Leseprobe
Contents
Chapter 1: Introduction
Background
Problem Statement
Clinical Review Goal
Research Questions
Relevance & Significance
Barriers and Issues
Assumptions, Limitations, and Delimitations
Definition of Terms
Summary
Chapter 2: Review of Literature
Depression Defined
Common Types of Adolescent Depression
How common is depression amongst adolescents
Clinical Presentation of Depressed Adolescents
Screening for Depression in Adolescents
Treatment of Adolescent Depression
Cognitive Behavioral Therapy
Selective Serotonin Reuptake Inhibitors
Combination Therapy
The Treatment of SSRI-Resistant Depression Study (TORIDA)
Treatment for Adolescents with Depression Study (TADS)
The Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT)
Treatment of Adolescent Suicide Attempters (TASA) Study
Chapter 3: Methodology
Chapter 4: Results
Chapter 5: Conclusion
Implications
Recommendations
Summary
Table I: Combined Treatment Trial Results (Brent et al, 2009)
Table 2: Escitalopram Studies Efficacy (Carandang et al., 2011).
Works Cited:
Abstract
Adolescent depression is a mental health disorder affecting teenagers. It is often characterized by feelings of sadness, loneliness and emotional pain. The National Institute of Mental Health (NIMH) has shown that nearly 11 percent of adolescents will develop depression by the age of 18 (NIMH, 2013). Despite these statistics, depression commonly goes undiagnosed and untreated. According to Greenberg (2009) an estimated 70% of teenagers suffering from depression go without treatment. Therefore, more awareness and information regarding treatment of adolescent depression is needed for effective maturation into adulthood . With numerous pharmacological and psychosocial modalities available, a safe and effective combination is important for a positive outcome. This article provides clinicians with an updated overview of the efficacy of popular pharmacological and psychosocial treatments for adolescent depression.
Key Words: depression, adolescents, pharmacotherapy, psychotherapy.
Chapter 1: Introduction
Many adolescents (defined in this literature review as children ages 6-18 years of age) suffer from depressive disorders. Depression is diagnosed based on specific symptoms including irritable mood, decreased pleasure or interest in daily activities, difficulty concentrating, as well as insomnia and chronic fatigue (DSM-IV-TR, 2000). Adolescent depression has a devastating impact on a child's ability to develop socially, emotionally, academically, and physically, all of which are imperative to normal development (Desha, Ziviani, 2007). Untreated depression can lead to severe repercussions such as self-injurious behavior and suicidal ideation. Studies indicate that between five to ten percent of adolescents will commit suicide within fifteen years of experiencing an episode of major depressive disorder. (Kaufman, Martin, King, Charney, 2001.)
Despite the vast amount of research that has been done regarding depression and its treatment; it continues to be a world issue. The National Alliance on Mental Illness states that eight percent of adolescents suffer from depression, and that as much as twenty-eight percent of adolescents seen in the primary care setting meet the criteria for depression (NAMI, 2010). Numerous studies have been conducted regarding the efficacy of psychosocial therapies such as cognitive behavioral therapy (CBT) and various interpersonal therapies. Additionally, much research has been conducted on pharmacological treatments including Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclic Antidepressants (TCAs), and Atypical Antidepressants. Although there is an abundance of research on treatment modalities and medication, there is little literature offering insight as to which treatment or combination of treatments is most effective in combating depressive disorders in adolescents. This literature review will offer in-depth analysis of the most popular therapies used to treat depression in adolescents.
Background
Adolescent depression presents a real threat to the quality of children’s lives and to the relationships that hold families and communities together. It is a significant problem, as it is associated with comorbidities. One serious impact of adolescent depression is suicidal ideation. According to The American Academy of Child & Adolescent Psychiatry, suicide is the third leading cause of death in children ages 15-24 and the sixth leading cause of death for children ages 5-14 (AACP, 2008). In 2010, the rate of suicide in the United States was 12.4:100,000, which equates to 38,364 suicides yearly (AFSP, 2013). The high rate of suicide could be dramatically reduced if clinicians could recognize and diagnose depression in the early stages, and an appropriate treatment plan could be implemented.
