Treatment of Depressive Disorders in Youth: Psychotherapy

A number of types of psychotherapy exist but only two types have a significant amount of research evidence for efficacy. These are cognitive behavior therapy (CBT) and interpersonal therapy (IPT).

Cognitive Behavioral Therapy
CBT is based on a theory that individuals with depression have negative assumptions about themselves, the world, and the future, which are learned through early experience and which interact with later life stress to distort the individual’s perception of their situation. These assumptions and resulting distortions lead the depressed individual to make faulty assessments of current life situations, thus supporting depression. The individual may also make decisions, based on these assumptions, which further support depression (e.g. choosing to isolate oneself and then feeling more lonely and hopeless).

CBT formats vary but most CBT programs involve a highly structured process, often guided by written manuals with specific steps and instructions for each step or session. The process involves two major goals: 1) identifying faulty assumptions (cognitive distortions) and correcting them gradually; and 2) behavioral interventions designed to minimize symptoms of depression.

CBT has been evaluated through randomized controlled trials in a number of settings and shown to have positive effects on depression. There have been conflicting results, however. The recent Treatment for Adolescents with Depression Study (TADS) compared a form of CBT with placebo, fluoxetine, and a fluoxetine plus CBT condition.[March: 2004] In TADS, CBT failed to separate from the placebo condition.

The TADS results raise some issues of interest. One is the issue of severity of depression and comorbidity. The TADS sample had a high degree of severity of depression. Other studies that failed to show a large effect for CBT also had highly severe samples. This finding may support the use of CBT for mild to moderate depression. Certain comorbidities, such as anxiety disorders, may predict better response while others, such as conduct disorder, may predict poor response to CBT.

Another issue is the form of CBT used. Many of the positive studies of CBT used very specific forms (e.g., Coping with Depression for Adolescents [CWD-A], a group therapy that has been used in almost half of all published studies of CBT). The TADS study used a novel form that had not been assessed in any other setting prior to the TADS study. This finding may imply that CBT efficacy depends upon using a specific format.

Interpersonal Therapy
IPT is based on the concept that depression occurs in the context of interpersonal relationships and that both development of depression and recovery from depression are affected by these relationships. IPT addresses these effects by first identifying problem areas (typically grief and loss; disputes or conflicts with family, friends, or teachers; life transitions; or social deficits). Therapy then focuses upon improving communication and problem solving skills to help resolve interpersonal problems and thus, to help improve mood.

IPT has been well studied and validated as an effective treatment for depression in adults. IPT has also been studied in two randomized trials in adolescents with positive results. There is a manualized IPT program (IPT-A) adapted specifically for use with adolescents. IPT shows promise as an evidence-based psychotherapeutic treatment for mild to moderate depression in adolescents. Some limitations of the use of IPT include that it has not been as well studied as CBT, and not as many therapists are trained in use of IPT.

One note of interest is that many, and perhaps most, therapists do not adhere to a single therapeutic theory or method. This fact must be considered when the desire to follow evidence-based methods is applied in real world treatment of children and adolescents with depression. “Eclectic” or individualized therapy programs may well be effective but cannot be readily evaluated in a controlled trial. Whatever type of therapy is chosen, the role of the referring physician can be invaluable in providing regular follow-up and symptom monitoring to help evaluate progress.

Page references: [Klomek: 2006], [Weersing: 2006], [March: 2004].