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Treating Adolescent Depression With Psychotherapy: The Three Ts

Treating Adolescent Depression With Psychotherapy: The Three Ts

Adolescence is a time of increased vulnerability for depression, with risk factors driven by biological, cognitive, and social-environmental changes in development. More than half of all adolescents report experiencing depressed mood, and 8% to 10% experience clinically diagnosable symptoms.1 Depression in the young negatively affects all areas of development, including academic, cognitive, social, and family functioning, and if untreated, it can have significant lasting consequences.

Depression in adolescence is a strong predictor of recurrent depression in adulthood and long-term functional impairment, and it confers a 10-fold increase in risk for suicidal behavior.2 Clearly, depression is a significant health concern among youths, with the potential for severe and lasting consequences: the need for effective intervention is unambiguous.

Fortunately, there is strong empirical evidence for successful therapeutic treatment of adolescent mental health disorders, including depression. Psychotherapy for depression is as effective as medication in many cases and is the recommended first-line intervention for mild to moderate depression in youths. This article offers a brief review of the psychotherapeutic “three T’s” for depression: cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), and dialectical behavior therapy (DBT).

Cognitive-behavioral therapy

CBT is an evidence-based approach that has been tailored to treat a wide variety of mental health concerns in youths, including anxiety, eating disorders, impulse control disorders, ADHD, oppositional defiant disorder (ODD), and a range of other problematic behaviors in addition to specific adaptations for depression. Generally, CBT is directive, time-limited, structured, problem-focused, and goal-oriented. Weekly session structure begins with collaborative agenda setting and homework review and ends with review and consolidation of new skills learned and the assignment of new homework.

Treatment typically ranges from 4 to 20 sessions, depending on program choice and setting, although treatment of comorbid conditions or severe symptoms can take longer. Clinicians may use various combinations of CBT techniques, or they may adhere to a specific manualized program. Common CBT interventions include psychoeducation (helping the patient and parents understand the connection between thoughts, feelings, and behaviors), mood monitoring (keeping a mood diary, linking emotions to thoughts), pleasant activities (creating a list of activities that the patient enjoys and setting aside daily time to engage in them), behavior activation techniques (joining a sports team, going for nightly family walks), and cognitive restructuring (identifying cognitive distortions and negative thinking patterns and re­placing them with more realistic and/or positive ways of thinking). Social, communication, conflict-resolution, and problem-solving skills are also frequent components of CBT programs.

CBT has an extensive research base and a longer history than either IPT or DBT; as such, the approach has traditionally been considered the gold standard for the treatment of childhood and adolescent depression. Meta-analyses in 1998 and 1999 found effect sizes for CBT treatment of depression in youths of 1.02 and 1.27 respectively.3,4 A more recent meta-analysis of 35 studies found a less pronounced effect size of 0.34, although this still represents a clinically significant small to medium treatment effect.5 On the basis of these findings, in 2008 CBT received status as a well-established treatment for youths, according to the guidelines set by Nathan and Gorman.6

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