Pediatric Annals

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CME Article 

Cognitive Behavioral Treatment of Depression in Youth

Jodi R. Mahoney, BS; Betsy D. Kennard, PsyD, ABPP; Taryn L. Mayes, MS

Abstract

Depression is a major public health problem in youth, with an estimated prevalence of 2% to 6% of children and adolescents manifesting this disorder at any one time, and lifetime prevalence rates estimated at 20% by late adolescence.1–3 The illness can contribute to significant impairment in youth academic, family, and social functioning and is associated with an increased risk for suicide. Additionally, depression may have a negative effect on youth development that can contribute to longstanding impairment and increased risk for depression and other mental illness into adulthood. Thus, it is imperative that depression be identified and treated early to reduce the burden on youth during this important developmental stage.

Abstract

Depression is a major public health problem in youth, with an estimated prevalence of 2% to 6% of children and adolescents manifesting this disorder at any one time, and lifetime prevalence rates estimated at 20% by late adolescence.1–3 The illness can contribute to significant impairment in youth academic, family, and social functioning and is associated with an increased risk for suicide. Additionally, depression may have a negative effect on youth development that can contribute to longstanding impairment and increased risk for depression and other mental illness into adulthood. Thus, it is imperative that depression be identified and treated early to reduce the burden on youth during this important developmental stage.

Jodi R. Mahoney, BS; Betsy D. Kennard, PsyD, ABPP; and Taryn L. Mayes, MS, are with University of Texas Southwestern Medical Center at Dallas.

Ms. Mahoney, Dr. Kennard, and Ms. Mayes have disclosed no relevant financial relationships.

Address correspondence to: Betsy D. Kennard, PsyD, ABPP, 5323 Harry Hines Blvd., Mail Code 8589, Dallas, TX 75390; fax: 214-456-4235; or email: Beth.Kennard@utsouthwestern.edu.

Depression is a major public health problem in youth, with an estimated prevalence of 2% to 6% of children and adolescents manifesting this disorder at any one time, and lifetime prevalence rates estimated at 20% by late adolescence.1–3 The illness can contribute to significant impairment in youth academic, family, and social functioning and is associated with an increased risk for suicide. Additionally, depression may have a negative effect on youth development that can contribute to longstanding impairment and increased risk for depression and other mental illness into adulthood. Thus, it is imperative that depression be identified and treated early to reduce the burden on youth during this important developmental stage.

The criteria for depression are essentially similar between children and adults (children can present with irritable as opposed to depressed mood), but the clinical presentation and description of the illness by youth and their parents can be vastly different. Children and adolescents are often less able to verbalize feelings of sadness and depression and are more likely to describe symptoms of irritability, labile mood, boredom, poor concentration, somatic complaints (unexplained headaches or stomachaches), and vegetative changes, including changes in sleep, weight, or appetite.3,4 Youth and their parents may be unaware of the nature of the difficulties the youth is experiencing; as a result, it is common for youth with depression to present to a primary care setting for treatment. Physicians must be alerted to the possibility of depression when the above symptoms are emphasized by a youth or his or her parent to ensure that the youth receives the appropriate diagnosis and treatment.

