Pediatric Annals

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CME Article 

Family Intervention Strategies for Adolescent Depression

Jennifer L. Hughes, PhD; Joan Rosenbaum Asarnow, PhD

Abstract

Youth presenting to primary care providers with physical complaints may also be experiencing psychiatric symptoms. Results of studies that have screened primary care patients for depressive symptoms have revealed high levels of depression (20% to 40%), with elevated rates of depression likely to be observed among youths with general medical conditions, as well as youths who use primary care services at high rates.1–2 Depression places youth at risk for numerous adverse outcomes, including psychosocial difficulties, drug and alcohol abuse, academic problems, early parenthood, suicidality, and adult depression.3–8 Both antidepressant medications and psychotherapy have demonstrated efficacy in the treatment of pediatric depression,9 and research demonstrates the value of integrating evidence-based depression treatment within primary care settings.10 In addition, the current American Academy for Child and Adolescent Psychiatry (AACAP) practice parameters for childhood depression highlight the importance of including the family in the child’s treatment, because factors such as family knowledge of depression, parental psychiatric symptoms, motivation for treatment, family conflict, and family monitoring of the youth must be addressed.

Abstract

Youth presenting to primary care providers with physical complaints may also be experiencing psychiatric symptoms. Results of studies that have screened primary care patients for depressive symptoms have revealed high levels of depression (20% to 40%), with elevated rates of depression likely to be observed among youths with general medical conditions, as well as youths who use primary care services at high rates.1–2 Depression places youth at risk for numerous adverse outcomes, including psychosocial difficulties, drug and alcohol abuse, academic problems, early parenthood, suicidality, and adult depression.3–8 Both antidepressant medications and psychotherapy have demonstrated efficacy in the treatment of pediatric depression,9 and research demonstrates the value of integrating evidence-based depression treatment within primary care settings.10 In addition, the current American Academy for Child and Adolescent Psychiatry (AACAP) practice parameters for childhood depression highlight the importance of including the family in the child’s treatment, because factors such as family knowledge of depression, parental psychiatric symptoms, motivation for treatment, family conflict, and family monitoring of the youth must be addressed.

Jennifer L. Hughes, PhD, is Postdoctoral Scholar, Integrated Mood Disorders Program, University of California, Los Angeles, Semel Institute for Neuroscience & Behavior. Joan Rosenbaum Asarnow, PhD, is Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Semel Institute for Neuroscience & Behavior.

Dr. Hughes and Dr. Asarnow have disclosed no relevant financial relationships.

Address correspondence to: Jennifer L. Hughes, PhD, 300 UCLA Medical Plaza, Los Angeles, CA 90095; or email: JLHughes@mednet.ucla.edu.

Youth presenting to primary care providers with physical complaints may also be experiencing psychiatric symptoms. Results of studies that have screened primary care patients for depressive symptoms have revealed high levels of depression (20% to 40%), with elevated rates of depression likely to be observed among youths with general medical conditions, as well as youths who use primary care services at high rates.1–2 Depression places youth at risk for numerous adverse outcomes, including psychosocial difficulties, drug and alcohol abuse, academic problems, early parenthood, suicidality, and adult depression.3–8 Both antidepressant medications and psychotherapy have demonstrated efficacy in the treatment of pediatric depression,9 and research demonstrates the value of integrating evidence-based depression treatment within primary care settings.10 In addition, the current American Academy for Child and Adolescent Psychiatry (AACAP) practice parameters for childhood depression highlight the importance of including the family in the child’s treatment, because factors such as family knowledge of depression, parental psychiatric symptoms, motivation for treatment, family conflict, and family monitoring of the youth must be addressed.9

Adolescent Depression and the Family

The period of adolescence includes several important developmental tasks. The youth is working toward increased independence and autonomy, which may create stress for caregivers as they maintain boundaries and limits to minimize risk. In addition, youth typically desire to spend increased time developing social relationships outside of the family context, requiring parents to trust their children to make safe choices related to friends and peer activities. Still, the family continues to be an important support system for the youth.