Another problem stemming from depression in adolescents is the negative impact it has on social and mental development. Depression interferes with one’s emotions, social interaction skills, and failure to thrive academically (Melvin, Rowe, Tong, 2004). This deviation in natural development has hampered the adolescent’s interactions with both parents and peers, as well as decreased involvement in activities and responsibilities. It has also been shown that depressed adolescents tend to engage themselves in high risk activities such as alcohol, drugs, violence, and sex (Bukstein et al, 2009).
One reason depression is highly prevalent in today's society is that the mental health field has been grossly underfunded. Between the years 2009-2011, the United States government made significant cuts to funding for children and adults suffering from depression (NAMI, 2011). As a result, emergency rooms, shelters, and prisons have had a steep increase in the number of mentally ill treated/admitted. In 2012, states cut over $1.6 billion dollars in mental health funding, while the demand for mental health professionals and resources grew significantly (NAMI, 2011). The shortage of funding has created a serious dilemma, leaving the field of mental health underfunded and understudied.
Problem Statement
Despite the many treatment modalities available, many adolescents struggle to find an effective treatment, and recurrence rates are extremely high. According to the National Alliance of Mental Health (NAMI), two percent of school-aged children and eight percent of adolescents have the symptoms necessary to diagnose major depressive disorder; and in the primary care setting depression rates are as high as twenty-eight percent. It is estimated that well over half of these adolescents will have a recurrence of depression within 7 years of treatment.
While the efficacy of various psychosocial and pharmacological modalities has been studied in-depth, little literature exists comparing and contrasting the different treatments. This article intends to provide an overview of the treatments for depression, help guide clinicians to formulate a safe and pragmatic treatment plan, and effectively reduce the high rate of reoccurring depression.
Clinical Review Goal
The purpose of this review is to create a literature review on the various treatment modalities for adolescent depression. In order to choose the optimal treatment regimen from the many different treatments available, a clinician needs to be knowledgeable about the various styles, modes, and milieus of treatment. The review will serve as a blueprint for clinicians to effectively diagnose and treat adolescents suffering from depression. It will enable health care professionals to read about the advantages and disadvantages of each modality, and determine upon which treatment or treatments will work best for their patient. This will not only result in a positive health outcome, but also reduce the rate of recurring depression.
Research Questions
1. What is depression, and what are the various subtypes of depression?
2. How is depression diagnosed?
3. What are the efficacious pharmacologic treatments for depression in adolescents?
4. What are the efficacious psychotherapies for depression in adolescents?
5. How can antidepressants and psychotherapy work together in the recovery process and decrease reoccurrence of depression in adolescents?
Relevance & Significance
This literature review is important, as there are very few articles comparing and contrasting the various treatment modalities for adolescent depression. It is important that this literature exists for the patient, the family, and the practitioner. The clinician will be able to review the most current literature on each of the treatment options and determine which is best for the patient. The patient will benefit from receiving the appropriate pharmacological and psychosocial treatments, and recidivism will be reduced.
In today’s society, youth continue to struggle with different forms and degrees of depression. Among the youth population suicide rates remain high, and many adolescents engage in high-risk and self-destructive behavior, which leads to difficulty flourishing both socially and emotionally. Practitioners continue to treat depression without evidence that their modality or combination of treatments is the most effective, and therefore patients are not receiving optimal treatment. As a result of this, high rates of recurrence and recovery setbacks will continue to be the trend in adolescent depressive disorders. This literature analysis could serve as a guide to clinicians to understand that different modalities that are available to patients, and utilize the best possible treatments.
Barriers and Issues
The issue of adolescent depression is clearly one of great complexity. Despite a multitude of medical advances over the past twenty years, depression still is a huge issue in today’s society. With multiple SSRI’s, TCA’s and various forms of counseling and therapy available to patients, one would think that these rates would be declining .
This paper will review the most prominent and common modalities of each therapy form, and attempt to create a guide to choosing the best treatment modalities. By comparing and contrasting the positives and negatives of each form of therapy, the most effective combinations can be found and implemented into daily medical practice.
The biggest barrier in conducting this literature review is the lack of research and data existing on the efficacy of certain pharmacologic agents in treating adolescent depression. According to the National Institute of Mental Health, only two SSRI’s have been approved for use by adolescents. Fluoxetine has been approved for use in children 8 years of age and older, and Escitalopram in children 12 years of age and older (NAMI, 2011). Atypical antidepressants have been prescribed for off label treatment of depression in adolescents; however the efficacy of these drugs such as Duloxetine and Bupropion has not been well researched in this age group. More studies and research is needed to understand how these drugs impact youth, and potential short and long term side effects from taking these drugs.
