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Carr, A. (2008). Depression in young people: Description, assessment and
evidence-based treatment, Developmental Neurorehabilitation, 11, 3-15.
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Depression in Young People:
Description, Assessment and Evidence-Based Treatment
Alan Carr
Running head or short title: Depression
Keyword: Childhood depression
Correspondence to Professor Alan Carr, School of Psychology, College of Human
Sciences, John Henry Newman Building, University College Dublin, Belfield, Dublin 4,
Ireland. Tel: +353-1-716-8740 (Direct) 716-8120 (Secretary) Fax: + 353-1-716-1181.
email: alan.carr@ucd.ie
Revised and resubmitted in June 2007 to: Jacquelyn Dick, Assistant Editor,
Developmental Neurorehabilitation, pdr@staffmail.ed.ac.uk,
www.informaworld.com/devneurorehab; David Johnson, The Department of Child Life &
Health, The University of Edinburgh, 20 Sylvan Place, Edinburgh, EH9 1UW, e-mail:
David.Johnson@ed.ac.uk
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ABSTRACT
Objective. The literature on depression in children and adolescents was reviewed to
provide an update for clinicians.
Review process. Literature of particular relevance to evidence-based practice was
selected for critical review. Meta-analyses and controlled trials were prioritized for review
along with key assessment instruments.
Outcomes. An up-to-date overview of clinical features, epidemiology, prognosis,
aetiology, assessment and intervention was provided.
Conclusions. Depression in children and adolescence is a relatively common,
multifactorially determined, and recurring problem which often persists into adulthood.
Psychometrically robust screening questionnaires and structured interviews facilitate
reliable assessment. There is growing evidence for the effectiveness of cognitive
behaviour therapy, psychodynamic therapy, interpersonal therapy and family therapy in
the treatment of paediatric depression. There is also evidence that SSRIs may be
particularly effective for severe depression, although they may carry the risk of increased
suicidality.
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CLINICAL FEATURES
A major depressive episode in children and adolescents is characterized by a period of
low mood of at least two weeks duration, accompanied by other cognitive and behavioural
features. The primary symptom of depression is low mood and / or loss of interest in daily
activities including those that youngsters normally find enjoyable. There may be diurnal
variation in mood, with mood being lowest in the morning. In adolescents, in some
instances, irritable, rather than low mood may be the central feature. The principal
cognitive features of depression are poor concentration, poor attention and
indecisiveness; low self-esteem; pessimism; suicidal ideation or intent; and feelings of
worthlessness or guilt. Fatigue; psychomotor retardation or agitation; and sleep and
appetite disturbance are the main behavioural features. The diagnostic criteria for a major
depressive episode from ICD 10 [1] and DSM IV TR [2] and are given in Table 1. Major
depression is an episodic disorder characterized by major depressive episodes and
intervening periods or normal mood. This is distinguished from dysthymia, which is a
milder but more persistent mood disorder, characterized by chronic low mood for at least
a year (in young people and 2 years in adults), accompanied by fewer additional cognitive
or behavioural symptoms than are required for a diagnosis of major depressive disorder.
For a DSM diagnosis only two additional symptoms are required and for and ICD
diagnosis 3 additional symptoms are required for a dysthymia diagnosis.
In both DSM IV TR and ICD 10, children and adolescents are diagnosed using
almost the same criteria employed as are used for adults. There are some noteworthy
minor differences. In DSM IV TR, irritability and failure to make expected weight gain
count as symptoms of major depression in children, but not adults; and the duration of
symptoms in dysthymia need only be 1 year for a diagnosis to be made in children
compared with a duration of 2 years in adults. In view of the evidence that developmental
changes in depressive symptoms and the overall depressive syndrome occur during
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childhood and adolescence, more extensive modifications to adult criteria have been
proposed [3,4]. Luby [3] in a series of studies aimed at revising DSM IV TR criteria for
preschoolers found that preschool children express depressive symptoms in thematic
play, and through loss of interest in play. Also she has shown that a more valid definition
of the depressive syndrome in preschoolers requires the presence of 4 (and not 5)
symptoms, most of the time (not all of the time) over a 2 week periods as specified in
DSM IV TR. Weiss & Garber [4] in a meta-analysis of 16 studies of depressive symptoms
in children of different ages found that anhedonia, hopelessness, hypersomnia, weightgain and social withdrawal are rarer in younger children but become more common as
children mature. In clinical practice, it is important to take account of these developmental
issues in assessing depression in children and adolescents.
EPIDEMIOLOGY
Depression in young people is not a rare condition. In a review of 18 epidemiological
studies of community samples, Costello et al., [5] found prevalence rates of major
depression in youngsters under 18 to range from 0.2-12.9%, with a median of 4.7%.