Once depression has been identified through the use of appropriate screening tools and a clinical evaluation, the medical professional will need to consider all of the relevant information about the child’s characteristics and clinical presentation to make a decision about the best treatment option. In the treatment of depression in children and adolescents, research has demonstrated the effectiveness of both antidepressant medication and psychotherapy in reducing depressive symptoms and preventing relapse.4 Current practice parameters for the assessment and treatment of childhood depression recommend that youth experiencing mild depression may benefit from initial treatment in a supportive psychotherapy environment. Depressed youth who do not respond to supportive psychotherapy or those who initially present with more severe depression, suicidality, or significant functional impairment, may benefit most from either a specific evidence-based psychotherapy, such as cognitive behavioral therapy, antidepressant medication, or their combination.4 In addition, youth should continue to receive treatment for an additional 6 to 12 months after the achievement of an initial response to consolidate gains and prevent relapse. To provide competent and comprehensive care for youth, medical providers and mental health professionals must maintain collaborative relationships throughout the course of treatment. Given the emphasis in current practice on the use of evidence-based psychotherapies in treating youth with depression, the following presents an overview of cognitive behavioral therapy and recent research support regarding its effectiveness.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a short-term, structured psychotherapy originally developed to treat adults with depression.5 The CBT model outlines the relationship between a person’s thoughts, feelings, and behaviors and their reciprocal influence on one another. In particular, cognitive errors, typically in the form of negative thoughts and misattributions of self and others, as well as maladaptive coping behaviors, such as isolation and avoidance, can lead to the experience of various negative emotions. According to this treatment model, depression occurs as a result of maladaptive cognitions about oneself, the world, and the future. The treatment focuses on recognizing and addressing these negative thoughts and behaviors to decrease depressive symptoms. CBT uses a structured approach to sessions and includes the teaching of specific strategies, which can be tailored to the individual needs of the patient. In the treatment of depression, some of the primary skills taught may include mood monitoring, behavioral activation, cognitive restructuring, and the development of problem-solving and social skills.

CBT is particularly amenable to research and dissemination because of its reliance on a specific structure and ease of breaking down the therapy into components. Several manuals have been developed, specifically for the treatment of depression in youth.6–8 Although these manuals differ in structure (set sequence of sessions vs. flexible), format (group, individual, inclusion of parent), and focus (emphasis on one component over another), several commonalities are present in the cognitive behavioral treatment of depression in youth.

The initial goal is to develop a collaborative relationship between the therapist and patient who then work together to formulate appropriate goals and achieve symptom relief.

Depending on the unique presentation of each youth, certain skills may be emphasized over others. For example, if a youth presents with significant anhedonia, defined as a loss of interest or pleasure in normally enjoyable activities, and hypersomnia, the therapist may encourage the client to begin monitoring his/her mood and planning some activities in which to engage; this strategy is called behavioral activation.

In contrast, cognitive restructuring may be the focus of therapy when working with a youth experiencing primarily ruminative depressed thoughts. These youth may become overly focused on their situation and become caught in a cyclical negative thought pattern. Cognitive restructuring can assist these youth in considering alternative information and forming a more realistic and helpful view of themselves, which can positively affect their mood. Although most of the evidence behind CBT has been established in clinical research settings as opposed to community based practices,9 the current manuals developed in the major clinical trials provide mental health professionals with a framework for the delivery of CBT in any setting. See Table 1 (page 308) for an outline of the typical sequence and Table 2 for a detailed description of the common skills taught in CBT for depression in youth.

Sample CBT Treatment Outline

Table 1. Sample CBT Treatment Outline

Common Components of CBT for Depression

Table 2. Common Components of CBT for Depression

Efficacy of Psychosocial Treatment for Depression

Estimates from a meta-analysis of randomized controlled trials indicate that the effects of psychotherapy for the treatment of depression in youth were modest (mean effect size = 0.34), across all types of psychotherapy.10 Recent evidence has provided support for specific psychotherapies for depression, such as CBT, interpersonal therapy (IPT), systemic behavioral family therapy (SBFT), and supportive therapy. The majority of these early studies compared a specific psychotherapy with an inactive control group, with relatively few studies comparing different psychotherapies to one another in a between-group comparison.11 However, results from a between-group design comparing CBT and IPT among Puerto Rican adolescents found that CBT produced slightly greater improvements in self-reported depressive symptoms.12

Additionally, depressed adolescents may experience a greater reduction in depressive symptoms and achieve remission more quickly when treated with CBT as compared with another psychosocial treatment or to wait-list controls.13 In relation to the other empirically supported therapies, CBT has the largest evidence base and is the most widely disseminated psychotherapy method for treating youth with depression.14 Thus, when considering the use of psychotherapy for the treatment of depressed youth, CBT is an effective treatment strategy.