Assumptions, Limitations, and Delimitations
It is assumed that adolescents who suffer from various forms of depression may benefit from some form of treatment whether it is pharmacological therapy, psychosocial therapy, or other modalities of treatment.
Limitations occur due to restrictive search engines used while conducting the research in this review. Psychinfo and Psycharticles are the primary databases utilized; and many of the clinical trials are difficult to access in entirety. Thus, some research studies are omitted, as not enough information was available. Another limitation of this study is that the DSM-V was recently released, and it not incorporated into this literature review. This is because the most recent clinical trials and psychiatric literature reflect the DSM-IV criteria and not the newer DSM-V.
Delimitations for this review are the primary focus is on cognitive behavioral therapy and SSRI’s, as these are the most common treatment methods in treating depression in adolescents. Other psychosocial therapies which are not discussed include interpersonal therapy, family therapy, dynamic therapy, group therapy, and supportive therapy. Alternative pharmacologic treatments for adolescent depression exist as well such as monoamine oxidase inhibitors (MAOI’s), tricyclic acids (TCA’s) and other newer classes of drugs; however these are considered off-label use. Also, electroconvulsive therapy may be considered in cases of adolescent depression which are refractory to pharmacologic or psychosocial treatments.
Definition of Terms
Selective Serotonin Reuptake Inhibitor (SSRI) - Class of compounds, which are typically, used as antidepressants for treating depression, personality disorders, and anxiety disorders.
Cognitive Behavioral Therapy (CBT) - Is a psychotherapeutic approach to treating depression and anxiety, which focuses on dysfunctional emotions, maladaptive behaviors, and cognitive process.
Children’s Depression Rating Scale Revised (CDRS-R)- Designed for children ages 6-12, generally used in adolescents for diagnosis and severity of depression. The score is based on 17 different symptom areas.
Clinical Global Impression Severity Scale (CGI-S)- A scale in which a clinician rates a patient on a scale from 1 (normal) to 7 (extremely ill), based on the presentation of other patient’s they have had with the same diagnosis (Guy, 2000).
Clinical Global Impression Scale (CGI-I)- This is a 7 point scale, in which a clinician assesses the amount of improvement a patient has had, 1 (very much improved) to 7 (very much worse) (Guy, 2000).
Children’s Global Assessment Scales (CGAS)- Children’s version of Global Assessment of Functioning (GAF). Children are rated on a scale of 1-100, with 1-10 requiring constant supervision due to severe/aggressive self-destructive behavior, whereas 91-100 represents superior functioning in all areas (WSMH, 2013).
Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) - Designed for children ages 6-18 and assesses for schizophrenia, schizoaffective, major depressive disorder, bipolar disorder, and anxiety disorder.
Summary
Despite there being a great deal of research on treatment modalities and medications for adult depression, adolescent depression continues to be underfunded and understudied. With the adolescent depression rate at 8% (NAMI, 2010), more studies and guidelines for optimal management of depression are necessary. This paper reviews the most current literature and clinical trials focusing on pharmacologic and psychosocial treatment modalities, and recommendations for treatment and management of adolescent depression is discussed.
Chapter 2: Review of Literature
Depression Defined
Depression is a condition that goes beyond feeling sad or down for a day or two. This is a serious medical illness which can affect multiple aspects of an individual’s life including thoughts, behaviors, feelings, mood and physical health. Depression is generally a prolonged illness characterized by periods of well-being alternating with recurrent illness. For many years it was thought that children and adolescents could not experience depression, and that it was solely an adult disease.
Depression involves a combination of symptoms which can be broken down into 6 major categories which include affective, motivational, cognitive, behavioral, vegetative, and somatic. Affective symptoms include anxiety, anhedonia, melancholia, depressed or sad mood, and irritable or cranky mood. Motivational symptoms of depression include loss of interest in daily activities, feelings of hopelessness and helplessness, suicidal thoughts, and suicidal acts or attempts (Evans, 2005). Cognitive symptoms are defined as difficulty concentrating, feelings of worthlessness, sense of guilt, low self-esteem, negative self-image, and delusions or psychosis. Vegetative symptoms are defined as sleep disturbance, appetite change, loss or gain of weight, loss of energy, psychomotor agitation and retardation, lack of energy, and decreased libido. The last set of symptoms, somatic, is defined as physical or bodily complaints, frequent stomachaches, and headaches (Evans, 2005).
