Index

1. INTRODUCTION

Adolescence is a developmental period characterized by important changes in personality traits and mood. The changes in how adolescents think, reason, and Understand can be even more dramatic than their obvious physical changes [1]. From a psy­chosocial perspective, Erikson views adolescence as a period of identity formation and role diffusion. An incoherent sense of self and values will result in the lack of a sense of identity. In essence, adolescence represents the second separation from adult caretakers, with the first having occurred when the youth attained the motor and cognitive ability to move away from the parents' constant watch. Adolescence marks the period where youth are biologically, albeit not usually psychosocially, capable of surviving on their own [2]. A healthy and stable self-image is of primary impor­tance in healthy adolescent development. Problems in the formation of a positive sense of self-show signifi­cant correlations depression and mood instability [3]. Epidemiologic studies show that major depression is comparatively rare among children, but common among adolescents, with up to a 25% lifetime prevalence by the end of adolescence [4]. Depression is associated with significant morbidity, disability (loss of work days, reduced quality of life), increased medical comorbidity (cardiovascular disease and stroke), and mortality (increased risk for suicide and death from comorbid medical disorders) [5].

In the past forty years, at least two main developments existed concerning theories and treatment of depression. One of the most used Treatments of this disorder is pharmacotherapy which used drugs for sedating depression signs and the other was a cognitive behavioral therapy [6]. In pharmacotherapy of major depression, various drugs are employed, they include selective serotonin reuptake inhibitors (SSRIs), other agents with varied mechanisms of action (e.g., venlafaxine, mirtazapine), and older classes such as tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) [7]. SSRIs and other newer agents have become first-line treatments for most primary care physicians, psychiatrists, and other medical specialists because of their relative tolerability and ease of use in terms of dosing schedules. Nonetheless, many of the patients are reluctant to accept pharmacotherapy [8] and may be prone to drug side effects and drug-drug interactions. The most commonly studied psychotherapeutic treatment of depression is cognitive behavior therapy, which is focused on changing maladaptive patterns of thinking, feeling, and behaving [9]. The advantages of psychotherapy include the lack of drug side effects and drug-drug interactions. Given that psychosocial stressors may engender or exacerbate depressive episodes [10] the focus in psychotherapy of enhancing social supports, resolving interpersonal stressors, or increasing coping abilities may be useful and desirable [11]. An often mentioned disadvantage of psychotherapy relative to medication is the slower response [12] but there are structural disadvantages too, including language, financial, and transportation barriers and the lack of psychotherapists who are trained to work with Rucci, et al. [13].

The main aim in cognitive behavioral therapy is reducing mental pressure and improving functions which have been disturbed due to mental disorders. The thoughts, beliefs, and mental images patients experience are the main core of cognitive behavioral therapy [14]. Treatment content includes identification of thoughts and beliefs, reviewing the evidence and investigating thoughts and cognitions related to the mood and behavior [15]. The techniques used, include behavioral and cognitive techniques. Relaxation therapy through muscle relaxation (regular contraction and relaxation of all the major muscle groups), meditation and targeted imagination (imagining a quiet place and listening to the soothing sounds) reduce physical and mental stress [16]. Increasing number of research studies have been dedicated on this type of treatment since emergence of cognitive behavioral therapy. Many studies have been conducted on depression [17, 18] anxiety disorders [19, 20] eating disorders [21, 22] and insomnia [23, 24] in order to evaluate the therapeutic changes.

Keller, et al. [25] investigated the differences between nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. The result of their study showed the overall) 48 percent rate of response (both remission and satisfactory response in both the nefazodone group and the psychotherapy group, as compared with 73 percent in the combined-treatment group. Rush, et al. [26] also had a research on topic of “Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients”; they asserted that the dropout rate was significantly higher with pharmacotherapy (8 Ss) than with cognitive therapy (1 S). Even when these dropouts were excluded from data analysis, the cognitive therapy patients showed a significantly greater improvement than the pharmacotherapy patients. Follow-up contacts at three and six months indicate that treatment gains evident at termination were maintained over time. Moreover, while 68%of the pharmacotherapy group re-entered treatment for depression, only 16%of the psychotherapy patients did so. In accordance with the previous researches, it becomes clear that most therapeutic interventions in the area of major depression have been performed on adults, while few researched have taken place on adolescents who are the vulnerable groups of society, particularly in Iran. Also, these few types of research on the adolescents suffering from major depression have not enjoyed a comprehensive look which covers all the potentialities of the combined therapies. Hence, given high rates of depression among the adolescents and its destructive impacts on the social, educational and personality growth and also the fact this disease is followed by some other psychological disorders like anxiety and conduct disorder and contradictory information in the superiority of treatment methods in the previous studies, this study was conducted with the aim of comparing the three methods of group therapy with the cognitive behavioral approach alone, pharmacotherapy alone and the combined therapy in the depressed adolescents.

