Treating Adolescent Depression With Psychotherapy: The Three Ts
Treating Adolescent Depression With Psychotherapy: The Three Ts
Adolescence is a time of increased vulnerability for depression, with risk factors driven by biological, cognitive, and social-environmental changes in development. More than half of all adolescents report experiencing depressed mood, and 8% to 10% experience clinically diagnosable symptoms.1 Depression in the young negatively affects all areas of development, including academic, cognitive, social, and family functioning, and if untreated, it can have significant lasting consequences.
Depression in adolescence is a strong predictor of recurrent depression in adulthood and long-term functional impairment, and it confers a 10-fold increase in risk for suicidal behavior.2 Clearly, depression is a significant health concern among youths, with the potential for severe and lasting consequences: the need for effective intervention is unambiguous.
Fortunately, there is strong empirical evidence for successful therapeutic treatment of adolescent mental health disorders, including depression. Psychotherapy for depression is as effective as medication in many cases and is the recommended first-line intervention for mild to moderate depression in youths. This article offers a brief review of the psychotherapeutic “three T’s” for depression: cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), and dialectical behavior therapy (DBT).
CBT is an evidence-based approach that has been tailored to treat a wide variety of mental health concerns in youths, including anxiety, eating disorders, impulse control disorders, ADHD, oppositional defiant disorder (ODD), and a range of other problematic behaviors in addition to specific adaptations for depression. Generally, CBT is directive, time-limited, structured, problem-focused, and goal-oriented. Weekly session structure begins with collaborative agenda setting and homework review and ends with review and consolidation of new skills learned and the assignment of new homework.
Treatment typically ranges from 4 to 20 sessions, depending on program choice and setting, although treatment of comorbid conditions or severe symptoms can take longer. Clinicians may use various combinations of CBT techniques, or they may adhere to a specific manualized program. Common CBT interventions include psychoeducation (helping the patient and parents understand the connection between thoughts, feelings, and behaviors), mood monitoring (keeping a mood diary, linking emotions to thoughts), pleasant activities (creating a list of activities that the patient enjoys and setting aside daily time to engage in them), behavior activation techniques (joining a sports team, going for nightly family walks), and cognitive restructuring (identifying cognitive distortions and negative thinking patterns and replacing them with more realistic and/or positive ways of thinking). Social, communication, conflict-resolution, and problem-solving skills are also frequent components of CBT programs.
CBT has an extensive research base and a longer history than either IPT or DBT; as such, the approach has traditionally been considered the gold standard for the treatment of childhood and adolescent depression. Meta-analyses in 1998 and 1999 found effect sizes for CBT treatment of depression in youths of 1.02 and 1.27 respectively.3,4 A more recent meta-analysis of 35 studies found a less pronounced effect size of 0.34, although this still represents a clinically significant small to medium treatment effect.5 On the basis of these findings, in 2008 CBT received status as a well-established treatment for youths, according to the guidelines set by Nathan and Gorman.6
In addition to comparisons with wait list control and treatment as usual (TAU), CBT has also been compared with psychopharmacological intervention, primarily SSRIs. One of the most cited and controversial studies is the multisite 2004 Treatment of Adolescent Depression Study (TADS).7 In this efficacy study, 439 depressed adolescents were treated with CBT, fluoxetine, a combination of the two, or a placebo. Results favored the combination of fluoxetine and CBT, followed by fluoxetine alone, and then CBT and placebo.
In contrast to existing findings, CBT was not found to be significantly more effective than placebo, and CBT’s effectiveness was questioned. However, supporters of CBT are quick to note mediating factors and design irregularities in the study. It remains noteworthy that the combination treatment in this study was most effective for depressed youths, particularly because of the potential of CBT to act as a buffer against negative life stress and suicide, which psychopharmacology alone may not address. In addition, later studies, such as the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA), support the finding for combined CBT psychotherapy and medication in recalcitrant cases.8
The Practice Parameters of the American Academy of Child and Adolescent Psychiatry (AACAP) suggest that youths with mild depression may respond to CBT alone, whereas moderately to severely depressed youths may require CBT (or other psychotherapies) along with antidepressants. These guidelines also recommend that treatment continue for 6 to 12 months to avoid relapse.9
Many of the CBT programs for treatment of depression were developed initially in a group-delivery modality for research expediency. However, these programs can be tailored to the individual and applied within a variety of clinical settings, including outpatient, inpatient, schools, and partial hospitalization programs. CBT manuals range in level of directedness, from specific session by session instruction (Taking Action) to more principle-based manuals that guide the therapy and allow greater flexibility (Brent’s model within the Pittsburgh clinical trials).10-12 The level of parental involvement also varies across CBT approaches but is generally viewed as an important element and essential for children and younger adolescents (Table 1).
IPT is a well-established, structured, time-limited therapy developed specifically for the treatment of nonbipolar, nonpsychotic major depression in adults. The original model was adapted for adolescents (IPT-A) by Mufson and colleagues13 in 1994. IPT-A defines the symptoms of depression and their consequences and the maintaining factors through an interpersonal lens, addressing problem areas in the adolescent’s current relationships and immediate social environments to reduce symptoms that contribute to depression.
IPT-A aims to improve communication and problem-solving skills to increase interpersonal effectiveness and relationship satisfaction in adolescents (aged 12 to 18 years). From a developmental psychopathology perspective, focus on interpersonal relationships is paramount during adolescence—a period in which more intimate peer and dating relationships are fostered and parent-child relationships undergo transitions based on adolescent autonomy development. IPT-A identifies 4 interpersonal problem areas that may become the focus of treatment: grief, role dispute, role transition, and interpersonal deficits. Through an interpersonal interview, working as a team, the therapist and patient identify 1 or 2 areas on which to focus.
Treatment is structured over 12 to 16 weeks in 60-minute sessions. The framework consists of 3 phases, in which the therapy aims to:
• Identify a specific interpersonal problem area by examining the patterns in current significant relationships
• Develop communication and problem-solving strategies to address the specific interpersonal problem area
• Practice the skills in session and then transition them to the social environment, providing the patient with support to maintain his or her sense of social competence and independence