How effective is psychotherapy for the treatment of depression in children and adolescents?
Concern has been raised recently about the efficacy andsafety of antidepressants for treatment of depressionin children. Some clinicians, therefore, have suggestedthat psychotherapy be started before medication treatmentof depression in children. How effective is psychotherapyfor the treatment of depression in children and adolescents?
Weisz and associates1 recently conducted a meta-analysis to assess the effects of psychotherapy for the treatment of depression in children and adolescents. This is the largest study sample to date on this topic. Given the significance of the findings, it is important to understand what kinds of studies were included in the analysis.
The authors applied strict inclusion criteria. Patients were required to have elevated levels of depressive symptoms, a diagnosis of a major depressive disorder or dysthymic disorder, or research diagnostic criteria diagnoses of minor or intermittent depression. Patients had to be randomly assigned to at least 1 active treatment group and to 1 nonactive treatment group (untreated, waiting list, minimally treated, or placebo-control group). The study sample had to have a mean age of 19 years or younger. Finally, the treatments used had to target depressive symptoms or disorder. In addition to including published studies, the authors also included non–peer-reviewed studies and doctoral dissertations in order to avoid possible publication bias.
Thirty-five studies met criteria for inclusion. The number of participants inthe separate studies ranged from 9 to 439. Many types of psychotherapy wereused, including cognitive-behavioral therapy with and without a family component; systemic behavioral family therapy; interpersonal psychotherapy; attachment-based family treatment; social skills training; relaxation training; social competency training; structuredlearning therapy; self-control; behavioral problem solving; rational emotive therapy; role-playing; and cognitive bibliotherapy. The patients were obtained from a wide variety of settings, such as the community, schools, day-treatment programs, and outpatient settings. Theage of the participants included in the sample ranged from 7 to 19 years.
A number of important clinical questions were addressed in the meta-analysis. First, is psychotherapy effective for depression in children and adolescents? The meta-analysis showed that the overall mean effect size for psychotherapy was 0.34, which is a modest effect size. (In general, a small effect size is about 0.20 and a large effect size is about 0.80.)
The investigators also compared the effect size of psychotherapy for depression to psychotherapy for other childhood conditions such as aggression,attention deficit hyperactivity disorder, and fears. The effect size for these nondepression conditions was 0.69, which was significantly higher than the effect of psychotherapy for depression.
Second, does the effect of psychotherapyfor depression in childrenand adolescents last? At follow-upassessments 1 year after treatment, therewas practically no treatment effect. Inessence, the improvements made duringthe course of acute treatment were notapparent a year later.
Third, are psychotherapy treatmentsthat focus on changing cognitions moreeffective than those that do not addresschanging cognitions? The analysisshowed that the mean effect size forcognitive treatments was 0.35 and fornoncognitive treatments was 0.47 Ñ nota significant difference. Therefore, therewas no advantage in using treatment thatemphasized change in cognitions, suchas cognitive-behavioral therapy.
Fourth, does psychotherapy have abeneficial effect on suicidality? Six ofthe studies in the sample included a measureof suicidality and were used for thisanalysis. The mean effect size for thesuicidality measures was 0.18. Therefore,the psychotherapy did not seem tohave an effect on improvement in suicidalthinking and behavior.
Overall, the results of the meta-analysisby Weisz and colleagues showed thatpsychotherapy for depression in childrenand adolescents had a modest effectand that this effect was not long lasting.These results raise concern as to whythe psychotherapy was not more effectivefor youth.
Study design issues such as patient characteristics,comorbid conditions, treatmentduration, assessment measures,skill of the therapist, and concurrenttreatments are some factors that mayaffect study outcome. These may berelated to the finding of weak efficacy for psychotherapy in depressed childrenand adolescents.
Another consideration, perhaps a morecrucial one, is that the leading psychotherapytreatments for depression were developedfor adults. Cognitive-behavioraltherapy, which focuses on changing apersonÕs thinking in order to improvedepressive symptoms, was developed forthe treatment of depressed adults.Similarly, interpersonal psychotherapy,which focuses on interpersonal behavior,was developed for depressed adults.Although these treatments have beenmodified for use in depressed adolescents,their origins are in the treatment of adultpsychopathology. It may be time todevelop new psychotherapy models thatare based on specific developmental levels(eg, social, emotional, and cognitivefeatures) specific to children and specificto adolescents in order to find more effectivepsychotherapy treatments.
Depression in children and adolescentsis a serious disorder that impairsa child's overall functioning and family life. Better medicationtreatments and better psychotherapytreatments are desperatelyneeded for these children. It maybe time to substantiallyincrease collaborationamong psychopharmacology researchers andpsychotherapy researchers in the areaof childhood depression, in the pharmaceuticalindustry, and in the NationalInstitute of Mental Health in order toidentify more effective treatments forchildhood depression.
Dr Wagner is the Robert L. StubblefieldProfessor in the department of psychiatry andbehavioral sciences and director of child andadolescent psychiatry at the University of TexasMedical Branch at Galveston.
Weisz JR, McCarty CA, Valeri SM. Effects of psychotherapyfor depression in children and adolescents: a metaanalysis.Psychol Bull. 2006;132:132-149.