Common Types of Adolescent Depression
The first type of depression, known as major depressive disorder requires two or more major depressive episodes. To meet this diagnosis an individual must have experienced depressed mood with loss of interest or pleasure in activities for at least two weeks, along with 5 of the following symptoms which significantly impair their social, work, or other activities of daily living. This criteria includes depressed mood for most of the day, diminished interest or pleasure in all or most activities, significant unintentional weight loss or weight gain, insomnia or sleeping too much, agitation or psychomotor retardation noticed by others, fatigue or loss of energy, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate or indecisiveness, and recurrent thoughts of death (DSM-IV-TR, 2000).
“The diagnosis of major depressive disorder (MDD) becomes more certain when this criteria is backed up by a positive family history of depression, a prior episode of depression or mania, or the presence of a precipitating factor such as a recent stroke or the use of medications known to cause mood disorders,” (Margolis, Swartz, 2002). Episodes of major depressive disorder can range from mild to severe. In milder episodes, patient’s symptoms barely meet the guidelines for major depressive disorder, and their level of impairment is minimal. Severe episodes of MDD are characterized by crippling symptoms which include obvious decrease in mood, interference with school and job performance, and severe damage and effect on family and social relationships. This may even include the inability to dress, feed, or maintain proper hygiene on a daily basis. (Margolis, Swartz, 2002).
A second type of depression known as dysthymic disorder (formerly known as depressive neurosis) has a different set of criteria to make a diagnosis. This is a chronic form of depression that tends to be milder than major depressive disorder. It is characterized by a depressed mood most of the day or more days than not for a minimum of two years. They must also meet the DSM criteria for dysthymia, which states that a patient must have at least two or more of the following symptoms which cause impairment with social, work, or other activities of daily living. These criteria include poor appetite or overeating, insomnia or excessive sleep, fatigue and loss of energy, low self-esteem, difficulty concentrating or making decisions, and feelings of hopelessness (DSM-IV-TR, APA 2000).
Roughly 10% of patients diagnosed with dysthymic disorder will also suffer from recurring episodes of major depressive disorder, which is known as “double depression.” Patients who have double depression exhibit symptoms such as feelings of worthlessness and lowered self-esteem, lethargy, inability to concentrate, noticeable change in weight either gained or lost, insomnia, and feelings of hopelessness (Margolis, Swartz, 2002).
How common is depression amongst adolescents
According to the American Academy of Family Physicians (AAFP), depression among children and adolescent is common, however frequently goes undiagnosed. Epidemiologic data on depression in adolescents in the United States is limited for a variety of reasons. For a long time MDD was viewed as a disease of adulthood and adolescent depression was simply a “normal” part of teengage passage. A second issue is the debate over who should assess the rate of depression in adolescents, the adolescent themselves or the parent (Evans, 2005). The data which does exists, suggests that in the United States, approximately 1 percent of preschoolers suffer from major depressive disorder, 2 percent of school-aged children, and 5 to 8 percent of all adolescents (Jellinek, Snyder, 1998). The prevalence of adolescent depression also appears to be increasing by generation; the age of onset is continually decreasing (Birmaher, Brent et al. 1998). The gender ratio is 1:1 in prepubescent children, and increases to a 2:1 female to male ratio in adolescents. The majority of those diagnosed with depression tend to have risk factors such as a family history of depression, poor academic performance, substance abuse issues, anxiety disorders, uncertainty with sexual orientation, and other various comorbidities (Felice, Drotar, Wolraich, 1996).
Dysthymic disorder has a pre-puberty incidence of 0.6 to 1.7%, and increases to 1.6 to 8 percent in adolescents. Dysthymia often develops earlier, and is considered a precursor to future mental illnesses such as major depressive disorder, substance abuse, and anxiety disorders (Evans, 2005).
Clinical Presentation of Depressed Adolescents
Depending on the age at which a patient presents with depression, various signs and symptoms are present. Infants and preschoolers are perhaps the most difficult to diagnose, as they do not have the ability to express their feelings into language. Because of this, a clinician must infer depression from the patient’s behavior which can include withdrawal from family or caregivers, missing developmental milestones, failure to thrive with no apparent cause, and lack of interest, enthusiasm, and concern during activities of daily living (AAFP, 2013).
