How to Use Cognitive Behavior Therapy for Youth Depression: A Guide to Implementation
DAVID A. LANGER
ANGELA W. CHIU
JOAN R. ASARNOW
KEY POINTS
Considerable evidence indicates that cognitive behavior therapy (CBT), alone or in combination with medication, is effective in the acute treatment of major depression in youth.
Combined treatment (CBT plus medication) appears to be the treatment for youth with moderate to severe depression with the best risk/benefit ratio, although the specific benefits of CBT are less clear with more severe depression.
The combination of medication and CBT appears to be the best treatment for depressed adolescents who did not respond to an adequate medication trial.
Efficacy of CBT is likely to be influenced by the characteristics of the specific CBT used, the patient population, clinician’s characteristics, and other parameters.
A CBT program contains three somewhat overlapping phases: conceptualization, skills and application training, and relapse prevention.
A typical CBT session begins by collaboratively setting an agenda for the session, reviewing homework from the previous week, teaching and practicing the current cognitive-behavioral skill, addressing crises and issues that have arisen in the youth’s life over the previous week, helping the youth summarize the skills that have been learned during the session, and allocating practice/homework assignments.
CBT is often provided weekly. Increasing session frequency is encouraged, particularly at the start of treatment if youth present with severe or chronic symptoms.
Different CBT approaches vary in the amount of parent involvement. However, at a minimum, most CBT clinicians recommend some family psychoeducation regarding depression and family or parent sessions.
The first goal of the activity module is to identify links between mood and activities in the youth’s life experience, followed by increasing the number of pleasant activities.
The cognitive module is rooted in the cognitive model of depression that views depressive symptoms as consequences of negative thought patterns. This module helps youth discriminate between “helpful” thoughts and “unhelpful” thoughts, develop strategies for generating more helpful thoughts, and practice using helpful thought patterns in response to potential stressful situations.
Depressed youth may often behave in ways that push others away. When they argue with family members and friends, they feel worse. The communication and problem-solving modules aim to equip youth with skills to build and maintain healthy relationships.
Common barriers to CBT can include perceived stigma associated with mental health treatment, immature cognitive skills, crises, and lack of completion of homework.
Younger patients require more active play-oriented approaches, whereas close family involvement is often less important for adolescents.
Introduction
Michelle is a 15-year old white girl living with her biological parents and her 12-year old sister. She presented with an acute onset of a depressive episode after her family moved 3 months earlier. Michelle’s mother expressed concern about Michelle’s school refusal, depressed mood, irritability, sudden loss of interest in extracurricular activities, apathy toward making new friends, and frequent complaints of headaches. In addition, Michelle’s academic performance has deteriorated significantly.
This chapter focuses on the use of CBT with youth like Michelle. CBT is an established treatment for youth depression, supported by substantial evidence documenting efficacy under controlled conditions, and recent data supporting effectiveness under usual practice conditions.1,2 The general CBT model is based on the assumption that depressive symptoms are associated with an individual’s behavioral responses and thought patterns, and changes in behavioral and thought patterns will help the youth feel better and cope more effectively. In this chapter we begin by reviewing the evidence base supporting the value of CBT, followed by a detailed description of how to use CBT with youth like Michelle.
THE EVIDENCE BASE AND PRACTICE PARAMETERS
Current practice parameters for the treatment of youth depression emphasize the value of beginning with a psychosocial treatment and considering medication or combined psychosocial and medication treatments for youth who fail to respond to an initial course of psychosocial treatment or present with severe depression.2 Emphasis on psychosocial treatment has been strengthened by recent warnings regarding the risk of suicidality with antidepressant medications.3 In the next section, we review the evidence supporting the efficacy and effectiveness of CBT for youth depression. To parallel the practice parameters, we (1) begin with the efficacy of CBT as a monotherapy, relative to alternative psychosocial treatment strategies, (2) proceed to a review of the data on the efficacy of CBT in combination with medication treatment, and (3) conclude with the evidence on effectiveness under routine practice conditions.
COGNITIVE BEHAVIOR THERAPY AS A MONOTHERAPY
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.
