Mindfulness-Based Cognitive Therapy and Fluoxetine for Treatment of Youth Depression

Mindfulness-Based Cognitive Therapy and Fluoxetine for Treatment of Youth Depression

Abstract

The top cause of youth illness and disability worldwide, adolescent depression is an issue that has warranted many studies; generally finding Mindfulness-based cognitive therapy (MBCT) and fluoxetine each efficacious for its treatment. This study will aim to compare the effects of MBCT and Fluoxetine for the treatment of adolescent depression. Participants will be 100 adolescents with Major Depressive Disorder (MDD) and a baseline Depression Anxiety Stress Scale-21 (DASS-21) depression sub-scale score of ≥ 11, indicating ‘severe’. This will be a randomised, controlled trial (RCT), independent measure design. Participants will be randomly assigned to MBCT or fluoxetine treatment variables and will complete the DASS-21 once each week over 10 weeks of treatment. As hypothesised, MBCT will result in a greater reduction in depression severity compared to Fluoxetine medication. Problems associated with medication side-effects, self-reporting and gender disparities call for future research to investigate gender, including other measures alongside the DASS-21.

Mindfulness-Based Cognitive Therapy and Fluoxetine for Treatment of Youth Depression

Adolescent depression is the top cause of illness and disability for youth worldwide; suicide the third highest cause of death (World Health Organised, 2014). Adolescent depression is a particularly prevalent issue with 20% of youth experiencing a diagnosable depressive episode by the time they’re 18 (Kessler et al., 2005) and 6-7% of Australians aged 16-24 suffering from depression in any year (Australian bureau of statistics (ABS), 2007).  With patients on anti-depressants reporting undesirable side-effects, low medication compliance and preference for psychosocial treatment (Van Shaik et al., 2004); and the effectiveness of psychotherapies like cognitive behaviour therapy (CBT) as a treatment for severely depressed patients remaining questionable (DeRubeis et al., 2005), more research is required to determine the most effective treatments for adolescent depression.

When trying to determine effective treatments for depressed youth, pharmaceuticals like SSRI’s are traditionally first to come to mind. A recent systematic review and meta-analysis on SSRI’s for treatment in adolescents (Usala, Clavenna, Zuddas & Bonati, 2008) found fluoxetine particularly had a moderate effect on reducing the symptoms of depression. With the side effects of SSRI’s like fluoxetine including tension, agitation, restlessness, sleep disturbances (Buchman et al., 2002), suicide attempt, mania, skin rash and headaches (Rohden et al., 2017), query remains of whether monotherapy or the combination of psychotherapy and pharmaceuticals should be deemed first-line treatment (Usala et al., 2008). In attempt to answer this question, the Treatment for Adolescents with Depression Study (TADS) investigated fluoxetine, CBT and their combination and found fluoxetine was superior to placebo and CBT while combined therapy was the most effective in treating adolescent depression (March et al., 2004).

A relatively new style of therapy, mindfulness-based cognitive therapy (MBCT; Segal, Teasdale, Williams & Gemar, 2002) has been compared with good results against both antidepressant medication (Kuyken et al., 2015) and CBT (Manicavasgar, Parker & Perich, 2011). Although the effects of MBCT on depression relapse have been found to be comparable to maintenance antidepressant medications, MBCT is superior in: decreasing symptoms and comorbidity; enhancing quality of life; and those with particularly severe childhood trauma (Kuyken et al., 2015). Manicavasgar, Parker & Perich (2011) found that although MBCT and CBT are equally effective in treating depression, post-treatment rumination scores correlated with post-treatment mindfulness in MBCT patients; suggesting a distinctive function for mindfulness in treating depression.

MBCT has also been found to markedly reduce depression severity in patients who don’t have a full response to typical treatments (Kenny & Williams, 2007) and more effective than typical treatments (characterised by treatment with antidepressants, psychotherapy and visits from a psychiatric nurse) when treating patients that meet the full criteria for depression (Barnhofer et al., 2009).

Although mindfulness-based interventions including meditation practices are feasible for the treatment of youth (Burke, 2009), there are few studies in this area. Furthermore, few studies compare the effectiveness of MBCT and SSRI’s like Fluoxetine in treating depression. Finally, there are few randomised, controlled trials (RCTs) on MBCT and adult patients (Hofmann, Sawyer, Witt & Oh, 2010; Piet & Hougaard, 2011) which have been criticised for their small sample size or correlational nature.

This study will aim to compare the effects of MBCT and Fluoxetine for the treatment of depression in adolescents. It is hypothesised that treatment with MBCT will lead to a greater reduction in depression symptoms severity, as measured by the Depression Anxiety Stress Scale-21 (DASS-21; Lovibond & Lovibond, 1995b), compared to treatment with Fluoxetine.

Method

Participants

The participants will be 100 adolescents with depression symptoms from Brisbane. The participants will be recruited from the general public. Inclusion criteria will be: between 12 and 17 years of age, having a baseline assessment Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V; American Psychology Association (APA), 2013) diagnosis of Major Depressive Disorder on Structured Clinical Interview for DSM-V (SCID); at least a DASS-21 depression score of 10 at baseline assessment; not taking medication for depression before the trial; and able to give informed consent from a parent or guardian. All procedures will be approved by the Monash University Human Research Ethics Committee.

Design

The independent variable, treatment type, will consist of two levels: Medication with Fluoxetine (10 mg/day for 1 week and then 20 mg/day for 8 weeks) based on effective results from previous studies (Emslie et al., 1997; Emslie et al., 2002; March et al., 2004); and MBCT (Segal, Williams, & Teasdale, 2002). Depression symptoms severity will be the dependant variable, as reflected by DASS-21 measurements. This will be a randomised, controlled trial (RCT), independent measure design. Participants who experience adverse effects or wish to cease treatment for other means will be excluded from the study.

Materials

Depressive symptoms were measured by self-report using the DASS-21 (Lovibond & Lovibond, 1995b) because of it’s a valid and reliable measure of depressive symptoms in clinical and non-clinical populations of adults, prevalent in the literature (Antony, Bieling, Cox, Enns & Swinson, 1998; Henry & Crawford, 2005) and proof of its use with adolescents suggesting the core symptoms of depression in adolescents are similar to those of adults (Szabo, 2010). 21 parts measuring distress across 3 dimensions – depression, anxiety and stress by self-report of values between 0 (‘Never’) and 3 (‘Always’).