Reviews of psychotherapy in the acute treatment of depression favor the effectiveness of CBT in both children and adolescents.10,13,15 Recent meta-analyses of acute treatment demonstrate that CBT is a well-established treatment for depression in both children and adolescents, with small to modest effect sizes.10,11 The designation of “well established” is the most stringent criteria in evidence-based research, and indicates that CBT has demonstrated efficacy in at least two well-designed independent clinical trials.16 Most of the earlier studies compared CBT to treatment as usual, to wait-list controls, or to alternative CBT formats (eg, with or without parent training). Reviewers have noted the need for additional studies with the following aims: to assess the comparative efficacy of CBT, antidepressant medication, and their combination; to provide a better understanding of characteristics that might influence treatment response; to investigate the effective components of CBT; and to demonstrate the long-term effects of CBT and its subsequent impact on relapse and recurrence.14,15

Acute Comparative Studies

Recently, several large, multisite randomized controlled trials (RCT) have assessed the comparative efficacy of CBT, antidepressant medication, and their combination. The Treatment of Adolescents with Depression Study (TADS), a NIMH-sponsored RCT, compared fluoxetine, CBT, the combination of fluoxetine and CBT, and placebo in 439 adolescents (ages 12 to 18 years) with major depressive disorder. Acute response rates after 12 weeks of treatment were greatest for the combination treatment (71%); followed by fluoxetine alone (61%); CBT alone (43%); and placebo (35%). Although the combination and fluoxetine treatments were significantly more effective than placebo, CBT administered alone was not.17 However, compared with youth receiving fluoxetine alone, the combination treatment significantly reduced suicidal ideation, suggesting that the addition of CBT to antidepressant medication may contribute to the reduction of this serious symptom in youth. Of note, another study examining the augmentation of medication with CBT did not replicate this effect on the reduction of suicidal ideation.18 Although the research findings are mixed, suicidality is a significant concern among youth with depression. Thus, youth presenting with suicidal ideation or more severe depression may benefit from the continuous support, monitoring, and teaching of coping skills inherent in CBT. This evidence should be considered when making recommendations regarding treatment options to youth and their parents.

Another RCT assessing the efficacy of combination treatment compared with medication alone was conducted in adolescents with treatment-resistant depression, defined as those youth who had not responded to an initial adequate trial of a selective serotonin reuptake inhibitor (SSRI). In The Treatment of Resistant Depression in Adolescents (TORDIA), 334 adolescents were randomly assigned to receive either a medication switch (a different SSRI or venlafaxine) or a medication switch plus CBT. The addition of CBT resulted in a higher rate of treatment response (55%) as compared to a switch in medication only (41%).18 TADS and TORDIA demonstrated superiority of combination treatment for the primary outcomes, but other studies have found that combination treatment may not be more effective than medication plus good clinical management.19–21 However, negative results in these studies may be the result of too few CBT sessions, inadequate doses of medication, and the inclusion of a more severely affected sample. In summary, results from the large, well-controlled trials have generally found combination treatment (antidepressant medication and CBT) to be superior to either treatment alone in the acute treatment of depression in youth.

Predictors and Moderators of Response

The NIMH has highlighted the importance of gaining an understanding of the contribution of particular characteristics that might predict or influence response to specific treatments.22 Predictors are variables present before treatment that influence an individual’s response to treatment, regardless of the type of treatment received. Likewise, moderators are variables or characteristics present before treatment, but they differentially predict treatment response. Thus, moderators allow the identification of characteristics in individuals that may make them more likely to benefit from a particular treatment over another.

