Depression: Medication versus Therapy in Adolescents

A Literature Review

Mental health is a growing issue in the United Kingdom. According to Reynolds (2016), one in four individuals are diagnosed with a mental health illness. This literature review will look at the various perspectives of the use of medication to treat depression against the perspectives of psychotherapy as there has been a great increase in the number of prescription antidepressants dispensed, with 3.9 million additional antidepressant drugs dispensed in 2015 than in 2014 in England alone (Health and Social Care Information Centre, 2016). On the other hand, in 2014, 947,640 were referred to psychological therapies (Health and Social Care Information Centre, 2014). However, in 2015, there were 1,267,193 referrals made to psychological therapies (Health and Social Care Information Centre, 2015). According to Compton et al (2004), “At any one time, approximately 1 in 20 children and adolescents suffers from major depressive disorder, with rates of depression rising dramatically in adolescents, especially in girls.”.

Depression is a mood disorder which causes a constant feeling of sadness and a loss of interest (Mayo Clinic, 2016). Depression was originally known as melancholia and was first noticed in the second millennium B.C, however, it was considered to be due to demonic possession (Nemade et al, 2007). The first medications to be introduced to treat depression were Iproniazid and Imipramine in the 1950s (López-Muñoz and Alamo, 2009), there are now over thirty types of antidepressants on the market which are separated via categories: Selective serotonin reuptake inhibitors (SSRIs), Serotonin and norepinephrine reuptake inhibitors (SNRIs), Monoamine oxidase inhibitors (MAOIs), Tricyclics and other types, with SSRIs being the most common type (Tracy, 2017). In relation to psychotherapy, there are many types of therapies an individual can have, however, this literature review will focus on cognitive-behavioural therapy (CBT).

There has been a substantial amount of research done in regards to treating depression with either medication or therapy. First to be discussed is the findings for combination treatment i.e CBT plus SSRIs. A qualitative study by Melvin et al (2006) found that both CBT and SSRIs, specifically Sertraline, were recommended for the treatment of adolescent depression. This study consisted of 73 participants: 22 were assigned CBT alone, 26 were assigned Sertraline alone and 25 were assigned a combination of both treatments. Participants receiving the CBT treatment were required to attend twelve 50 minute individual weekly sessions while the participants receiving Sertraline were required to take 25mg/day for one week. All groups exhibited considerable improvements which were then maintained for the following six months.

Furthermore, a previous study by Asarnow et al (2009) also found the combination of medication and CBT to be superior to medication alone. However, this was only the case with adolescents who were white, in their late adolescent years and who did not exhibit self-harming behaviour. Contradicting, a qualitative study by March et al (2004), revealed a combination of a SSRI and CBT was found not to be the most effective form of treatment. This study included a variety of groups including SSRI alone, Placebo alone, CBT alone and CBT plus SSRI. In regards to limitations, the groups who received SSRI alone and placebo alone were blinded, meaning they did not know what medication they would be receiving. This was done to eliminate bias, however, some say that this is unethical as it deceives the participant (Schattner, 2011).

On the other hand, Goodyer et al (2007) conducted a qualitative study involving SSRIs and CBT treatment in the NHS Child and Adolescent Mental Health Service (CAMHS) yet found no evidence to suggest that the combination of CBT plus a SSRI was superior to SSRI alone. This study consisted of 208 adolescents between the ages of 11 and 17 with moderate and severe depression. 103 received a SSRI medication and routine care while 105 received SSRI, routine care and CBT.  Although the medication in this study was different to the Melvin et al (2006) study, they were both in the SSRI group. Contrasting Melvin et al, Goodyer et al included adolescents who were experiencing active suicidality and self harm, which Melvin et al did not. This could explain the differences in results between the two studies. Although combined treatment has been shown to be an effective way of treating adolescent depression, it can also have some its disadvantages. Vitiello (2009) voices that combined treatment requires more resources and is more expensive.

To be argued next are the findings for SSRIs superior to CBT. Returning to the study carried out by March et al (2004), unlike the other studies March et al found that the SSRI alone treatment was superior to CBT alone treatment. However, it is noted that this could be due to the low dose of SSRI used. Although SSRI in this study was superior in rapidly reducing depressive symptoms, it doesn’t present to be more beneficial than psychotherapy in the long run. Also, it has been found that there are disadvantages to SSRI treatment. According to a systematic review, of eight studies, conducted by Barbui et al (2009), there is an “increased risk of contemplated or attempted suicide among adolescents” who are prescribed SSRIs. Barbui et al also mentioned that specific SSRIs such as Paroxetine and Venlafaxine would be better avoided when treating adolescent depression as the risks associated with these medications outweigh the benefits. Contradicting, a meta-analysis of randomised controlled trial by Bridge et al (2007), found the benefits of antidepressants for adolescents to be far greater than the risk of suicidal thoughts and/or suicide attempts. Due to these risks, in 2004 the Food and Drug Administration (FDA) (as cited in McCain, 2009) required a “black box” warning, which is the most serious warning and consists of the warning surrounded by a black border. The FDA’s boxed warning on the labelling of antidepressants mentioned an increased risk of suicidal thoughts and behaviours in paediatric patients when using the medication. Conflicting, Valuck et al (2004) conducted a study which involved 24,119 adolescents from across the United States of America and found “SSRIs has no significant independent effect on the risk of suicide attempts among adolescents”.