Depression is more common among adolescents than children; more common among
teenage girls than boys; and very common among clinical populations [6]. Community
studies of depression co-morbidity rates, show that high rates of co-morbidity occur with
anxiety disorder, conduct disorder and attention deficit hyperactivity disorder in childhood
and with eating disorders and substance abuse in adolescence [5, 7].
PROGNOSIS
While the majority of youngsters recover from a depressive episode within a year, they do
not grow out of their mood disorder [6]. Major depression is a recurrent condition and
depressed youngsters are more likely than their non-depressed counterparts to develop
episodes of depression as adults, although they are no more likely to develop other types
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of psychological problems [8]. Double depression: that is, chronic dysthymia combined
with major depressive episodes; severe depressive symptoms; maternal depression;
comorbid conduct disorder or drug abuse; family problems; and social adversity have all
been shown in longitudinal studies to be predictive of worse outcome [6, 8, 9].
In a large North American community study, Lewinsohn et al. [10] found that 12%
of adolescents with depression relapsed within a year and 33% within 4 years. Interepisode intervals decrease as more episodes occur. This may be due to the
neurobiological process of kindling [11] and the cognitive process of rumination [12, 13].
According to cognitive therapists, small stresses, which lead to small negative mood
changes, can give rise to chronic rumination and catastrophising and precipitate later
episodes of depression. According to neurobiological theorists, multiple episodes of
depression, through a process of kindling, probably render the neurobiological systems
that maintain depression more vulnerable to depressogenic changes in response to minor
stresses.
Children and adolescents with depression are at a higher risk of suicide than
youngsters with other disorders, so the assessment and management of suicide risk is a
priority when dealing with depressed young people [14,15,16].
SEX DIFFERENCES
In adulthood twice as many women have depression as men. This sex difference in
depression rates begins after the onset of puberty. Hankin and Abramson [7] have argued
that multiple constitutional, personal and contextual factors may account for this, and have
drawn support for their position from a review of a considerable body of empirical
evidence. What follows are some key findings of their extensive review. Girls experience
more independent and dependent stressful life events than boys. Independent life events
are outside the individual’s control, for example, bereavement. Dependent life events are
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elicited by the individual’s behaviour, for example, interpersonal rejection. Girls also
ruminate more and have a more depressive inferential style in response to these events.
Girls have higher levels of the personality trait –neuroticism – which is a vulnerability
factor for depression and which is partially genetically determined. Finally, genetic factors
may render teenage girls more vulnerable to depression than boys. For example, in a
study of 377 depressed and non-depressed adolescents exposed to high and low levels
of life stress, Eley and colleagues [17] found that for girls (but not boys), depression
occurring during exposure to high stress was associated with a specific molecular genetic
deficit, 5-HTTLPR, a short allele form of the promoter region of the serotonin transporter
5-HTT. Collectively, the aggregation of these factors, reviewed by Hankin and Abramson
[7] . may partly explain the higher rates of depression in teenage girls.
AETIOLOGY
Research on the aetiology of depression is converging in support of a diathesis-stress
model [18, 19]. Children and adolescents are rendered neurobiologically vulnerable to
depression by genetic factors which interact with environmental factors to give rise to
mood disorders.
Neurobiological vulnerability to depression is polygenetically determined [20]. The
genes associated with this vulnerability are different in males and females [21]. Genetic
factors play an increasingly significant role in the aetiology of depression with the
transition to adolescence, particularly in girls [22]. Genetic factors may render young
people vulnerable to depression by affecting their temperament and personality, and by
affecting neurobiological factors associated with depression. Genetic factors influence the
level of the personality trait, neuroticism, which is a predisposing factor for depression
[23]. Genetic factors may also influence the functioning of the hypothalamic-pituitaryadrenal axis, and the functioning of the serotonin, cholinergic and noradrenergic systems,
which show deregulation under stress in depression [24].
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Environmental factors which place undue stress on youngsters; which outstrip their
coping capacities; and which occur in the absence of social support, interact with genetic
factors and may initially render youngsters psychologically vulnerable to depression. Later
they may precipitate the onset of depressive episodes and prevent recovery or precipitate
relapse [25]. Loss of important relationships, failure experiences, bullying, illnesses and
injuries, and disruptive life transitions such as moving house or the onset of puberty all
constitute stressful life events. There is some evidence that stressful events are more
likely to precipitate depression when they occur in the same domain as those that
rendered the individual vulnerable to depression earlier in their lives. So youngsters who
suffered interpersonal losses in early childhood are more likely to have a depressive
episode later in their development precipitated by an interpersonal loss, and those that
experienced significant achievement failures early in life are more likely to become
depressed when they experience failure in academic and work domains later in their
development [26, 27].
