid condi- sion in children and young adolescents in three tions. Following therapy, there was a decrease in co- morbid conditions, particularly anxiety disorders and This includes cases of dysthymia and ‘‘double conduct disorders, which are often associated with depression'' which are generally considered to be depressive disorders. This occurred in both therapy more difficult to treat. There has also been an overall reduction in co-morbid conditions across the study.
The results of this study suggest both Individual Therapy (response rate 74% by End of Therapy) andFamily therapy (response rate 75% by End of Ther- Clinical implications apy) may be more effective in the treatment ofdepression than other forms of treatment. Previousstudies have found a response rate in the region of 1. This study provides evidence supporting the use of 60% to CBT [] and 52–56% to Fluoxetine [ both Individual Psychodynamic Therapy and and 71% to CBT and Fluoxetine combined [A Family Therapy in this age group.
NNT analysis was undertaken using the End of 2. It may be possible for trained therapists, with the Therapy results in this study. Using the Placebo data help of the manuals, to deliver effectively, these in the TADS study as a comparator, the NNT for both focused forms of therapy.
Individual Therapy and Family Therapy is 3. This 3. Both treatments also appear to be exportable to compares favourably with the NNTs reported in the wider settings in culturally diverse populations.
TADS study, where the NNT for Fluoxetine and CBTcombined was 3, Fluoxetine was 4 and CBT was 12. Inthe absence of a control group in our study, a NNTanalysis was also conducted using the Nondirective supportive therapy (NST) group from the Brent studyas an alternative comparator. The NNT for both 1. The study is limited by the sample size, which was Individual therapy and Family therapy was 6. It is influenced by recruitment difficulties. This be- important to note in both the Individual and Family comes even more significant when comparing therapy groups, further improvement was reported at smaller sub-groups e.g. countries, and therapy Follow up. We would therefore expect to find lower groups within countries.
NNTs at the Follow up point, were comparable data 2. The effect of the 4 ‘‘lost to follow up'' cases is also significant, especially in relation to the total sample The chronicity and severity of the depression in size, and more so, because all of them were in the our study led us to believe that spontaneous remis- Family Therapy group. Intention to treat analysis sion was unlikely to have occurred in the vast principles were used in order not to lessen the majority of cases, particularly in light of the extent of power of the study or over-rate the effect of the co-existing dysthymia. Furthermore, the TADS study demonstrated a response rate of only 35% to placebo.
3. The absence of an ‘‘untreated'' control group limits The Brent/Birmaher study , ] found that CBT did the study's ability to prove with certainty the effi- not confer any long-term advantage over family cacy of the therapies provided.
European Child & Adolescent Psychiatry (2007) Vol. 16, No. 3
Steinkopff Verlag 2007 Jane Cassidy, Lois Colling, Carol Desousa (statistician), EmiliaDowling, Elspeth Earle, Anna Fitzgerald, Henia Goldberg, IngeGregorious, Agathe Gretton, Judith Loose, Ryan Lowe, Sue McNab, Further analysis will be looking at whether differential Gillian Miles, Renos Papadopoulos, David Pentacost, Maria Rhode, predictors of response can be identified in the two Margaret Rustin.
therapy groups, and whether there are any significant Members of the Athens project team: Alexandra Alexopoulou, Evi differences across the three different cultural settings.
Athanassiadou, Maria Belivanaki, Vaso Chantzara, Stelios Chris-togiorgos, Kostas Francis, Dimitris Georgiadis, Georgios Gritzelas, Data from additional instruments about the child, his/ Terpsi Korpa, Olga Lanara, Effie Lignos, Dimitris Magriplis, Maria her parents and family, and his/her environment will Marangidi, Olga Maratos, Vasso Moula, Valeria Pomini, Eleni provide further insight into the current findings. It Stavrou, Marianna Tassi, Irene Tsanira, L. Tsarouhi.
will also be important to establish if any specific Members of the Helsinki project team: Christina Bostrom, Taru components of the respective forms of therapy were Forst, Reija Graeffe, Susanne Friman, Kaarina Hastbacka, LiisaHisinger, Eija Korpinen, Anna Kuikka, Sakari Lehtonen, Helena likely to have contributed to the patients' response.
Lounavaara-Rintala, Kaija Mankinen, Pirkko Pingoud, Liisa Pi- Further studies should take measures to counteract rhonen, Marja Schulman, Esko Varilo, Leena Varilo, Maija von the limitations as discussed above. Other factors to Fieandt, Pirjo Vuornos, Jan-Christer Wahlbeck, Hanna Westerinen.
consider would include gender distribution and We would also like to thank the young people and their families fortheir contribution to the study.
family mental health history, as well as user prefer- This study was partly funded by the European Community: Con- ence for therapy type.
certed action contract No. BMH4-CT98-3231 DG12-SSMI. Centralco-ordination of the project took place at the Tavistock Clinic,London. Prof Kolvin was funded whilst developing the project by j Acknowledgements Members of the London project team: Anne the Leverhulme Foundation.
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