Predictors of poorer treatment outcome in youth with depression, irrespective of type of treatment, include more severe depression, longer duration of illness, comorbidity (anxiety disorders in particular), older age, family conflict, hopelessness, lower level of functioning, and presence of suicidal ideation and self-injurious behavior.23,24 Additionally, several moderators of treatment have been identified. Socioeconomic status (SES) has been associated with response to CBT in particular, with adolescents from high-income families responding more favorably to CBT than those from low-income families.23 Adolescents with less severe depression and with fewer cognitive distortions responded more favorably to CBT when compared to youth with more severe depression and greater cognitive distortions.23 In treatment-resistant depression, youth with more comorbid disorders, no physical or sexual abuse history, and lower levels of hopelessness achieved higher rates of response to combination treatment (medication plus CBT) than to medication alone.24

In summary, youth with less severe depressive episodes, from high-income families, presenting with comorbid disorders, fewer cognitive distortions, low levels of hopelessness, and without abuse histories, may be more likely to benefit from CBT than their counterparts. Of note, many of these predictor and moderator reports are from secondary analyses of efficacy trials that were designed primarily to examine treatment outcomes. As a result, the sample sizes in these trials were often insufficient to clearly identify all of the important individual and clinical characteristics that may influence treatment response. More research is needed to identify those characteristics that predict a more favorable response to CBT to contribute to the development of a personalized care approach in the treatment of depression.

Effective Components of CBT

Given the variety of treatment manuals and methods, researchers have begun to examine the particular components of CBT that most directly contribute to symptom relief and positive treatment effects. To achieve favorable outcomes in CBT, patients must participate in an adequate number of sessions. In general, longer treatment protocols may have better outcomes than those with fewer scheduled sessions, with 16 sessions being the most common effective length.25 In a study of treatment-resistant depression, adolescents who received nine or more sessions had a higher rate of response than those with fewer CBT sessions.26 Effective core skills tend to include an emphasis on cognitive restructuring and/or behavioral activation.25,27 Teaching problem-solving and social skills, especially among treatment-resistant depressed youth, has also been found to be an important component of CBT.26 Although some protocols rely more heavily on one or the other of these primary components, it appears that sufficient time must be spent on the teaching and practicing of any one component to yield positive results.25 Thus, youth appear to gain greater benefit with CBT when given sufficient time for skill acquisition, with the most effective skills being cognitive restructuring, behavioral activation, and problem-solving.

Continuation and Maintenance Treatment

Given findings that few patients achieve remission by the end of acute treatment (only 23% in TADS across four treatment groups) or go on to experience a relapse during long-term follow-up periods (24% to 75%),28–30 recent studies have examined whether CBT administered during continuation or maintenance phases of treatment can provide additional gains. The treatment of depression is typically divided into three stages: acute, aimed at achieving clinical response and remission of symptoms (typically 8 to 12 weeks); continuation, aimed at continuing to relieve residual symptoms and preventing relapse of the treated episode; and maintenance, aimed at the prevention of recurrence. Table 3 lists definitions of response, remission, relapse, recovery, and recurrence.28,31

Definitions of Outcomes in Depression

Table 3. Definitions of Outcomes in Depression

Few studies have examined the long-term effects of acute, continuation, and maintenance treatments on youth with depression. In TADS, youth were followed for a period of up to 5 years from the start of treatment. The percentage of youth who had achieved a response continued to increase as time passed during the first year of treatment. By 18 weeks, at the end of the short continuation phase treatment, 85% of youth in combination, 69% of youth receiving medication only, and 65% of youth receiving CBT only, had achieved a response. By 36 weeks, at the end of the maintenance phase of treatment, these rates increased to 86%, 81%, and 81%, respectively.32 Some youth were followed for an additional year after treatment. Results indicate that the gains made by week 36 of active treatment continued to persist. Additionally, of those followed openly for an additional 3.5 years, 96.4% of youth had achieved recovery from their index depressive episode. However, regardless of treatment type, 46.6% had experienced a recurrence of their depression.33

When followed during a long period of time, most youth achieve recovery. However, many will experience a new episode of depression. In adults, residual symptoms have been associated with relapse and recurrence.34,35 Likewise, youth often continue to experience some residual symptoms at the end of acute treatment, which may be associated with poorer outcomes, including relapse and/or recurrence. Remission rates are higher among those youth experiencing fewer residual symptoms at the end of acute treatment.32 In summary, the episodic nature of depression points to the need for both longer-term strategies and interventions that reduce the risk of relapse and recurrence. When youth continue to experience residual symptoms after the acute treatment of their depressive episode, they may benefit from augmentation with additional treatment strategies, such as CBT.