As children grow older, they begin to internalize stress, which can lead to low self-esteem and feelings of guilt. According to the AAFP, “much of this inner turmoil is expressed through somatic complaints (headaches, stomachaches), anxiety (school phobia, excessive separation anxiety) and irritability (temper tantrums and other behavioral problems) (AAFP, 2013). Many school aged children try to compensate for their depression by pleasing others. This may show in academic success, good behavior, and doing favors for others, thus, masking their depression, making it difficult to diagnose.
Despite the differences between pre-pubescent children and adolescents, they share many similarities in symptoms of depression. The symptoms of anger, irritability, suicidal ideation, low self-esteem, guilt, and flat affect are experienced by both age groups. Many of these symptoms are also seen in adults, showing that depression can develop in early childhood and continue throughout their adult life.
Many adolescents who struggle with a form of depression will likely suffer from another psychiatric issue concurrently. One instance of this is an individual with major depressive disorder also being diagnosed with dysthymia at the same time. This is known as “double depression,” (Birmaher, Brent et al., 1998). It is estimated that 40 to 70 percent of patients with major depressive disorder have a second comorbid psychiatric condition, whereas 50 to 70 percent of those with dysthymia will have an additional psychiatric disorder (Birmaher, Brent et al., 1998). The most common comorbidities experienced in adolescents include attention deficit disorder, attention deficit hyperactivity disorder, anxiety disorders, and various other forms of depression.
Screening for Depression in Adolescents
According to the American Academy of Family Physicians, diagnosing depression in adolescents is challenging as information must be integrated from multiple sources including the patient, the parents, teachers, and potentially other siblings and peers. Depression appears to be less likely in children younger than six years of age, however, rates increase dramatically during adolescence and up to 8% of teenagers in the United States are actively affected (AAFP, 2013). Therefore, it is recommended that screening for depression is appropriate for all children beginning at seven years of age in the primary care setting.
The Reynolds Adolescent Depression Scale (RADS) is one of a few depression screening tools designed specifically for children and adolescents. This test was created in 1987 by Dr. William M. Reynolds to assess depressive symptoms in adolescents ages 11-20. The test is easy to administer, and takes an average of 5-10 minutes to complete, and covers dysphonic mood, anhedonia, negative self-evaluation, and somatic complaints. The severity of these symptoms is classified as normal, mild, moderate or severe based on score (AAFP, 2012).
Other alternative screening tests used in diagnosing adolescent depression include The Center for Epidemiologic Studies Depression Scale for Children (CES-DC), the Center for Epidemiologic Studies Depression Scale (CES-D), the Beck Depression Inventory (BDI), and the Children’s Depression Inventory (CDI). The BDI and CES-D are commonly used in practice when warranted, as they are easy to score, low cost, and comparable psychometric properties (AAFP, 2012). There is little evidence as to which screening test is most effective; therefore clinicians use the method which they are most comfortable with (Avins, Miranda, Whooley et al., 1997).
To date, these screening tools are generally used in research studies, and not applied in everyday practice. The American Academy of Family Physicians (AAFP) currently states that the screening tools should be used only when there is a high index of suspicion, or to measure response to various pharmacologic or psychotherapeutic treatments. It is however recommended that The Pediatric Symptom Checklist be used as a screening tool for adolescent depression at routine wellness examinations. This is a 35 item questionnaire which is to be filled out by the parents of children ages 6 to 12. The goal of the questionnaire is for parents to assess their child’s mental health and psychological state (AAFP, 2012). While this checklist is not specific for depression, it can help parents and practitioner to identify a patient in need of further evaluation. Based on the answers of the pediatric symptom checklist, a clinician can determine if further in-depth testing is warranted.
Other agencies and organizations have differing opinions on routine screening for adolescent depression. The US Preventative Services Task Force (USPSTF) infers that, “Routine screening for emotional and behavioral problems has been recommended by Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. The American Academy of Pediatrics recommends that pediatricians ask questions about depression in routine history-taking throughout adolescence. The American Medical Association recommends screening for depression among adolescents who may be at risk as a result of family problems, drug or alcohol use, or other indicators of risk,” (USPSTF, 2009). Ultimately, it is left to the clinician’s discretion to screen children and adolescents for depression and to identify risk factors and red flags which would require further testing and evaluation.
