Should adolescents with depression be prescribed antidepressants, and if so, should they be given only with a psychological therapy, as advocated by the National Institute for Health and Clinical Excellence (NICE)?

A study published on bmj.com last month found that adding cognitive behaviour therapy (CBT) to selective serotonin reuptake inhibitor (SSRI) treatment is unlikely to improve outcomes for adolescents with moderate to severe depression.

These findings challenge current NICE guidelines that recommend SSRIs be prescribed only in conjunction with psychological therapies.

In an editorial in this week’s BMJ, a child psychiatry expert reviews the evidence and explains what this means for clinicians managing adolescents with depression.

This is the fourth study to assess the combination of SSRI and cognitive behavior therapy over monotherapy for depression in adolescents, writes Professor Philip Hazell from the University of Sydney.

A US study published in 2004 found that the combination of fluoxetine and cognitive behavior therapy was better than fluoxetine or behavior therapy alone in reducing depressive symptoms.

However, a more recent trial in 2006 found no advantage of sertraline plus cognitive behavior therapy over monotherapy. A third trial published in 2005 also found that the addition of cognitive behavior therapy to SSRIs had no significant effect on symptoms of depression.

The results of the BMJ trial suggest a further trend away from the positive findings of the US trial, says Professor Hazell. Differences in the dose and duration of treatment may have contributed to some variation, but the data suggest that combining cognitive behavior therapy with an SSRI has only a modest advantage over an SSRI alone.

Combining cognitive behavior therapy with and SSRI may have other advantages, such as reducing suicidal thoughts and prolonging the benefit of treatment, he says, but evidence for this across the four trials is equivocal.

So what does this mean for clinicians managing adolescents with depression? he asks.

Contrary to NICE guidelines, evidence suggests that monotherapy with an SSRI is a reasonable treatment option for moderate to severe depression in adolescents, particularly if access to cognitive behavior therapy may be delayed, he writes.

He adds that trial participants received a high level of clinical care, with frequent clinical reviews and rigorous monitoring of the benefit of treatment and adverse events. The implication for clinical practice is that good quality drug treatment involves more than simply writing the prescription, he concludes.