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.
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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
1. Shaffer D, Fisher P, Dulcan MK, et al. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. J Am Acad Child Adolesc Psychiatry. 1996;35:865-877.
2. Berman A, Jobes D, Silverman M. Adolescent Suicide: Assessment and Intervention. 2nd ed. Washington, DC: American Psychological Association; 2006.
3. Reinecke MA, Ryan NE, DuBois DL. Cognitive-behavioral therapy for depression and depressive symptoms during adolescence: a review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 1998;37:26-34.
4. Lewinsohn PM, Clarke GN. Psychosocial treatments for adolescent depression. Clin Psychol Rev. 1999;19:329-342.
5. Weisz J, McCarty C, Valeri S. Effects of psychotherapy for depression in children and adolescents: a meta-analysis. Psychol Bull. 2006;132:132-149.
6. Nathan PE, Gorman JM, eds. A Guide to Treatments That Work. 2nd ed. New York: Oxford University Press; 2002.
7. March J, Silva S, Petrycki S, et al; Treatment for Adolescents With Depression Study (TADS) Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292:807-820.
8. Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA. 2008;299:901-913.
9. Birmaher B, Brent D; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:1503-1526.
10. Stark KD, Streusand W, Krumholz LS, Patel P. Cognitive-behavioral therapy for depression: The ACTION treatment program for girls. In: Weisz JR, Kazdin AE, eds. Evidence-Based Psychotherapies for Children and Adolescents. 2nd ed. New York: Guilford Press; 2010:93-109.
11. Stark KD, Simpson J, Schnoebelen S, et al. Therapist’s Manual for ACTION. Broadmore, PA: Workbook; 2004.
12. Brent DA, Holder D, Kolko D, et al. A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Arch Gen Psychiatry. 1997;54:877-885.
13. Mufson L, Moreau D, Weissman MM, et al. Modification of interpersonal psychotherapy with depressed adolescence (IPT-A): phase I and phase II studies. J Am Acad Child Adolesc Psychiatry. 1994;33:695-705.
14. Cuijpers P, Geraedts AS, van Oppen P, et al. Interpersonal psychotherapy for depression: a meta-analysis [published correction appears in Am J Psychiatry. 2011;168:652]. Am J Psychiatry. 2011;168:581-592.
15. Rosselló J, Bernal G. The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. J Consult Clin Psychol. 1999;67:734-745.
16. Tang TC, Jou SH, Ko CH, et al. Randomized study of school-based intensive interpersonal psychotherapy for depressed adolescents with suicidal risk and parasuicide behaviors. Psychiatry Clin Neurosci. 2009;63:463-470.
17. Bolton P, Bass J, Betancourt T, et al. Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: a randomized controlled trial. JAMA. 2007;298:519-527.
18. de Mello MF, de Jesus Mari J, Bacaltchuk J, et al. A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders. Eur Arch Psychiatry Clin Neurosci. 2005;255:75-82.
19. Elkin I, Shea MT, Watkins JT, et al. National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments. Arch Gen Psychiatry. 1989;46:971-982.
20. Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press; 1993.
21. Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav. 2002;32:146-157.
22. Miller AL, Rathus JH, Linehan MM. Dialectical Behavior Therapy With Suicidal Adolescents. New York: Guilford Press; 2007.
23. Salsman NL, Arthur R. Adapting dialectical behavior therapy for suicidal adolescents. Curr Psychiatry. 2011;10:18-23.
24. Lynch TR, Chapman AL, Rosenthal MZ, et al. Mechanisms of change in dialectical behavior therapy: theoretical and empirical observations. J Clin Psychol. 2006;62:459-480.
25. Fleischhaker C, Böhme R, Sixt B, et al. Dialectical behavior therapy for adolescents (DBT-A): a clinical trial for patients with suicidal and self-injurious behavior and borderline symptoms with a one-year follow-up. Child Adolesc Psychiatry Ment Health. 2011;5:3.