The optimal interval for screening adolescents is still unknown. Recurrent screening may be the best option in those with a personal history of depression, family history of depression, unexplainable somatic symptoms, and other psychological illnesses. The benefits of routine screening of adolescents for depression are still unknown.
Treatment of Adolescent Depression
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is an example of a psycho-therapeutic approach in which the patient gains insight into their emotions and maladaptive thoughts and feelings through individual, small-group and family therapy sessions. “CBT is a therapeutic model derived from Aaron Beck's cognitive approach to treating depressed adults,” (Weersing & Brent, 2006). This mode of therapy is based on the belief that individuals develop depression as a result of a negative self-image, as well as their surrounding environment.
Cognition behavioral therapy (CBT) is based on the notion that patients “patients faulty evaluations of the data they take in through their senses produce pathological moods – anxiety, depression, worry, guilt, etc.,” (Kilgus, Maxmen, Ward, 2009). The goal of a cognitive behavioral therapist is to identify ways in which patients distort information, and correct this way of thinking. Adolescents battling depression tend to, “make mountains out of molehills, project their own fears onto others, or see things in the worst light possible,” (Kilgus, Maxmen, Ward, 2009). This line of thought is known as “automatic thoughts” which are followed by “automatic emotions” such as feelings of sadness, worry, tension, and anger. A cognitive behavioral therapist focuses on these automatic thoughts and emotions, and helps a patient to identify them, which situations trigger them, and their usual patterns of thinking and processing information. Once this is accomplished, the therapist is able to help a patient to form a thought process opposite of their norm, in order to process these situations and feelings in a more rational and tolerable way.
Cognitive behavioral therapy is often used to treat mild to severe depression, anxiety, panic attacks, and phobias. Typical CBT treatments consist of meeting with a therapist once a week for a total of 10-25 total sessions. Patients are asked to record episodes at home which trigger their depression as well as troubled feelings and thoughts; at each following session these events are analyzed and discussed in detail. In doing so, the therapist is able to identify and modify negative thought patterns and improve abnormal behavioral and social regulation skills which lead to the various forms of depression. “In youth depression treatment, these foci have been addressed through the application of cognitive and behavioral techniques such as mood monitoring, cognitive restructuring, behavioral activation, pleasant activity scheduling, and goal setting strategies; relaxation and stress management, social skills and conflict resolution training; and training in general problem solving skills” (Kaslow & Thompson, 1998).
One study conducted by Wood, Harrington, and Moore (1996) compared the impact of cognitive behavioral therapy versus relaxation therapy in adolescents. This clinical trial was conducted in an outpatient setting, where 53 psychiatric patients with depressive disorders were randomly allocated to either brief cognitive behavioral therapy (N=26), or to a control group receiving relaxation training (N=27). These sessions consisted of 5 to 8 treatments over the course of 2 months. At the end of the initial phase of this study it was found by clinicians that 54% of the adolescents in the CBT group went into remission, whereas 26% of those in the relaxation sessions went into remission (Moore et al., 2006). The participants also took self-evaluations which revealed that those who participated in cognitive behavioral therapy showed improvement in depressive symptoms, self-esteem, and general psychosocial adjustment. “Patients who had the cognitive behavioral therapy were also more likely to be rated by the assessor with the K-SADS as having clinically remitted from their depressive disorder than patients who had relaxation therapy (p=.02). In addition, they had significantly lower (i.e., more improved) clinical global improvement scores (p < .01),” (Moore et al., 2006). In essence, 22 of 24 cases who received cognitive behavioral therapy were rated by the assessor as having improved post-treatment, whereas only 15 of 24 improved with relaxation therapy. Also of note, children receiving CBT were significantly more satisfied with their treatment regimen than those who had relaxation therapy (p < 0.5), (Moore et al., and 2006). The participants in this study were again evaluated at a 6 month follow up, and the success of the two groups had equalized partially due to the fact that those who received relaxation therapy continued improvement, and there were a few cases of relapse in the cognitive behavioral therapy group. It was found that in this study, a younger age of diagnosis and higher level of function at intake were associated with higher rates of remission and a better overall outcome. (Moore et al., 2006).
