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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Combined treatment with cognitive-behavioural therapy in adolescent depression: meta-analysis

B Dubicka, R Elvins, C Roberts, G Chick, P Wilkinson, and IM Goodyer.

Review published: 2010.

Link to full article: [Journal publisher]

CRD summary

The authors found no evidence of any significant additional benefit for CBT when combined with antidepressant medication for depressive symptoms, suicidality and global improvement; benefit in impairment scores had unclear clinical implications. The small number of included studies, a poorly-reported review process and potential for missed studies mean that the authors' conclusions should be interpreted with some caution.

Authors' objectives

To evaluate the effect of adding cognitive-behavioural therapy (CBT) to antidepressant treatment in adolescents with unipolar depression.


PsycINFO, MEDLINE and The Cochrane Library were searched from January 1980 to March 2009 for articles published in English. Search terms were reported. Selected journals were searched and the reference lists of relevant publications (including NICE guidelines) were scanned. Authors in the field were contacted.

Study selection

Randomised controlled trials (RCTs) that compared comparing CBT combined with a newer-generation antidepressant against antidepressant treatment alone and primarily included adolescents (11 to 18 years) with a Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) diagnosed episode of depression were eligible for inclusion. Primary outcomes of interest were depression and impairment scores, overall improvement, suicidality and adverse events.

The mean age of included participants was 15 years. The proportion of females ranged from 54% to 79%. Participants were recruited largely from clinics. Baseline characteristics and intervention content varied. Fluoxetine, sertraline and venlafaxine were the principle antidepressants used (where reported). Routine care was included as part of the combined therapy in some trials. CBT was delivered by psychiatrists, psychologists or other qualified therapists. All programmes included some degree of parental participation. The mean number of sessions attended in the acute treatment phase ranged from five to 11. Most trials focused on major depression. Twelve-week outcomes were reported in all trials and most also reported outcomes from 26 weeks to two years. Several measurement tools for depression were reported in the paper; all trials used interviewer-rated and self report measures.

The authors did not state how many reviewers selected studies for inclusion.

Assessment of study quality

Trial quality was assessed using nine criteria that covered randomisation, use of intention-to-treat analysis, blinding, expectancy assessment, clarity of description of improvement, informants, dosage regimes, therapy manualisation and adherence and medication adherence. Each criterion was scored on a zero to 3 scale, with a maximum of 27 achievable.

Two independent reviewers carried out the quality assessment. Disagreements were resolved by consensus.

Data extraction

Data were extracted to calculate mean differences and 95% confidence intervals (CI).

The authors did not state how many reviewers carried out the data extraction.

Methods of synthesis

Where possible, weighted mean differences (WMDs) or standardised mean differences (SMDs) were pooled in a fixed-effect (Mantel-Haenszel) or random-effects (DerSimonian and Laird) meta-analysis using the inverse variance method. Random-effects analysis was used where substantial heterogeneity was measured by the I2 statistic. Outcomes from 26 weeks to nine months were pooled.

Results of the review

Five RCTs (1,206 participants, range 73 to 439) were included in the review. The mean quality score was 21 out of 27 points and the authors reported that none of the trials scored less than 50% of the total score. All studies described randomisation and used intention-to-treat analysis. Most studies reported blinding. Other criteria were variably met.

There were no statistically significant differences at 12 weeks or longer in relation to self-reported depression outcomes (five trials, I2=0%; three trials, I2=32.8% at follow-up), interviewer-rated depression outcomes (four trials, I2=32.3%; three trials, I2=5.1% at follow-up), overall improvement (three trials, I2=25%; two trials, I2=43.8% at follow-up) and suicidality (three trials, I2=0%; I2=19.3% at follow-up). Combined treatment showed a statistically significant improvement in relation to impairment outcomes at 12-weeks using the Children's Global Assessment Scale (CGAS) (WMD -2.32, 95% CI -3.91 to -0.74, I2=0%; four trials). There was no evidence of treatment effect at follow-up (three trials, I2=0%).

Fluoxetine resulted in significantly more spontaneous reported suicidal events than combined treatment at 36 weeks (one trial); venlafaxine (one trial) and selective serotonin reuptake inhibitors (SSRIs) (one trial) were also associated with more events. Psychiatric and non-psychiatric adverse events were reported in three trials; the most common were headaches, nausea and tiredness, disinhibition, sedation, insomnia, vomiting/abdominal pain, sleep difficulties and irritability.

Authors' conclusions

There was no evidence of any significant additional benefit for CBT when combined with antidepressant medication for depressive symptoms, suicidality and global improvement in the short- or long-term. There was benefit in impairment scores (measured by CGAS), but the clinical implications of this were unclear.

CRD commentary

The review question was clear and inclusion criteria were potentially reproducible for all aspects. The search strategy included several relevant sources, but restriction to published studies in English mean that relevant articles may have been missed and publication/language biases could not be ruled out. The review process was poorly reported and other than in the assessment of study quality it was unclear to what extent attempts were made to minimise error and bias. Relevant quality assessment criteria were presented and overall quality appeared to be reasonable. A good level of detail was provided on baseline characteristics and intervention content, which the authors acknowledged suggested a high level of clinical heterogeneity between the studies. However, statistical heterogeneity was assessed and no evidence was found in the only outcome that reached statistical significance. The chosen methods of synthesis seemed appropriate.

The small number of included studies, potential for missed studies in the search and a poorly reported review process that suggested potential for error and bias mean that the authors' conclusions should be interpreted with some caution.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated a need for further research to assess individual predictors of response and non-response to treatment and to provide economic data.


Not stated.

Bibliographic details

Dubicka B, Elvins R, Roberts C, Chick G, Wilkinson P, Goodyer IM. Combined treatment with cognitive-behavioural therapy in adolescent depression: meta-analysis. British Journal of Psychiatry 2010; 197(6): 433-440. [PubMed: 21119148]

Indexing Status

Subject indexing assigned by NLM


Adolescent; Child; Cognitive Therapy; Combined Modality Therapy /methods; Depressive Disorder /therapy; Female; Humans; Male; Practice Guidelines as Topic; Psychiatric Status Rating Scales; Randomized Controlled Trials as Topic; Serotonin Uptake Inhibitors /therapeutic use; Suicidal Ideation; Suicide, Attempted /statistics & numerical data; Treatment Outcome



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 21119148