2. METHODOLOGY

2.1. Subjects

With regard to the overall goal of this study, to compare the effectiveness of three methods of cognitive behavioral therapy, pharmacotherapy and combined therapy in the treatment of youth's depression; this experimental study was performed in Isfahan city, Iran, with pretest and posttest and a four-month follow-up in 2009. The Statistical Society was 330 depressed young adolescence, studying in one of the threesome grades of junior high school in Isfahan, who were identified due to the previous research entitled "Epidemiology of depression in adolescents in Isfahan". Based on that research person whose score was 19 or more in the Maria Cowax questionnaire as well as having diagnostic criteria for depression based on DSM-IV, such as frustration, depression, low motivation, irritability, changes in appetite, low self-esteem, social withdrawal and feelings of inferiority, determined as a depressed person.

2.2. Research Design

After determination of statistical society, 120 male and female students were selected from different areas as the sample of this research based on cluster random sampling. And then randomly divided into four groups of 30 patients. Each group consists of 15 girls and 15 boys. It is noteworthy that at first, for a 12 people group of boys the cognitive behavioral therapy was conducted by way of pilot in order to identify the shortcomings of the administrative method of the research and dominance in applying the therapeutic methods, wherein vertical flashes were used, however, it was not a perfect protocol. Also, in this group, most students were present with low average scores and educational status which caused problems for cooperation and enough comprehension of the material presented. In addition, there were some accompanying disorders such as learning disorder or hyperactivity-inattention that led the researchers to a conclusion that for participating in cognitive behavioral sessions, it is imperative for people to have at least an average score of higher than 15 so that they enjoy enough thinking abilities and enough participation in this treatment and avoid some other disorders that would reduce the adolescents'' cooperation for concentrating on cognitive material. Then, this protocol was completed and was translated from a book by Munoz and Miranda [20] and transformed into some PowerPoint slides. This protocol was employed for increasing the attention of the junior school students who were energetic and the tendency for these discussions among them was weak.

2.3. Inclusion Exclusion Criteria

The criteria for entering the research were: 1. The students suffering from major depression based on the DSM-IV diagnostic criterion determined in-depth psychological screening interview, 2. Age between 13-16 and at the junior school level, 3. Educate in Isfahan, 4. Students' written disclaimer for participating in the program based on active presence till the end of the research, 5. An average score of 15 at least, and 6. A lack of accompanying disorders. Also, the criteria for exiting the research were 1. Severe mental disorders, 2. An absence of more than two sessions, 3. Lack of interest among people to continue education.

2.4. Interventions

Therapeutic programs for each group were executed as follow:
Group 1: cognitive behavioral therapy, twice a week and each session for 45 minutes; Group 2: pharmacotherapy that includes 20 milligrams of Fluoxetine as prescribed by a specialist doctor for 8 weeks and Group 3: pharmacotherapy with cognitive behavioral therapy for 8 weeks. Pharmacotherapy interventions were performed by a psychiatrist and cognitive behavioral therapy was done by a professional therapist. It should be noted that the group cognitive behavioral therapy period of 12 sessions included 4 sessions about the relationship between thought and feeling, 4 sessions about the relationship between feeling and daily activities an 4 sessions of relationship between feeling and social relations.  Slides prepared in the cognitive behavioral and combined therapy groups were displayed and were read by the research subjects and explained by the therapist. Also, participants in the research explained their own views and states while implementing therapeutic programs. A briefing of cognitive behavioral therapy sessions is presented in table, 1.

Table-1. A brief Description of Cognitive Behavioral Therapy Sessions

2.5 Research Tools

Demographic questionnaire: the required demographic information of this research was age, gender and educational average score.