In a similar study conducted by Vostanis, Feehan, and Grattan, 57 children and adolescents (ages 8-17) were recruited from four different departments of child and adolescent depression psychiatry. Parents and their children were asked to complete a mood and feelings questionnaire, and if a subject scored higher than 15 they were invited to partake in the clinical trial. The average age of participants was 12.7 years, consisting of 32 females (56%) and 25 males (44%). The types of depression in this study included major depressive disorder (17), minor depression (31) and dysthymic disorder (9). These subjects were alternated randomly between a group to receive cognitive behavioral therapy or a control treatment known as the non-focused intervention group (Feehan, Grattan, Vostanis, 1998).
The cognitive behavioral therapy group had a total of nine sessions, with one session occurring every other week. These sessions focused on recognition and labeling of emotions, enhancement of social skills, and changing negative cognitive attributions. The goal of each session was recognition (sessions 1-2), self-reinforcement (session 3), social problem-solving skills (sessions 4-5), cognitive restructuring (sessions 6-7) and treatment review plan (session 8). In the non-focused intervention group (control group), therapists focused on reviewing of the participants mental state and social activities. In essence, the children described their moods and feelings, while the therapists gave positive feedback. No interpretations, solutions, or suggestions were offered during these sessions (Feehan, Grattan, Vostanis, 1998).
Immediately following treatment the CBT group study (N-27) showed that post-treatment 4 adolescents met the depression for major depressive disorder (14%) whereas in the NFI group (N=27) 7 participants (25%) had diagnosable major depressive disorder (Feehan, Grattan, Vostanis, 1998).
Two years following treatment, 54 of the participants (94.7%) took part in a follow up study. (One family dropped out of the study immediately following treatment, while two families declined to participate in this study.) It was found that 6 participants were still participating in outpatient therapy services (11.1%), while the remaining 88.9% had been cleared for discharge by a therapist. In the CBT group, 7 had diagnosable major depressive disorder (25.9%) whereas the NFI group 4 participants (15%) had diagnosable MDD (Feehan, Grattan, Vostanis, 1998). It is noted that there were no statistically significant findings in this study
Another clinical trial was conducted in Puerto Rico, composed of 112 adolescents ranging in age from 12-18 years old (M = 14.52) 55.4% of which were females who were diagnosed by DSM-III-R criteria with major depressive disorder, or were deemed to be impaired due to depression by a psychiatrist (Rosello, Guillermo, Rivera-Medina, 2012). All of the individuals participating in the study were referred by schools located in San Juan, Puerto Rico. The participants were in school from 6th to 12th grade and none were receiving any medications. The study group were randomly assigned to either Cognitive Behavioral Treatment Individual group (CBT-I), Cognitive Behavioral Treatment Group (CBT-G), Interpersonal Treatment Individual (IPT-I), and Interpersonal Treatment-Group (IPT-G) (Guillermo, Rivera-Medina, Rosello, 2012).
The individual treatment conditions consisted of twelve 1 hour therapy sessions held once a week over the span of twelve weeks. The group treatments also consisted of 12 sessions which were 2 hours in length and held of a total of twelve weeks. The CBT conducted was based on a manual developed my Munoz and Miranda, which details group intervention for depressed Hispanic adults. The model attempts to identify thoughts and actions that influence mood, and diminish depressive feelings while teaching alternative ways of preventing depression. The interpersonal therapy was conducted in three phases. The first phase focused on depression and its development, and evaluation of interpersonal relationships. The second phase, aimed to help the patient work on selected interpersonal problems, and the final phase targets acknowledgment of feelings related to separation from the therapist and reviewing the treatment course and plan developed. Manuals were developed for each treatment group, and therapists conducting the treatments followed the guidelines (Guillermo, Rivera-Medina, Rosello, 2012).
The results of this study showed that when comparing the mean change from pre-treatment to post-treatment for the interpersonal therapy in group format, the pre-treatment mean was 20.74 and the post-treatment mean was 13.41, an improvement of 7.33 units on the Children’s Depression Inventory Scale (CDI). For the individual format cognitive behavioral therapy group (IF), the pre-treatment mean was 23.41, and the post-treatment mean was 13.43. This treatment method resulted in a reduction of 9.98 units on the CDI. Overall the CBT group therapy outperformed the IPT group therapy by an average of 2.65 units. In the interpersonal therapy individual condition, the pre-treatment mean was 21.52 and the post-treatment mean was 14.62, yielding a 6.9 point average reduction of depressive symptoms on the CDI scale (Rosello, Guillermo, Rivera-Medina, 2012). For the cognitive behavioral therapy individual treatment group, the pre-treatment mean was 22.62 and the post-treatment mean was 12.04, resulting in an average of 10.58 point reduction on the CDI scale (Guillermo, Rivera-Medina, Rosello, 2012).
