Treatment of Depressive Disorders in Youth: Psychotherapy

Many types of psychotherapy exist, but only cognitive behavior therapy (CBT) and interpersonal therapy (IPT) have a significant amount of research evidence for efficacy.

Cognitive Behavioral Therapy
CBT is based on a theory that individuals with depression have negative assumptions about themselves, the world, and the future that are learned through early experience and 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 lonelier and more hopeless).

CBT formats vary, but most CBT programs involve a highly structured process guided by written manuals with specific steps and instructions for each step or session. The process involves 2 major goals:

1. Identifying faulty assumptions (cognitive distortions) and correcting them gradually
2. Behavioral interventions designed to minimize symptoms of depression

Although some studies have had conflicting results, CBT has been shown to have positive effects on depression. Two studies compared a form of CBT with placebo, fluoxetine, and a fluoxetine plus CBT condition and CBT failed to separate from the placebo condition. [March: 2004] [Freeman: 2018]

The TADS result raises 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 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, improve mood.

IPT has been well studied and validated as an effective treatment for depression in adults. IPT has also been studied in 2 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.

Most therapists do not adhere to a single therapeutic theory or method, and this 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.