Depression in youth affects the family unit as a whole, and parental depression and child depression can often co-occur in families.11–13 Other common difficulties in families of depressed youth include communication problems, low levels of family cohesion and support, excessive control, and increased conflict.14–16 High levels of negative affect, conflict, and hostility in families are also associated with depression.17–21

Family factors may also affect treatment outcomes and maintenance of depression in youth.20, 22–26 In young preadolescent child psychiatric inpatients, children’s perceptions of high levels of family conflict and low support were associated with suicide attempts, while depression was associated more closely with measures reflecting negative cognitive biases (eg, hopelessness, low self-esteem).27,28 In contrast, strong family relationships may play a protective role. In the youth suicide prevention literature, family variables, including parent-child connectiveness and active parent supervision, are related to better outcomes.29

Because family factors are highly related to pediatric depression, treatment strategies for youth should involve the family.16 Mental health providers may use multiple approaches to include the family, with flexibility in which family members are included, in their roles (eg, coach, co-therapist, patient), and in session format (eg, parent groups, individual and family sessions, etc.).30

Treatment of depression in any one family member might have beneficial effects on others in the family. Children of depressed mothers have exhibited improvement in depressive symptoms and functioning over the course of the mother’s treatment, with continued longer-term gains for the youth.31–32 In another study, maternal depressive symptoms improved as youth were treated for depression.33

Family-Focused Interventions for Adolescents

Evidence for family therapies for pediatric depression is limited but promising. Diamond and colleagues randomly assigned 32 adolescents with major depressive disorder (MDD) to 12-week attachment-based family therapy (ABFT) or a 6-week waitlist control group.34–35 They found that 81% of adolescents treated with ABFT no longer met criteria for MDD, compared with only 47% in the waitlist control. The ABFT treatment group also reported decreases in family conflict, depressive symptoms, and anxiety symptoms.35 The ABFT was designed to address maladaptive interactions in the family by enhancing adolescent-parent relationships and promoting attachments, as well as enhancing the adolescent’s strengths.34–35

Family psychoeducation is often used in the treatment of mood disorders in youth36–40 and adults,41 including education about the mood disorder coupled with coping skills. In a recent treatment development study, Tompson and colleagues introduced a family therapy approach for childhood depression42 in which families were taught that interpersonal processes are related to mood states, providing a rationale for intervening in these processes. The therapist then introduced skills to enhance interactional processes. After treatment, 66% of youth no longer met diagnostic criteria for depressive disorders on the Schedule for Affective Disorders and Schizophrenia for School-Age Children — Present and Lifetime Version (KSADS-PL),43 and 77% reported recovery 3 months post-treatment.42

Individual Interventions with Family Elements

Cognitive behavioral therapy (CBT) interventions for youth depression often include family components, varying in the number of sessions, content, and structure of sessions (see Table).44–49 For example, the Treatment of Resistant Depression in Adolescents (TORDIA) study included parent psychoeducation sessions across treatments. These sessions provided basic information about depression, possible treatments, and coping with a depressed youth.49 The CBT intervention also included conjoint parent and youth sessions to address family communication, decreased criticism, enhanced support, and problem-solving, with three to six of the acute phase sessions designed to be family sessions.49 In later analysis of the CBT treatment components, adolescents received a mean of one family session (range = 0 to 7), and 12% of participants received a family-oriented component.50 Receipt of a family-oriented component was not associated with treatment response,50 which is in line with prior results.44,47 Thus, it remains unclear whether adding family intervention to individual or group CBT results in treatment gains for adolescents being treated for depression.

Common Family Components of CBT for Depression

Table. Common Family Components of CBT for Depression

Family-Based Therapy vs. Individual Therapy

Two studies have directly compared family therapy with individual therapy, with mixed results. Brent and colleagues randomly assigned 107 adolescents with MDD to either CBT, SBFT, or individual nondirective supportive therapy (NST).51 Youth received 12 to 16 weekly sessions, followed by two to four monthly booster sessions. All three treatments included up to 1 hour of family psychoeducation, with the SBFT treatment focusing on the identification of dysfunctional behavior patterns in families, enhanced communication, and problem-solving skills. At the end of treatment, the CBT group demonstrated significantly lower rates of MDD compared with the NST group, and higher remission rates compared with both the NST and SBFT groups (remission rates: CBT, 60%; NST, 39%; SBFT, 38%). All three groups showed improvements in functioning and suicidality.51 There were no differences on depression recovery or recurrence between the three groups at 2-year follow-up.24

Trowell and colleagues randomly assigned 72 youths (ages 9 to 15) to individual psychodynamic psychotherapy (n = 35) or family therapy (n = 37).52 Youths received treatment for 9 months with either family therapy or individual psychodynamic psychotherapy with parent sessions by a separate case manager. The individual psychodynamic psychotherapy addressed interpersonal relationships, life stress, and problematic attachments, whereas the family therapy addressed family dysfunction with attention to unresolved conflicts and early childhood.52 There were no differences between treatments on clinician-rated measures of depression both post-test and at 6 months, with both treatments resulting in improvements. The family therapy group was superior on self-reported depression at post-treatment.

