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(Drug information on 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
Tips for clinicians using cognitive-behavioral therapy
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).
Interpersonal psychotherapy
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