1. Maria Cowax depression in children questionnaire (CDI): In this questionnaire, 27 questions are designed that would provide various feelings and thoughts. The way this questionnaire is scored is like the Beck depression questionnaire and is 0, 1 and 2. The score range is between 0-54. The cutting off point and determining the depressed people is a score of higher than 18. A score of 0-8 is healthy, 9-19 means depression signs, but without depression disorder while 20 and higher is labeled depressed. The more people's score in this questionnaire, the more the depression level will be. To measure the CDI scale validity, the concurrent validity with teachers' assessment was applied where it indicated a validity coefficient of 0.193, being statistically significant [27]. Ostovar and Razvye reported the divergence validity of the questionnaire along with the social anxiety scale for the adolescents (SAS-A) as 0.35 (10). Saylor et al, by using the Cronbach's alpha reported the internal consistency of the questionnaire as ranging from 0.71 to 0.94 (11). Also, Ostovar and Razavye reported the reliability of the questionnaires as 0.91 by using a retest with a time interval of two weeks (10).

3. FINDINGS

The participating groups in the research were the same in terms of gender, age and educational status variables and there was no need for equivalence. To analyze the data, at the first stage, prior to the comparison of the three therapeutic methods, first the effects of each therapy (pharmacotherapy, cognitive behavioral therapy and combined therapy) were individually evaluated on treating the patients suffering from major depression. For this purpose, using the twin t test, scores of pretest-posttest and those of pretest-follow up were separately compared.
In the first group who were placed under the cognitive behavioral therapy, the statistical test having been implemented, given the p-value=0.001 it was determined this method was found to be significantly effective for treating major depression. The average difference of the scores of pretest-posttest was 11.70 while the rate for those of pretest-follow up was 13.20.

The second group being under the pharmacotherapy measures, after the implementation of the related test with the p-value=0.001, it was determined that this method was significantly effective in reducing the scores. In other words, it was significantly effective in treating depression. The average difference of the scores of pretest-posttest was 13.27 while the same rate for and those of pretest-follow up was 12.30.

The third group being under the combined therapy measures, after the implementation of the related test with the p-value=0.001, it was determined that this method like its predecessors was significantly effective in reducing the scores. In other words, it was significantly effective in treating depression. The average difference of the scores of pretest-posttest was 14.80 while the same rate for and those of pretest-follow up was 15.03.

Table-2. The average difference of the scores of pretest-posttest and average score of the pretest-follow up in three cognitive behavioral, pharmacotherapy and combined therapy methods.

Source: Output from SPSS 18 software

After investigating the significance of therapeutic methods separately, in the second stage, the three therapeutic methods were compared. The test used in this stage was the covariance analysis.

Table-3. A summary of covariance analysis results relating to the comparison of average treatment scores in experimental groups at the posttest and follow up stage

Source: Output from SPSS 18 software

Covariance analysis results set forth in table 3 indicate that by eliminating the effects of the pretest scores, a significant difference was seen between the modified average depression score of the students based on group membership (three pharmacotherapy, combined therapy and cognitive behavioral therapy groups) at the posttest and follow up stage (P<0.05). Hence, it is concluded that therapies provided have an effect on depression. The difference rate suggests that 52.4% of the depression score variance at the posttest stage and 59.5% of the depression score variance at the follow up stage are because of the group membership. The statistical power of 1 indicates a high statistical accuracy of this test and sufficiency of the sample size. Totally, there is a significant difference between the three therapeutic methods. For investigating these differences, the LSD test was used in more details.

Table-4. Pair comparison of the average differences of the groups under study after the treatment and posttest stages

Source: Output from SPSS 18 software

Table, 4results indicate that between the average difference of the two cognitive behavioral therapy and pharmacotherapy groups at the posttest is a significant difference (P<0.01). Thus, observing the average differences is indicative of the advantage of the pharmacotherapy over the cognitive behavioral therapy at the posttest. However, there is no significant difference between the average differences of the two cognitive behavioral and combined therapy groups (P<0.20). Also, there is no significant difference between the two combined and pharmacotherapy groups (P<0.23).

Table-5. Pair comparison of the average differences of the groups under study after the treatment and follow up

Source: Output from SPSS 18 software

Table, 5 results indicate that no significant difference between the average difference of the two cognitive behavioral therapy and pharmacotherapy groups (P<0.46). Thus, observing the average differences is indicative of the advantage of the combined therapy over the cognitive behavioral therapy and the pharmacotherapy. However,

there is no significant difference between the average differences of the two cognitive behavioral and combined therapy groups (P<0.24). Also, there is a significant difference between the two combined and pharmacotherapy groups (P<0.05). Also, the effectiveness of the cognitive behavioral therapy at the follow up stage was higher than the pharmacotherapy. This tells that the CBT needs more time for leaving effects.