Clinical significance in this study was defined as the number and proportion of patients who move from a dysfunctional or clinical range to a normative range of depressive symptoms. In this study, the cut-off score on the CDI depression scale was determined to be 12. As a result, 62% of patients in the CBT treatment groups and 57% of patients in the IPT groups were functioning in a nonclinical range of depression after completing the treatment. The study concluded that overall CBT outperformed IPT as measured by the CDI (p=.016) (Guillermo, Rivera-Medina, Rosello, 2012).
Another study utilizing cognitive behavioral therapy was conducted in Australia, using new computerized cognitive behavioral therapy. In this study, 32 adolescents’ ages 13-16 (56% of which were males) who were excluded from public school education due to mental health needs tested the efficacy of SPARX computerized cognitive behavioral therapy program. All of the subjects in this study had either highly probable depression or diagnosed depression as scored on the Child Depression Rating Scale Revised (CDRS-R). The participants were randomized into either a group receiving SPARX treatment over the course of 5 weeks (N=20), or a waitlist control group (N=12). The SPARX cognitive behavioral therapy consisted of seven modules, each 30 minutes in length (Dixon et al, 2011). The modules included a “guide” who spoke about dealing with depression, and a game where the participant would try to “shield against depression.” The adolescents were assessed at baseline, 5 weeks, and 10 weeks. (The adolescents who were in the control group were invited to participate in the SPARX therapy session after the 5 week trial, and those who participated were factored into the results.) The study found that those who completed the five weeks of computerized cognitive behavioral therapy had a mean improvement of 14.7 points on the CDS-R score while those in the control group had a mean improvement of 1.1 (p <0.001) remission 78% versus 36% (p=0.047) (Dixon et al, 2011). These results were maintained at the 10 week follow ups. The study concluded that computerized cognitive behavioral therapy is an asset for children with depression, especially those who are not able to partake in mainstream schools education and therapy programs (Dixon et al., 2011).
Another study performed by Brent and his colleagues in 1997, compared cognitive behavioral therapy against systemic behavior family therapy (SBFT), and nondirective supportive therapy (NST). In this study there were a total of 107 adolescents, two thirds of which were referred from local healthcare clinics while the other one third was recruited from newspaper advertisements. In this study the subjects participated in their therapy sessions once weekly for a total of 16 weeks (Evans, 2005). At post-treatment assessment, 17% of participants receiving cognitive behavioral therapy still had diagnosable major depressive disorder, whereas 42% of participants receiving nondirective supportive therapy still had diagnosable major depressive disorder. Remission was defined as absence of major depressive disorder, and at least three consecutive becks depression index scale score of less than 9. In the cognitive behavioral therapy group, 60% of participants met the criteria for remission, whereas the NST group had a 39% remission rate, followed by the SBFT group at a rate of 38%. It was also found that the CBT group had a greater efficacy in improving cognitive distortions than the other two treatment groups. There was no variation between the treatment groups in suicidal ideation (Evans, 2005). No statistical analysis was available for this study.
Selective Serotonin Reuptake Inhibitors
Selective Serotonin Reuptake Inhibitors (SSRIs) are a newer class of antidepressants that are now regarded as the first line pharmacological therapy in treating depression in both adolescents and adults. This class is comprised of fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and Escitalopram (Lexapro). SSRIs are now preferred over tricyclic antidepressants (TCAs) as they are regarded as having less autonomic side effects, and are safer in the case of overdose as they generally do not induce arrhythmia or seizures (Brenner, 2010). According to the National Institute of Mental Health (NIMH), the use of SSRIs in treatment of adolescent depression in children ages 10-19 has risen drastically over the past several years. Fluoxetine (Prozac) and Escitalopram (Lexapro) are the only medications currently approved by the FDA for treating adolescent depression in children ages eight and older, however the other SSRIs are commonly used “off label” for the treatment of depression in children (NIMH, 2013).
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