Increasing evidence supports the use of empirically-derived algorithms that use symptom monitoring to guide ongoing treatment planning
Adolescents with depression who were treated with interpersonal psychotherapy (IPT-A) had significantly better outcomes when their therapists regularly assessed depression symptoms and augmented treatment for insufficient responders after four weeks of therapy rather than waiting until Week 8, reports a study published in the January 2019 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP).
The authors also found that after four weeks of IPT-A, augmenting treatment for insufficient responders by increasing the frequency of therapy sessions to twice per week for a period of four weeks, or adding the antidepressant medication, fluoxetine, resulted in similar outcomes.
“Depression affects approximately 11 percent of adolescents, and this represents a significant increase in prevalence over the past decade,” said lead author Meredith Gunlicks-Stoessel, PhD, Assistant Professor at the Department of Psychiatry & Behavioral Sciences and the Institute for Translational Research in Children’s Mental Health at the University of Minnesota, Minneapolis, MN, US. “This is particularly concerning given that psychotherapy for youth depression has the poorest outcomes of all the childhood psychiatric disorders. However, if therapists routinely assess depression symptoms over the course of treatment and intervene early, when indicated, to augment treatment, this may improve outcomes.”
The findings are based on a 16-week sequential multiple assignment randomized trial (SMART). In SMARTs, subjects can be randomized multiple times, and these randomizations occur sequentially at selected critical decision points.
Forty adolescents (age 12-17) who were diagnosed with a depressive disorder began treatment with an initial treatment plan of 12 IPT-A sessions. Adolescents were randomized to reassess their treatment response at either Week 4 or Week 8. Adolescents who were classified as insufficient responders, based on criteria developed from data from a previous trial of IPT-A (< 20 percent reduction in depression symptoms at Week 4 or < 40 percent reduction in symptoms at Week 8) were randomized a second time to the addition of fluoxetine. An additional four IPT-A sessions were also delivered twice per week. Adolescents who were classified as sufficient responders continued with the original treatment plan of 12 sessions of IPT-A.
The researchers found that the earlier time point for assessing and identifying potentially insufficient responders (Week 4), was more successful in reducing adolescents’ depression symptoms than the later time point (Week 8), based upon the Children’s Depression Rating Scale-Revised [CDRS-R] (34.94 ± 2.05 versus 40.65 ± 2.05).
Dr. Gunlicks-Stoessel and her co-authors also found that among insufficient responders identified at Week 4, increasing the frequency of therapy sessions to twice per week for a period of four weeks resulted in similar outcomes compared to adding fluoxetine (CDRS-R 33.33 ±2.09 versus 36.11±1.97).
The results of this study provide a concrete guideline that therapists can follow to deliver personalized care that is adapted over time to meet their needs of each individual patient. Dr. Gunlicks-Stoessel and her team are currently conducting a larger scale trial of these treatment algorithms in a community mental health care setting with the goal of increasing the applicability of results to general clinical practice.