Cognitive-Behavioral Therapy to Prevent Relapse in Pediatric Responders to Pharmacotherapy for Major Depressive Disorder
Open accessAbstract
Objective We present results of a feasibility test of a sequential treatment strategy using continuation phase cognitive-behavioral therapy (CBT) to prevent relapse in youths with major depressive disorder (MDD) who have responded to acute phase pharmacotherapy. Method Forty-six youths (ages 11-18 years) who had responded to 12 weeks of treatment with fluoxetine were randomized to receive either 6 months of continued antidepressant medication management (MM) or antidepressant MM plus relapse prevention CBT (MM+CBT). Primary outcome was time to relapse, defined as a Childhood Depression Rating Scale-Revised score of 40 or higher and 2 weeks of symptom worsening or clinical deterioration warranting alteration of treatment to prevent full relapse. Results Cox proportional hazards regression, adjusting for depression severity at randomization and for the hazard of relapsing by age across the trial, revealed that participants in the MM treatment group had a significantly greater risk for relapse than those in the MM+CBT treatment group (hazard ratio = 8.80; 95% confidence interval 1.01-76.89; chi = 3.86, p =.049) during 6 months of continuation treatment. In addition, patient satisfaction was significantly higher in the MM+CBT group. No differences were found between the two treatment groups on attrition rate, serious adverse events, and overall global functioning. Conclusions These preliminary results suggest that continuation phase CBT reduces the risk for relapse by eightfold compared with pharmacotherapy responders who received antidepressant medication alone during the 6-month continuation phase.
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In two trials, acute phase treatment lasted 12 weeks before maintenance and re-randomisation.
“In two trials, acute phase treatment lasted 12 weeks (Emslie 2008; Kennard 2008), at which point participants entered a maintenance phase and were re-randomised, potentially to a new treatment arm.”
From Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents (2012) · cites this paper as Kennard 2008
The Methods (Procedures; page not provided) describe 12 weeks of acute fluoxetine treatment, followed by randomization of responders into continuation-phase treatment. The paper describes this as their first randomization, not re-randomization; participants had received open treatment during the acute phase. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThree trials contained children and adolescents aged 7-18; one contained adolescents aged 13-19.
“Three trials contained both children and adolescents between the ages of 7 and 18 years (Emslie 2004; Emslie 2008; Kennard 2008) and one contained adolescents between 13 and 19 years (Cheung 2008).”
From Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents (2012) · cites this paper as Kennard 2008
The Methods (Procedures) specify participants aged 11–18, and the Results (Participant Characteristics) report that randomized participants ranged from 11 to 18. Kennard 2008 therefore supports the upper age limit of 18, but not the lower limit of 7 attributed to it. The separately cited Cheung trial is not assessed here. (LLM, conf=0.88)
Experimental — accuracy not yet measuredMedication trials all involved SSRIs; three administered fluoxetine and one sertraline.
“Medication trials all involved SSRIs; three trials administered fluoxetine (Emslie 2004; Emslie 2008; Kennard 2008) and one involved sertraline (Cheung 2008).”
From Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents (2012) · cites this paper as Kennard 2008
Sample sizes in acute phase ranged 66-219; in relapse-prevention phase ranged 22-102.
“Sample sizes in the acute phase of treatment ranged from 66 (Kennard 2008) to 219 participants (Emslie 2004), and in the relapse-prevention phase ranged from 22 (Cheung 2008) to 102 participants (Emslie 2008).”
From Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents (2012) · cites this paper as Kennard 2008
During acute treatment, one trial openly treated all participants with sertraline and two others with fluoxetine.
“During the acute phase of treatment, one trial openly treated all participants with sertraline (Cheung 2008) and two others treated participants with fluoxetine (Emslie 2008; Kennard 2008).”
From Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents (2012) · cites this paper as Kennard 2008
Therapists in Kennard 2008 were doctoral or master's level psychologists.
“Therapists were doctoral or master's level psychologists (Kennard 2008).”
From Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents (2012) · cites this paper as Kennard 2008
The Kennard 2008 psychotherapy focused on residual symptoms and aimed to promote strengths.
“It focused on the symptoms that remain residual following adequate response to acute treatment, and aimed to promote current strengths to enhance well being.”
From Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents (2012) · cites this paper as Kennard 2008
There is a suggestion from one small pilot study (Kennard 2008) that specifically formulated relapse-prevention CBT may be beneficial.
“Indeed, there is a suggestion from one small pilot study (Kennard 2008) that specifically formulated relapse-prevention CBT may be beneficial.”
From Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents (2012) · cites this paper as Kennard 2008
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- Authors
- Kennard, B. D., Emslie, G. J., Mayes, T. L., Nightingale-Teresi, J., Nakonezny, P. A., Hughes, J. L., Jones, J. M., Tao, R., Stewart, S. M., & Jarrett, R. B.
- Affiliations
- The University of Texas Southwestern Medical Center (US)
- Corresponding author
- Kennard, Betsy D.
- ORCID
- Venue
- Journal of the American Academy of Child & Adolescent Psychiatry
- Publisher
- Elsevier BV
- Published
- 2008-12
- Volume
- 47
- Issue
- 12
- Pages
- 1395-1404
- ISSN
- 0890-8567 (ISSN-L)
- PMC
- PMC2826176
- OpenAlex
- W2048973211
- Cited by
- 98
- References
- 39
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 2 · 2023: 3 · 2022: 5 · 2021: 2 · 2019: 3 · 2018: 2 · 2017: 2 · 2016: 6 · 2015: 8 · 2014: 17 · 2013: 9 · 2012: 11
- FWCI
- 5.86
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of the American Academy of Child & Adolescent Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (R34MH072737, R01-MH39188, K24MH001571, MH K24 01571, R01MH039188)
- Topics
- Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- major depressive disorder, childhood depression, relapse prevention, cognitive behavioral therapy, antidepressant maintenance, fluoxetine, sequential treatment strategy, treatment-resistant depression, patient satisfaction, attrition
- MeSH terms
- Adolescent, Child, Combined Modality Therapy, Depressive Disorder, Major, Major Depressive Disorder, Family Therapy, Feasibility Studies, Female, Fluoxetine, Humans, Male, Personality Inventory, Psychometrics, Cognitive Behavioral Therapy, Proportional Hazards Models, Antidepressive Agents, Second-Generation, Secondary Prevention
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