COMBINATION THERAPY: CBT COMBINED WITH MEDICATION
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.
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.
EFFECTIVENESS OF COGNITIVE BEHAVIOR THERAPY UNDER ROUTINE PRACTICE CONDITIONS
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.
SUMMARY OF COGNITIVE BEHAVIOR THERAPY EFFICACY/EFFECTIVENESS
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.
PRINCIPLES OF COGNITIVE BEHAVIOR THERAPY
CBT is based on two major assumptions: (1) depressed mood states are associated with an individual’s behaviors and thoughts, and (2) changing behavioral and cognitive patterns leads to reductions in depressive symptoms and improved functioning. The model presented in most CBT programs is one in which a youth is exposed to a range of stressors and responds to these stressors with feelings (emotional states), thoughts, and behaviors. Sometimes these feelings, thoughts, and behaviors make the youth feel worse and contribute to downward spirals in which sad/bad feelings lead to unhelpful negative thoughts and behaviors, which lead to worse feelings and even more negative thoughts and behaviors. The goal of treatment is to turn upward these downward depressive spirals. This is done by understanding how one’s feelings, thoughts, and behaviors are interconnected and developing strategies for finding more helpful patterns of thinking and behaving, which in turn lead to better feelings. In this chapter, we emphasize our approach for adolescents that is based on the manual of Clarke and colleagues19 and combines elements of approaches developed originally by Meichenbaum20 and Seligman, Jaycox, and colleagues.21 We also describe other approaches, including those for younger children.
CONDUCTING A CBT PROGRAM FOR DEPRESSED YOUTH
PHASES
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.
Conceptualization
CBT builds on a strong therapeutic relationship and a “collaborative empiricism” through which the clinician adopts the role of “coach.” The clinician, youth, and parents (as appropriate) systematically consider and “gather data” to help inform the treatment and develop strategies for coping with depression, changing thoughts and behaviors that contribute to depression. This approach emphasizes the active involvement of the youth in treatment. A successful CBT program for youth depression involves working with the youth to understand the cognitive-behavioral model of depression and how treatment is likely to be beneficial. The youth and clinician “collaborate” to discover the influence of thoughts and behaviors on the youth’s mood and the cognitive-behavioral strategies that are most effective for the individual youth.
Skills Training and Application Training
The second major task in CBT is to build the youth’s cognitive and behavioral skills for coping with depression and help the youth practice those skills in real-world scenarios. Skills that are polished during the session will not help the youth unless the clinician specifically trains for generalization as each skill is learned (e.g., using practice assignments/homework to be done outside of the session), enlisting the help of parents and others (e.g., friends, teachers) who can help the youth apply his or her skills outside of the therapy session.
Relapse Prevention
As therapeutic work comes to a close, it is important to address the youth and family’s strategies to maintain therapeutic gains. The clinician and youth identify potential stressors and develop plans
to cope with those stressors. General coping strategies are emphasized because it is not possible to anticipate all possible future stresses. The clinician works with the youth and his or her family to recognize signs of depression early. This way the youth can use his or her coping strategies before the downward spiral of depression has gained momentum and seek treatment early if depressive symptoms begin to escalate. The goal during the relapse prevention phase is to provide the youth and family with strategies they can use to prevent depressive reactions from triggering full-blown depressive episodes. This emphasis on relapse and recurrence prevention is particularly important in depression, given the high risk of relapse and recurrence among depressed youth.2,22,23,2425,26 Issues related to termination are also addressed at the end of treatment.
to cope with those stressors. General coping strategies are emphasized because it is not possible to anticipate all possible future stresses. The clinician works with the youth and his or her family to recognize signs of depression early. This way the youth can use his or her coping strategies before the downward spiral of depression has gained momentum and seek treatment early if depressive symptoms begin to escalate. The goal during the relapse prevention phase is to provide the youth and family with strategies they can use to prevent depressive reactions from triggering full-blown depressive episodes. This emphasis on relapse and recurrence prevention is particularly important in depression, given the high risk of relapse and recurrence among depressed youth.2,22,23,2425,26 Issues related to termination are also addressed at the end of treatment.