Integration of Depression Treatment in Primary Care Settings

A review of the emerging literature2,10,53–56 demonstrating the value of integrating depression treatment for children and adolescents within primary care settings is beyond the scope of this article. However, we provide some examples of various approaches below.

Gledhill and colleagues introduced an intervention involving primary care screening plus a management strategy involving: 1) Providing feedback regarding the depression; 2) Suggesting coping strategies, such as mobilizing help, identifying a confidant, activity scheduling, and reinforcement; 3) Emphasizing the likely resolution of symptoms; and 4) Inviting the adolescent back for a follow-up visit.56 Adolescent satisfaction with this approach was high.

A more intensive 6-month quality improvement intervention was evaluated in the Youth Partners in Care (YPIC) study in six different clinical sites within five different health care organizations. The intervention was designed to increase access to evidence-based depression treatment (primarily CBT and antidepressant medication) through primary care.10 Intervention patients demonstrated significant improvements in depressive symptoms at 6 months, with longer-term changes in illness course at 12 and 18 months.10,57 Intervention patients were also more likely to receive mental health care and therapy.10

An alternative approach is being used in a study in progress, in which the focus is placed on reducing health risk behaviors associated with depression, specifically substance use, smoking, obesity (diet and exercise), and risky sexual behavior. Since these topics may be more easily integrated with the general health focus of the primary care setting (eg, pregnancy and STI prevention), and our prior work demonstrates that youths tend to prefer psychosocial versus medication treatments,58 this type of cognitive-behavioral intervention could have broader acceptability within primary care youth populations.

Conclusions

Family components have generally been included in interventions for depressed children and adolescents, and are particularly critical for younger children who are dependent on their parents to support them in achieving critical developmental tasks and transitions. There is considerable research in progress evaluating the value of family-centered interventions for youths; treatments with demonstrated efficacy generally include some work with parents.

There is a general belief that some family education is needed regarding the nature of depression, how to cope with depressive symptoms, and how parents and families can support recovery. Moreover, depressed children often have parents with depression, and treatment for depression in parents has been shown to be associated with improved outcomes in children.31 Recent advances in strategies for integrating behavioral health treatment within primary care practices in conjunction with the advances achieved in depression treatment are likely to lead to improved depression care within pediatric practice.

References

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Common Family Components of CBT for Depression

ComponentDescription
PsychoeducationOrienting the family to the model of understanding depression, the treatment model and treatment goals, and the structure of therapy.
Behavioral activationEncouraging positive family interactions through planning and engaging in fun activities.
Expressed emotionReducing negativity (eg, criticism and emotional over-involvement) in the home.
Problem-solvingFamily practice of problem-solving strategies, including describing the problem, brainstorming possible solutions and evaluating the pros and cons of each, and making a plan to implement the chosen solution.
CommunicationIntroducing active listening and communication skills to the family and practicing use of these skills in session.
Contingency managementHelping parents/caregivers identify target behaviors, which might be contributing to the maintenance of depressive symptoms. Collaborating with the family to develop a system of reinforcement and punishment to shape the target behaviors.

CME Educational Objectives

  1. Describe the relationship between family function and the development of depression during adolescence.

  2. Discuss family-focused interventions for adolescents with depression, as well as individual interventions that may include family elements.

  3. Spotlight the role of primary care interventions in the management of depression in adolescents.

Authors

Jennifer L. Hughes, PhD, is Postdoctoral Scholar, Integrated Mood Disorders Program, University of California, Los Angeles, Semel Institute for Neuroscience & Behavior. Joan Rosenbaum Asarnow, PhD, is Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Semel Institute for Neuroscience & Behavior.

Dr. Hughes and Dr. Asarnow have disclosed no relevant financial relationships.

Address correspondence to: Jennifer L. Hughes, PhD, 300 UCLA Medical Plaza, Los Angeles, CA 90095; or email: .JLHughes@mednet.ucla.edu

10.3928/00904481-20110512-07

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