Comparing Apples and Oranges in Youth Depression Treatments? A Quantitative Critique of the Evidence Base and Guidelines

Question: Should a young person receive psychotherapy or medication for their depression, and on what evidence do we base this decision? In this paper, we test whether the basic conditions required to draw valid inferences to answer this question are currently met. Study selection and analysis: We included 88 RCTs of psychotherapy and medication for child and adolescent depression (mean age 4-18 years). Using meta-analyses, we compared a) participant characteristics and b) trial characteristics in medication and psychotherapy trials. Lastly, we examined whether psychotherapy controls are well-matched to active conditions. Findings: Participants in medication RCTs had higher depression severity and were more frequently male compared to psychotherapy RCTs. There was a dramatic difference in the within-subject improvement due to placebo (SMD=-1.9 (95% CI: -2.10 to -1.70)) vs psychotherapy controls (SMD=-0.5 (95% CI: -0.75 to -0.25)). Within psychotherapy RCTs, control conditions were less intensive on average than active conditions. Conclusions: Medication and psychotherapy RCTs differ on fundamental participant and methodological characteristics, thereby violating key conditions for valid comparison between them. Psychotherapy controls often involve little therapist contact and are easy-to-beat comparators. These findings cast doubt on the confidence with which psychotherapy is recommended for youth depression, and highlight the pressing need to improve the evidence base.