Few studies have examined the effectiveness of CBT administered during the continuation phase in youth. One study found that the efficacy of adding booster CBT sessions after acute phase treatment was inconclusive.36 Although these booster sessions did not reduce relapse rates, remission was accelerated among youth receiving additional CBT sessions. Pilot studies have found that continuation phase CBT may significantly lower relapse rates in youth. Compared with historical controls, youth receiving continuation phase CBT had a significantly lower rate of relapse (6% vs. 50%).37 In a more recent pilot study, youth with major depressive disorder were treated acutely with medication; those who responded were then randomly assigned to continuation phase treatment consisting of either medication only or medication plus Relapse Prevention-CBT (RP-CBT). Those who received medication only during the continuation phase of treatment were eight times more likely to relapse compared with youth who received RP-CBT in addition to medication.38 Thus, CBT may have a prophylactic effect when added sequentially to depressed youth who respond to acute medication treatment.

Summary/Conclusions

Youth often present to a pediatric or other primary care setting in the midst of their first depressive episode; thus, it is imperative that medical professionals accurately diagnose and make appropriate treatment recommendations to promote recovery. When making clinical decisions related to treatment, practitioners need to identify treatments with a sufficient evidence-base for the disorder in question and consider any patient characteristics that may influence treatment response. Given the preponderance of evidence from multiple studies, CBT is a well-established treatment for depression in both children and adolescents, with moderate effectiveness. The combination of CBT with pharmacotherapy appears to provide the greatest benefit, relative to either treatment alone, particularly in more severely depressed populations and among youth with suicidal ideation. Although some predictors and moderators have been identified, further work is needed to determine which patient characteristics are associated with response to particular treatments, thus moving us closer to the goal of providing more personalized care for youth with depression.

Effective components of CBT for the treatment of depression in youth include behavioral activation, cognitive restructuring, and teaching problem-solving and social skills. Additionally, continuation treatment appears to be important in the achievement of full remission and the prevention of relapse in youth with depression. By having an awareness of the current research on effective treatments for youth with depression, in combination with some knowledge of particular characteristics that might influence a youth’s response to a particular treatment, medical professionals can be better equipped to make appropriate treatment decisions and recommendations. Additionally, physicians who are comfortable with the concepts and structure of CBT will be better equipped in informing their patients and patients’ parents about this effective treatment option for the treatment of depression in youth.

References

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  19. Clarke G, DeBar L, Lynch F, et al. A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication. J Am Acad Child Adolesc Psychiatry. 2005;44(9):888–898. doi:10.1016/S0890-8567(09)62194-8 [CrossRef]
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  23. Curry J, Rohde P, Simons A, et al. TADS Team. Predictors and moderators of acute outcome in the treatment for adolescents with depression study (TADS). J Am Acad Child Adolesc Psychiatry. 2006;45(12):1427–1439. doi:10.1097/01.chi.0000240838.78984.e2 [CrossRef]
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  25. Weersing VR, Rozenman M, Gonzalez A. Core components of therapy in youth: do we know what to disseminate?Behav Modif. 2009;33(1):24–47. doi:10.1177/0145445508322629 [CrossRef]
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  30. Kennard BD, Silva SG, Vitiello B, et al. Remission and residual symptoms after short-term treatment in the treatment of adolescents with depression study (TADS). J Am Acad Child Adolesc Psychiatry. 2006;45(12):1404–1411. doi:10.1097/01.chi.0000242228.75516.21 [CrossRef]
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  33. Curry J, Silva S, Rohde P, et al. Recovery and recurrence following treatment for adolescent major depression. Arch Gen Psychiatry. 2011;62(3):263–269. doi:10.1001/archgenpsychiatry.2010.150 [CrossRef]
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  35. Karp J, Buysse D, Houck P, et al. Relationship of variablity in residual symptoms with recurrence of major depressive disorder during maintenance treatment. Am J Psychiatry. 2004;161(10):1877–1884. doi:10.1176/appi.ajp.161.10.1877 [CrossRef]
  36. Clarke G, Rohde P, Lewinsohn P, et al. Cognitive-behavioral treatment of adolescent depression: efficacy of acute group treatment and booster sessions. J Am Acad Child Adolesc Psychiatry. 1999;38(3):272–279. doi:10.1097/00004583-199903000-00014 [CrossRef]
  37. Kroll L, Harrington R, Jayson D, et al. Pilot study of continuation cognitive-behavioral therapy for major depression in adolescent psychiatric patients. J Am Acad Child Adolesc Psychiatry. 1996;35(9):1156–1161. doi:10.1097/00004583-199609000-00013 [CrossRef]
  38. 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]

