First depressive episodes tend to arise in vulnerable individuals exposed to current chronic psychosocial adversities and acute adverse life events [
1‐
3]. Later episodes of recurrent disorder are however associated with fewer external stressors suggesting that a history of depressive episodes may itself increase the risk of further illness even in the presence of reduced external adversities [
4,
5]. Individuals who experience a depressive episode in their adolescent years are at higher risk of recurrence and relapse during their adult life [
6]. A history of MD during adolescence is associated with the subsequent emergence of personality disorders and substance misuse in adult life [
7,
8]. At least 30% of adult affective disorders start in adolescence and thus reducing the duration of an episode and the risk for recurrence would not only reduce short-term morbidity but also help to prevent depressive conditions and suicidal behaviour in later life [
9]. Experiencing a depressive episode at any time during adolescence represents a significant health and economic burden on the young person, their family, school and ultimately the gross domestic product of the nation [
10,
11]. Additionally, depression in adult life is amongst one of the top causes of loss of income to employers in the western world. Therefore, finding ways to improve treatment and decrease the risk of recurrent adolescent depression through adequate treatment of early episodes and reducing the risk for relapse and recurrence would be of a major individual and public health advantage. Currently around 1 in 10 cases referred to CAMHS are identified as having depression so focusing treatment efforts on this severe group may have marked clinical and public health benefits through in adulthood [
12].
Treatments for adolescent major depression
One randomised study in the UK showed that even in adolescent patients who were compliant with full active treatment for 6 months results were moderate; only 20% fully recovered, 30% achieved some level of remission, a further 30% had high number of residual symptoms and 20% did not respond to treatment at all [
13]. The possible reasons for such variable responses to apparently adequate treatment well delivered and received are numerous including insufficient treatment dose, higher non compliance than was measured, incorrect treatment choice, failure to select out participants with treatment resistant characteristics and patients who were resistant to current available therapeutics.
Cognitive Behaviour Therapy (CBT) has been widely investigated and shown to be effective in the treatment of mild and moderate depressions in the short term [
9,
14]. Recent studies reporting treatment of moderate to severe depression episodes have shown that the short term outcomes at 12 weeks for the combination of Fluoxetine and CBT produces some greater clinical improvement than CBT alone [
15,
16]. Depressed adolescents who were treatment resistant at 12 weeks to an SSRI may show significant clinical improvement with a change to a different SSRI if prescribed with CBT [
17]. A recent meta-analysis of the short term (6-12 weeks) outcomes from treatment studies suggested adding CBT to an adequate dose of SSRI provided no statistical improvement for clinical features but some statistical benefit for improving social functioning [
18]. As yet no study conducted on depressed adolescents has determined the effectiveness of any psychological treatment on the subsequent risk for relapse and recurrence in the medium term (i.e. 12 -18 months after treatment).
A small study of moderately to severely depressed young people attending clinical services has shown that patients may begin to relapse within 3 months of discharge, even in those fully recovered, and over the next 5-10 years some 50%-70% will relapse with a small group of patients never attaining remission over the third decade of life [
19].
There is now a growing evidence base for psychodynamic psychotherapy with adults [
20,
21] including evidence specifically showing the efficacy of treatment for depressed adults using STPP [
22‐
25]. Relatively few studies have however tested the effectiveness of psychodynamic psychotherapy for children and much of the existing evidence for effectiveness is based on relatively small scale studies [
26]. A chart review study [
27] of 763 patients included 65 children and adolescents with major depression at the Anna Freud Centre who were treated with long term (average 24 months) psychodynamic therapy showed that by the end of treatment, over 75% demonstrated reliable improvement in functioning and no depressive symptoms. A clear dose-response relationship was also demonstrated with treatment intensity and length of treatment both predicting remission after controlling for level of impairment at referral. A small pragmatic effectiveness trial of psychodynamic psychotherapy versus family therapy for mild to moderately depressed children and adolescents aged 9 through to 15 years showed both treatments were as effective as each other in the short term with a >70% remission rate for either [
28] and two other European studies have demonstrated the effectiveness of psychodynamic therapy with depressed children and adolescents [
29,
30].
Specialist Clinical Care (SCC) refers to the active treatment process that is administered routinely in many but not all UK outpatient child and adolescent mental health services (CAMHS). Specialist Clinical Care is usually delivered through a multidisciplinary team and unlike CBT and STPP is available in the vast majority of all CAMHS across the UK. This treatment approach has recently been manualised and is now being taught to mental health practitioners working in mental health services [
31]. To date, no studies have investigated the efficacy or effectiveness of SCC alone or against another psychological treatment. The only UK RCT of adolescent depression conducted in CAMHS clinics has shown however that SCC combined with Fluoxetine is as effective as SCC combined with Fluoxetine and CBT in producing remission at 28 weeks of treatment [
32]. This finding supports prior research that SCC could be a psychological treatment of choice with Fluoxetine if an anti-depressant is required as some cases receiving SCC appear to enter remission without medication.
Finally interpersonal psychotherapy (IPT), a conversational treatment with some principles derived from STPP (e.g. therapeutic relationship development, attending to the here and now) and SCC (problem solving in the real world and promoting peer group relationships) has been shown to be efficacious and effective with children and adolescents with mild to moderate depression suggesting that relatively brief, active psychological treatments not focussed on distorted or abnormal cognitive processing treatments are indeed able to alleviate depressive symptoms and improve social functioning at least in the short term [
33].
In summary there is now substantial data that 3 active specialist psychological treatments (CBT, STPP, IPT) derived from different theoretical perspectives and requiring therapists to be trained in specific modalities of delivering treatment are efficacious and clinically effective in alleviating depressive symptoms and improving social function in the short term in at least 50% of depressed adolescents. It is likely, but yet to be demonstrated that SCC will have similar properties for the treatment of acute depressive episodes. In contrast there is no evidence that the successful management of acute depression in this age range has longer term benefits through reducing relapse and recurrence risk.
The current randomised controlled trial was designed firstly to determine i) whether psychological treatment delivered to moderately to severe depressed adolescents would reduce risk of relapse and recurrence and if so ii) which was the most likely to reduce the risk of relapse 12 and 18 months after therapy began. This paper describes the design of this trial, how we will implement the protocols and analyse the results.