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School-based interpersonal psychotherapy improves depression in older adolescents
  1. Jean Starling, MBChB, FRANZCP, MPH
  1. Head of Department of Psychological Medicine, The Children’s Hospital,
    Westmead, NSW, Australia

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Q What is the effectiveness of interpersonal psychotherapy compared with school-based psychotherapy in adolescents with depression?

METHODS

Embedded ImageDesign:

Randomised controlled trial.

Embedded ImageAllocation:

Unconcealed.

Embedded ImageBlinding:

Clinicians and participants unblinded; assessors masked to allocated treatment.

Embedded ImageFollow up period:

16 weeks.

Embedded ImageSetting:

Five school-based clinics in urban, underprivileged areas, New York; April 1999 to July 2002.

Embedded ImagePatients:

Sixty three adolescents aged 12–18 years (mean age 15 years, 84% female, 71% Hispanic) referred to mental health sectors of school-based health clinics for depression (DMS-IV diagnosis). Inclusion criteria: Hamilton Depression Rating Scale (HAMD) score of ⩾10 and a Children’s Global Assessment Scale (C-GAS) score of ⩽65. Participants were excluded if they were actively suicidal, mentally retarded, or chronically ill, had current substance abuse, were psychotic, were already in treatment for depression, or were taking antidepressants.

Embedded ImageIntervention:

Interpersonal psychotherapy (IPT-A): Twelve sessions over 12–16 weeks which focused on identifying and categorising current problems to develop resolutions and combat depressive symptoms plus prioritising social functioning. Participants received a mean of 10.5 sessions over 16 weeks. Treatment as usual (TAU): This varied, but usually followed a pattern of supportive counselling. Participants received a mean of 7.9 sessions over 16 weeks. Treatment for both groups was performed by school psychologists. For both groups, if an individual’s HAMD score reached >25 they were evaluated by a child psychologist/psychiatrist and offered medication where appropriate.

Embedded ImageOutcomes:

Depression (HAMD and Beck Depression Inventory (BDI)); Global functioning (Clinical Global Impressions scale (CGI), Children’s Global Assessment Scale (C-GAS)), and social functioning (Social Adjustment Scale-Self Report (SAS-SR)). Assessments were performed at baseline and at 4, 8, 12, and 16 weeks.

Embedded ImagePatient follow up:

89% completed the trial; 98% included in analysis.

MAIN RESULTS

At 12 weeks, IPT-A reduced depression compared with TAU (mean HAM-D score: 8.7 v 12.8, p = 0.04; mean BDI score: 8.4 v 12.3, p = 0.14). IPT-A significantly improved global and social functioning compared with TAU (global functioning: mean CGI scores (severity) 2.4 v 3.0, p = 0.03; mean CGI scores (improvement) 2.3 v 3.1, p = 0.03; mean C-GAS scores 66.7 v 59.5, p = 0.04; social functioning: mean SAS-SR score: 2.23 v 2.59, p = 0.01). At 16 weeks, depressive symptoms were still significantly reduced with IPT-A, but improvements in global functioning were slightly attenuated (mean HAM-D score: 6.9 v 10.6, p = 0.04, effect size 0.51 (95% CI 0.003 to 1.02); C-GAS trend to improvement, p = 0.06). Subgroup analysis found that the effects of IPT-A were much greater in older adolescents.

CONCLUSIONS

Interpersonal psychotherapy is effective in the school-based treatment of depression, especially in older adolescents.

Commentary

Depression is a chronic illness with a high burden of disability. One third of first episodes occur before the age of 21.1 It makes good sense to identify adolescent depression early and provide effective treatment.

Unfortunately, the evidence for effective treatment of depression in adolescence is limited. There is good evidence for three interventions: medication, cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT-A). All three have some problems. Many antidepressants have either not been adequately researched in adolescence, or appear to be ineffective. Only fluoxetine has data from several trials.2 There is also concern that SSRIs may increase suicidal behaviour in young people.3 While this needs further evaluation, alternatives to medication are needed. CBT has good evidence for effectiveness4 but does not suit all patients. IPT-A has several potential advantages. There have been other well conducted trials using a treatment manual.5

Using rigorous methodology, the current study found IPT-A to be effective in a school setting, reducing depressive symptoms and improving functioning. This study is useful for clinical practice for several reasons. The treatment was conducted in a school setting by the school clinicians, providing “real world” subjects and clinicians. IPT-A was simple to learn, by reading a manual, participating in two days of training, and attending weekly supervision. Participants were not withdrawn from the study if they were on antidepressants. The severity of depression ranged from mild to severe, with the mean at the lower end in the moderate to severe range. Only suicidal young people were excluded.

Although trials in other community settings would be useful, this is an encouraging finding and supports the addition of IPT-A to the treatment repertoire of those working with depressed adolescents.

References

View Abstract

Footnotes

  • For correspondence: Laura Mufson PhD, New York State Psychiatric Institute, 1051 Riverside Drive, Unit 24, New York, NY 10032, USA; MufsonLchildpsych.columbia.edu

  • Sources of funding: Substance Abuse and Mental Health Administration, Rockville, and Psychotherapy Core of the National Institute of Mental Health Child Psychiatry Intervention Research Center, Rockville.

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