4. DISCUSSION

The current paper aimed to determine the effects of three methods of cognitive behavioral therapy, pharmacotherapy and combined therapy on the depressed adolescents Isfahan. Results indicated that there is a significant difference between the average depression scores of the three groups in the posttest and follow up stages compared t the pretest (P<0.001).In other words, all the three therapeutic treatments resulted in a significant reduction of the subjects' depression. Also, the highest depression improvement rate was achieved in the group with the combined therapy, because in this method the average difference of the scores of the pretest-posttest was 14.80 and while it was 15.03 in the follow-up stage, and resulted in reduced depression rate among the adolescents more than other methods. Therapeutic methods used in the major depression disorder are varied and most studies suggest that a combination of cognitive behavioral therapy and pharmacotherapy are the most effective treatment in treating the depression disorder [12].

In this area, Jonghe De, et al. [28] argues that a combination of pharmacotherapy and cognitive behavioral therapy in the patients suffering from major depression disorder is more effective than the pharmacotherapy and the cognitive behavioral therapy individually, where these findings are in line with those of this research [28]. In this research three cognitive behavioral therapy, pharmacotherapy and combined therapy methods were assessed. Results indicated that in the pharmacotherapy method the students' depression under study was reduced after prescription, such that the Maria Cowaks average depression difference (CDI) of them was statistically significant before and after the pharmacotherapy. Also, the findings revealed that the effectiveness of the pharmacotherapy at the posttest was higher than that of the cognitive behavioral therapy. On the other hand, the cognitive behavioral therapy (CBT) was effective in treating major depression disorder and a statistical test analysis is indicative of a significant difference. In fact, the CBT is a useful way for treating depression in the past five years [29]. Also, research results in the follow up stage indicated that cognitive therapy not only maintains its reliability in the course of time but it also overtakes the pharmacotherapy in terms of effectiveness (13.20 vs. 12.30).

Some researchers, following depressed patients undertaking the CBT method for six years concluded that cognitive therapy tactics would reduce considerably the risk of depression relapse [28]. This finding is in line with the present paper. Research results suggest a reduction of pharmacotherapy at the follow up stage, indicating pharmacotherapy needs a longer treatment period of time and in case drugs consumption is stopped, there is a possibility of a relapse of the disease. This finding is in line with Paykel researches who writes in this regard: despite the taking of antidepressants, the problem of depression relapse still remains and using the CBT substantially reduces the relapse of this patience [30]. In this regard, Scott et al, write over the effectiveness of the CBT over the depression disorder: the depressed patient undertaking cognitive therapy measures had a substantial low relapse level compared to the control group (47%) [29]. Research findings by Paykel and Scott et al reaffirm those of the current paper with respect to a combination of the CBT with the pharmacotherapy in order to avoid the relapse. Because in this a sense, the CBT by the therapist through altering thoughts and changing daily and social activities of the affected will break down a vicious cycle of negative automatic thoughts and unpleasant emptions among the patients and hereby, it will result in the improvement of the patients [31]. Hence, the effectiveness of the CBT can be justified in treating the major depression and its stability in the course of time based of the Beck theory. 

All in all, Due to the hormonal changes of adolescence, it was assumed that pharmacotherapy can have a greater impact on the mood and treating depression in adolescents compared to cognitive behavioral therapy. But as a result of this study, we got to this point, that cognitive behavioral therapy is more effective in improving symptoms of depression in adolescents. Piaget’s theory can be cited to explain this result. As he say, from the concrete, black-and-white thinkers, adolescents become able to think abstractly and in shades of gray. They are now able to analyze situations logically in terms of cause and effect and to entertain hypothetical situations and use symbols, such as in metaphors, imaginatively [32]. This higher-level thinking allows them to think about the future, evaluate alternatives, and set personal goals [33]. Although there are marked individual differences in cognitive development among youth, these new capacities allow adolescents to engage in the kind of introspection and mature decision making that was previously beyond their cognitive capacity. Cognitive competence includes such things as the ability to reason effectively, problem solving, think abstractly and reflect, and plan for the future. So as mentioned before it can be deduced that the impact of cognitive behavioral therapy was great in youth as a result of cognitive development in them and more involvement to the cognitive tasks more than before.

At the end a noteworthy point in this research is that the range of therapeutic method was extended to the junior school level from the hospital arena and from adults to the adolescents. Also, the researchers maintain that for treating the major depression, it is better to combine the therapeutic method instead of solely relaying on one method.

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