Next to be discussed are the findings for CBT superior to SSRIs. Returning to the study conducted by Melvin et al (2006), Although this study found the combined treatment to be effective, Melvin et al (2006) also found that CBT received a stronger response at the posttreatment assessment compared to Sertraline alone. Although, Melvin et al recognised that this cannot demonstrate an advantage to CBT as the lower dose and slower titration schedule could explain the difference compared with previous studies. In addition, an evidence-based medicine review by Compton et al (2004) found CBT, at the time, to be the best treatment for depressive disorders in adolescents. CBT can be extremely helpful in cases where medication hasn’t worked. According to the National Institute of Mental Health (NIMH, 2008), “about 40 percent of adolescents with depression do not adequately respond to a first treatment course with an antidepressant medication”. In cases like this, a combination of both CBT and SSRIs are used.

Moreover, there has been research done on other types of treatment for adolescent depression, one being exercise. Although there has been little research done on this topic a randomised controlled trial orchestrated by Nabkasorn et al (2005), found exercise to improve depressive states. However, Nabkasorn et al did note that this study had some limitations such as its participants only being a very small group of adolescent females, 59 to be exact. Meaning that results from this study could not be transferred to other populations, ages, and severity of depression. In addition, a meta-analysis review (Cooney et al, 2013) of twenty five randomised controlled trials comparing exercise to various treatments such as placebo, pharmacological and psychological treatment. Cooney et al, found the exercise groups to have substantial improvement in depressive symptoms as opposed to the other groups. Divergent to Cooney et al, Blumenthal (1999, as cited in Carek et al, 2011) found that a variety of groups including exercise, pharmacological and combined, all had considerable improvement in their depressive symptoms with no a major difference between them.

Another treatment method which has been studied is music therapy. According to Nauert (2014), a new study, the largest study of its kind, including 251 children and young people, found adolescents who “received music therapy had significantly improved self-esteem and significantly reduced depression compared with those who received treatment without music therapy”. Nauert states that these findings show the need for music therapy to be readily available as a treatment option. In addition,  Erkkila et al (2011), conducted a randomised controlled trial for music therapy alone or in combination with standard care including 79 participants. The results showed participants who received a combination of those treatments showed greater improvement in depression symptoms than those who received standard care only. According to Erkkila et al, the number of participants was sufficient enough to identify a difference between the two treatment options. Also, Castillo-Pérez et al (2010), performs a randomised control trial for the effects of music therapy compared with psychotherapy for depression. This trial also consisted of 79 participants and found the participants receiving music therapy had fewer depression symptoms than those in the psychotherapy group. Dissimilar to Erkkila et al, Castillo-Pérez et al noted that one of the major limitations for their trial was the somewhat small participant size yer the differences in depressive symptoms between the two trial groups were evident.

There are many reasons as to why an individual would decide to take an alternative route for treating depression such as music therapy or exercise. According to Hanzell (2007, as cited in Maratos et al, 2008), this could be due to “a lack of satisfaction with conventional treatments and/or a wish to avoid side-effects from medication or the stigma attached to seeking talking therapy”. Also, Tartakovsky (2013) states other reasons could be the severity of the depression as many people aren’t sure if their state needs to be treated as there may be people with worse symptoms who need treatment more. Tartakovsky also states money can be an obstacle, in the UK the majority of the treatment individuals receive is free through the National Health Service, however, in other countries such as the USA, not everyone can afford to put their children into therapy and other treatments as their insurance plans may not cover the costs.

In conclusion, it is apparent from research conducted that a combination of both SSRI treatment and CBT treatment is recommended to treat adolescent depression and appears to be the most effective way of treating adolescent depression. Although this is the most effective treatment it is not always the first in line, and SSRIs are more commonly the first point of call for adolescent depression. However, it has been noted that other forms of treatment such as exercise are equally as beneficial and should, in fact, be one of the first lines of treatment for adolescent depression. In addition, other treatments such as music therapy have shown to be beneficial and could be used as an additional treatment. Although there is research showing the benefits of treatments, there could be more research done in order to quickly find the right course of treatment for the individual.