Extant research supports the efficacy of CBT, relative to wait-list, inactive control, and active control conditions. Effect sizes for CBT have varied somewhat. Early meta-analyses reported impressive outcomes, with effect sizes ranging from 1.02 to 1.27,4,5 far surpassing Cohen’s6 criteria for a large effect, set at 0.80; more recent meta-analyses, which examined a broader group of “treatments with cognitive components,” have found a smaller average effect size, 0.35, which is statistically similar to the effects of other psychosocial treatments.7 Thus, although the overall data support the efficacy of CBT, treatment efficacy is likely to be impacted by the characteristics of the specific CBT, the patient population, clinician characteristics, and other parameters.

Two recent large scale studies have underscored the value of combination treatment, in which youth receive CBT plus medication. First, the multisite Treatment for Adolescents with Depression Study (TADS)8 randomized moderately to severely depressed adolescents to receive CBT alone, medication alone (fluoxetine), CBT plus medication, or pill placebo. After 12 weeks of acute treatment, medication alone and CBT plus medication outperformed placebo. Although youth receiving CBT alone did not significantly differ from youth in the placebo condition, there was some evidence that combining CBT and medication led to reduced suicidality, enhancing the safety of medication treatment. After 36 weeks of treatment, response rates were identical for CBT alone and fluoxetine alone (81%), with a slight, nonsignificant advantage (86% response rate) continuing for combined treatment.9
Thus it appears that combination treatment or medication alone leads to accelerated recovery, but with time, recovery rates look similar for CBT and medication monotherapies. However, it is important to note that there were some moderators of treatment response in the TADS, which should be acknowledged when considering CBT. For instance, in TADS, combined treatment was more beneficial for adolescents with milder presentations of depression, whereas youth with more severe depression responded similarly to the combined treatment and monotherapy with fluoxetine.10 Additionally, not all studies have shown an advantage for combined CBT plus medication.11,12 Lastly, because nonresponders were offered additional treatment at the end of the TADS trial, data are not available on longer term outcomes for youth assigned to the placebo condition, leaving open questions regarding whether longer term improvement was owing to the effects of active treatments or to the natural trend toward recovery seen in adolescent depression.

Results of the Treatment of Resistant Depression in Adolescents study (TORDIA)13 also support the value of combination therapy. This study was the first to examine treatment strategies for youth who failed to respond to an initial trial of antidepressant medication (as opposed to the TADS sample of youth who were excluded if they had demonstrated prior treatment resistance). Results indicated that at the end of 12 weeks of acute treatment, youth receiving combined CBT plus a change in medication were more likely to show an adequate clinical response when compared with youth receiving a change in medication alone. Thus results of the TORDIA study support the value of adding CBT as a second-step treatment for youth who fail to respond to initial medication treatment.

The Youth Partners in Care Study (YPIC)1 examined the effectiveness of a quality improvement intervention aimed at improving access to evidence-based depression treatment (CBT and/or medication) through primary care among youth screened for probable depression. In this study, usual providers in the participating health care organizations were trained in manualized CBT for depression. When given a choice of treatment type, patients and providers chose higher rates of CBT relative to medication.1 Results indicated that youth in the intervention condition, relative to youth receiving usual care, showed both increased rates of CBT and psychosocial treatment and improved depression outcomes, suggesting that the improved outcomes were associated with the increased rate of psychosocial treatment, primarily CBT.1 With a more severe sample of youth with major depressive disorder selected for selective serotonin reuptake inhibitor (SSRI) treatment by their primary care providers, Clarke and colleagues found only a weak advantage for combined CBT and medication compared with medication alone.14 Moreover, a British effectiveness/pragmatic trial found no advantage at 12 to 24 weeks for combined CBT plus SSRI medication versus SSRI medication, with both conditions including usual clinical care and the sample including youth with definite and probable major depression who had failed to respond to a brief initial psychosocial intervention.11,15 These studies thus underscore the complexity of translating research findings to usual care settings.

In summary, the bulk of the evidence supports the efficacy of CBT in the acute treatment of depressed youth and that CBT can be delivered under routine practice conditions with beneficial effects. For youth with moderate to severe depression, combined treatment (CBT plus medication) appears to be the treatment with the best risk/benefit ratio. For youth who fail to respond to an initial SSRI trial, the addition of CBT leads to improved outcomes.13 However, extant effectiveness data suggest that translating these findings to usual care contexts may be complex, raising questions regarding the added value of combined CBT plus medication under more routine practice conditions (e.g., versus controlled treatment trials).1,11,12,13,14 Although the majority of CBT research has focused on adolescents,7 CBT is also effective with younger school-age children with depressive symptoms.16,17,18 Note, however, that to date no published randomized controlled trials have documented the efficacy of CBT for school-age children with depressive disorders.

A CBT program for depressed youth can be viewed as containing three phases: conceptualization, skills and application training, and relapse prevention. The focus of treatment varies over time, with an initial emphasis on conceptualization, followed by a focus on skills training and application practice, and concluding with relapse prevention and termination. However, each component listed here is addressed throughout treatment (e.g., the therapist continues to emphasize the CBT model of depression and relapse prevention is anticipated from the early phase of treatment). Nonspecific factors such as a strong therapeutic relationship and alliance with the youth and family are viewed as necessary conditions for treatment.