Sample CBT Treatment Outline

SessionGoal
Sessions 1 through 4Psychoeducation and teaching of core skills
Sessions 5 through 10Practice and application of core skills and additional skills dependent on youth’s individual needs
Sessions 11 through 12Consolidation, review, and discussion of techniques for relapse prevention

Common Components of CBT for Depression

Core SkillsCoping Strategies
PsychoeducationOrient youth to the CBT model, conceptualization of depression, and goals and procedures of therapy.
Mood monitoringTeach youth to identify key emotions and rate mood. Help youth identify connections between external situations, behaviors, thoughts, and mood.
Behavioral activation/activity schedulingEncourage youth to engage in activities that provide a sense of mastery and pleasure to promote positive changes in mood.
Cognitive restructuringTeach youth to examine their automatic thoughts and recognize inaccuracies in their thought processes. Help youth evaluate and modify their thoughts to be more realistic and helpful to promote positive changes in mood.
Problem-solvingEngage youth in brainstorming solutions, evaluating consequences, and making choices to resolve relevant issues.
Other Skills
Social skillsHelp youth to recognize the effect of their own thoughts and behaviors on their engagement in social situations. Encourage youth to slowly practice engaging in social interactions with others.
Relaxation techniquesAs a means of calming anxiety or other negative mood states, teach youth relaxation techniques, including deep-breathing exercises, progressive muscle relaxation, or mindfulness-based meditation exercises.
Relapse preventionAssist youth in identifying any residual symptoms of depression. Teach youth to recognize lapses early on and to use learned coping skills to improve mood before a relapse occurs.

Definitions of Outcomes in Depression

OutcomesDefinitions
ResponseSignificant reduction in depressive symptoms or clinically significant improvement.
RemissionNo or minimal symptoms of depression, which present for at least 2 months.
RelapseReturn of symptoms sufficient to meet criteria for depressive episode during the period of remission.
RecoveryMaintenance of remission for an extended period (≥ 2 months).
RecurrenceEmergence of depressive episode after complete recovery (≥ 2 months well).

CME Educational Objectives

  1. Define cognitive behavioral therapy and describe its use as a therapeutic modality for pediatric depression.

  2. Identify key predictors and moderators of response to therapy for adolescent depression.

  3. Provide the key effective components of CBT and discuss the continuation of maintenance of treatment for depression in the adolescent population.

Authors

Jodi R. Mahoney, BS; Betsy D. Kennard, PsyD, ABPP; and Taryn L. Mayes, MS, are with University of Texas Southwestern Medical Center at Dallas.

Ms. Mahoney, Dr. Kennard, and Ms. Mayes have disclosed no relevant financial relationships.

Address correspondence to: Betsy D. Kennard, PsyD, ABPP, 5323 Harry Hines Blvd., Mail Code 8589, Dallas, TX 75390; fax: 214-456-4235; or email: .Beth.Kennard@utsouthwestern.edu

10.3928/00904481-20110512-06

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