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.
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.
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.
- Asarnow JR, Jaycox LH, Duan N, et al. Depression and role impairment among adolescents in primary care clinics. J Adolesc Health. 2005;37(6):477–483. doi:10.1016/j.jadohealth.2004.11.123 [CrossRef]
- Kramer T, Garralda ME. Psychiatric disorders in adolescents in primary care. Br J Psychiatry. 1998;173:508–513. doi:10.1192/bjp.173.6.508 [CrossRef]
- American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry. 2001;40(4):495.
- Kandel DB, Davies M. Adult sequelae of adolescent depressive symptoms. Arch Gen Psychiatry. 1986;43(3):255–262.
- Kessler RC, Berglund PA, Foster CL, Saunders WB, Stang PE, Walters EE. Social consequences of psychiatric disorders, II: Teenage parenthood. Am J Psychiatry. 1997;154(10):1405–1411.
- Kessler RC, Foster CL, Saunders WB, Stang PE. Social consequences of psychiatric disorders, I: Educational attainment. Am J Psychiatry. 1995;152(7):1026–1032.
- Lewinsohn P. Depression in adolescents. In: Hammen C, Gotlib I, eds. Handbook of Depression. New York, NY: Guilford Press; 2002:541–553.
- Rao U, Ryan ND, Birmaher B, et al. Unipolar depression in adolescents: clinical outcome in adulthood. J Am Acad Child Adolesc Psychiatry. 1995;34(5):566–578. doi:10.1097/00004583-199505000-00009 [CrossRef]
- Birmaher B, Brent Dthe 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(11):1503–1526. doi:10.1097/chi.0b013e318145ae1c [CrossRef]
- Asarnow JR, Jaycox LH, Duan N, et al. Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial. JAMA. 2005;293(3):311–319. doi:10.1001/jama.293.3.311 [CrossRef]
- Kovacs M, Devlin B, Pollock M, Richards C, Mukerji P. A controlled family history study of childhood-onset depressive disorder. Arch Gen Psychiatry. 1997;54(7):613–623.
- Puig-Antich J, Goetz D, Davies M, et al. A controlled family history study of prepubertal major depressive disorder. Arch Gen Psychiatry. 1989;46(5):406–418.
- Todd RD, Neuman R, Geller B, Fox LW, Hickok J. Genetic studies of affective disorders: should we be starting with childhood onset probands?J Am Acad Child Adolesc Psychiatry. 1993;32(6):1164–1171. doi:10.1097/00004583-199311000-00008 [CrossRef]
- Fendrich M, Warner V, Weissman MM. Family risk factors, parental depression, and psychopathology in offspring. Dev Psychol. 1990;26:40–50. doi:10.1037/0012-1618.104.22.168 [CrossRef]
- Kaslow NJ, Deering CG, Racusin GR. Depressed children and their families. Clin Psychol Rev. 1994;14:39–59. doi:10.1016/0272-7358(94)90047-7 [CrossRef]
- Sheeber L, Hops H, Davis D. Family processes in adolescent depression. Clin Child Fam Psychol Rev. 2001;4:19–35. doi:10.1023/A:1009524626436 [CrossRef]
- Downey G, Coyne JC. Children of depressed parents: an integrative review. Psychol Bull. 1990;108(1):50–76. doi:10.1037/0033-2909.108.1.50 [CrossRef]
- Fleming JE, Offord DR. Epidemiology of child depressive disorders: A critical review. J Am Acad Child Adolesc Psychiatry. 1990;29(4):571–580. doi:10.1097/00004583-199007000-00010 [CrossRef]
- Garber J, Flynn C. Predictors of depressive cognitions in young adolescents. Cognit Ther Res. 2001;25:353–376. doi:10.1023/A:1005530402239 [CrossRef]
- Gillham JE, Shatte AJ, Freres DR. Preventing depression: a review of cognitive-behavioral and family interventions. Appl Prev Psychol. 2000;9:63–88. doi:10.1016/S0962-1849(00)80007-4 [CrossRef]
- Tamplin A, Goodyer IM. Family functioning in adolescents at high and low risk for major depressive disorder. Eur Child Adolesc Psychiatry. 2001;10(3):170–179. doi:10.1007/s007870170023 [CrossRef]
- Asarnow JR, Goldstein MJ, Tompson M, Guthrie D. One-year outcomes of depressive disorders in child psychiatric inpatients: evaluation of the prognostic power of a brief measure of expressed emotion. J Child Psychol Psychiatry. 1993;34:129–137. doi:10.1111/j.1469-7610.1993.tb00975.x [CrossRef]
- Asarnow JR, Emslie G, Clarke G, et al. Treatment of SSRI-resistant depression in adolescents: predictors and moderators of treatment response. J Am Acad Child Adolesc Psychiatry. 2009;48(3):331–340. doi:10.1097/CHI.Ob013e3181977476 [CrossRef]
- Birmaher B, Brent DA, Kolko D, et al. Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder. Arch Gen Psychiatry. 2000;57(1):29–36. doi:10.1001/archpsyc.57.1.29 [CrossRef]
- Brent DA, Kolko DJ, Birmaher B, et al. Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression. J Am Acad Child Adolesc Psychiatry. 1998;37(9):906–914. doi:10.1097/00004583-199809000-00010 [CrossRef]
- Hammen C, Rudolph K, Weisz J, Rao U, Burge D. The context of depression in clinic-referred youth: neglected areas of treatment. J Am Acad Child Adolesc Psychiatry. 1999;38:64–71. doi:10.1097/00004583-199901000-00021 [CrossRef]
- Asarnow JR, Carlson GA, Guthrie D. Coping strategies, self-perceptions, hopelessness, and perceived family environments in depressed and suicidal children. J Consult Clin Psychol. 1987;55(3):361–366. doi:10.1037/0022-006X.55.3.361 [CrossRef]
- Asarnow JR, Carlson G. Suicide attempts in preadolescent child psychiatry inpatients. Suicide Life Threat Behav. 1988;18(2):129–136.
- Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry. 2006;47(3–4):372–394. doi:10.1111/j.1469-7610.2006.01615.x [CrossRef]
- Diamond G, Josephson A. Family-based treatment research: a 10-year update. J Am Acad Child Adolesc Psychiatry. 2005;44(9):872–887. doi:10.1097/01.chi.0000169010.96783.4e [CrossRef]
- Weissman MM, Pilowsky DJ, Wickramaratne PJ, et al. Remissions in maternal depression and child psychopathology: a STAR*D report. JAMA. 2006;295(12):1389–1398. doi:10.1001/jama.295.12.1389 [CrossRef]
- Wickramaratne P, Gameroff MJ, Pilowsky DJ, et al. Children of Depressed Mothers 1 Year After Remission of Maternal Depression: Findings From the STAR*D-Child Study. Am J Psychiatry. 2011Mar15. [Epub ahead of print] doi:10.1176/appi.ajp.2010.10010032 [CrossRef]
- Kennard BD, Hughes JL, Stewart SM, et al. Maternal depressive symptoms in pediatric major depressive disorder: Relationship to acute treatment outcome. J Am Acad Child Adolesc Psychiatry. 2008;47(6):694–699. doi:10.1097/CHI.0b013e31816bfff5 [CrossRef]
- Diamond G, Siqueland L. Family therapy for the treatment of depressed adolescents. Psychother Res Prac. 1995;32(1):77–90. doi:10.1037/0033-322.214.171.124 [CrossRef]
- Diamond GS, Reis BF, Diamond GM, Siqueland L, Isaacs L. Attachment-based family therapy for depressed adolescents: A treatment development study. J Am Acad Child Adolesc Psychiatry. 2002;41(10):1190–1196. doi:10.1097/00004583-200210000-00008 [CrossRef]
- Asarnow JR, Scott C, Mintz J. A combined cognitive-behavioral family education intervention for depression in children: a treatment development study. Cognit Ther Res. 2002;26:221–229. doi:10.1023/A:1014573803928 [CrossRef]
- Fristad MA, Gavazzi SM, Soldano KW. Multifamily psychoeducation groups for childhood mood disorders: a program description and preliminary efficacy data. Contemp Fam Ther. 1998;20:385–402. doi:10.1023/A:1022477215195 [CrossRef]
- Fristad MA, Goldberg-Arnold JS, Gavazzi SM. Multifamily psychoeducation groups (MFPG) for families of children with bipolar disorder. Bipolar Disord. 2002;4(4):254–262. doi:10.1034/j.1399-5618.2002.09073.x [CrossRef]
- Fristad MA. Psychoeducational treatment for school-aged children with bipolar disorder. Dev Psychopathol. 2006;18(4):1289–1306. doi:10.1017/S0954579406060627 [CrossRef]
- Miklowitz DJ, George EL, Axelson DA, et al. Family-focused treatment for adolescents with bipolar disorder. J Affect Disord. 2004;82(Suppl 1):S113–128. doi:10.1016/j.jad.2004.05.020 [CrossRef]
- Miklowitz DJ, Tompson MC. Family variables and interventions in schizophrenia. In: Sholevar GP, ed. Textbook of Family and Couples Therapy: Clinical Applications. Arlington, VA: American Psychiatric Publishing; 2003:585–617.
- Tompson MC, Pierre CB, Haber FM, Fogler JM, Groff AR, Asarnow JR. Family-focused treatment for childhood-onset depressive disorders: results of an open trial. Clin Child Psychol Psychiatry. 2007;12(3):403–420. doi:10.1177/1359104507078474 [CrossRef]
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- Kennard BD, Emslie GJ, Mayes TL, et al. Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder. J Am Acad Child Adolesc Psychiatry. 2008;47(12):1395–1404. doi:10.1097/CHI.0b013e31818914a1 [CrossRef]
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Common Family Components of CBT for Depression
|Psychoeducation||Orienting the family to the model of understanding depression, the treatment model and treatment goals, and the structure of therapy.|
|Behavioral activation||Encouraging positive family interactions through planning and engaging in fun activities.|
|Expressed emotion||Reducing negativity (eg, criticism and emotional over-involvement) in the home.|
|Problem-solving||Family 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.|
|Communication||Introducing active listening and communication skills to the family and practicing use of these skills in session.|
|Contingency management||Helping 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.|