Non-optimal early parenting environments are particularly important sources of
environmental stress, and deserve special mention. Non-optimal parenting environments
include those characterized by lack of parental attunement, parental psychopathology
(notably maternal depression and paternal substance use), family conflict, stressful
parental separation, domestic violence, and child maltreatment, all of which may be
influenced by wider sociocultural factors such as poverty and social isolation [19].
Non-optimal parenting environments may render youngsters psychologically
vulnerable to depression by contributing to the development of poor skills for regulating
negative emotional states and coping with both minor daily stresses and larger stressful
life events [28]; self-criticism [26]; a low sense of control over one’s life [29]; a pessimistic
cognitive style [30]; a negative and hopeless inferential style [31]; a ruminative response
style [32]; insecure attachment styles [33]; and poor skills for developing supportive social
networks [19, 34].
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Once an episode of depression occurs it may be maintained at a psychological
level by all of these personal psychological factors; and also by neurobiological
processes, life stresses and non-optimal parenting environments mentioned earlier.
On the positive side, personal and contextual protective factors may reduce the
likelihood of depression or contribute to recovery. These include intelligence, problemsolving skills, an active coping style, the capacity for self-reflection, self-esteem, an
internal locus of control and sense of mastery, higher levels of physical activity, good
social skills, a supportive cohesive family, a positive school environment, supportive peer
relationships, and a supportive community [19, 35, 36]
ASSESSMENT
Assessment for depression should begin with a broad screening for psychological
difficulties. If this suggests that there are mood problems, a more detailed assessment of
depressive symptoms may be conducted. If appropriate, this may be followed by
structured interviewing about depressive syndromes. Then a wider interview covering risk
and protective factors mentioned in the previous section, along with suicide risk
assessment should be conducted. Guidelines for such broader interviews are given in
Carr [15, 37] and elsewhere [14, 16, 38, 39].
For screening school-aged children and adolescents for any type of psychological
disorder, including depression, the Achenbach System of Empirically Based Assessment
(ASEBA) [40, 41] and the Behavioural Assessment System for Children (BASC) [42] are
very useful. These are both reliable, valid and well standardized multi-informant
assessment packs, which contain parent, teacher and child report forms, and which
assess a wide range of emotional and conduct problems including depression. However,
because these instruments span a wide range of problems, the depression subscales
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included in them, contain only a small number of items. If children screen positive for
mood disorders on BASC or ASEBA depression scales, it is appropriate to conduct a
more detailed assessment of depressive symptoms.
The most widely used and best validated self-report instruments for assessing
depressive symptoms in children are the Children’s Depression Inventory (CDI) [43], the
Beck Depression Inventory for Youth (BDIY) [44] and the Reynolds Child and Adolescent
Depression Scales (RCDS and RADS) [45, 46]. The Mood and Feelings Questionnaire
[47] has parent and self-report versions, and is the most widely used and best validated
screening instrument with this feature. For preschool children, the parent-report
Preschool Feelings Checklist [48] is one of the very few available measures for screening
toddlers for depression. All of these instruments have good internal consistency and testretest reliability. They also have strong criterion validity, distinguishing between groups of
cases with and without a diagnosis of depression [43, 44, 45, 46, 47, 48]. These
instruments are useful for evaluating symptom severity, and changes in symptom severity
over time. However, unlike structured interviews they do not evaluate depressive
syndromes as conceptualized in DSM IV TR and ICD 10. Where young people obtain
elevated scores on depressive symptom assessment instruments, it is appropriate to
conduct a structured interview to assess depression from a syndromal perspective.
There are many structured interviews for assessing depression (and other DSM IV
TR or ICD 10 disorders), most of which have parent and child-report versions, or which
allow for data from multiple informants to be combined. In the UK the most widely used is
the Development and Well-being Assessment (DAWBA), [49]. In North America, for
school aged children, some of the most widely used include the Diagnostic Interview
Schedule for Children (DISC-IV) [50], the Diagnostic Interview for Children and
Adolescents (DICA) [51], the Child and Adolescent Psychiatric Assessment (CAPA) [52]
and the Schedule for Affective Disorders and Schizophrenia for School-age Children (KSADS) [53]. The Berkeley Puppet Interview [54] may be used for assessing preschool
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children. The Young-Child DISC-IV [55] and the Preschool Age Psychiatric Assessment
(PAPA) [56] are parent report interviews for use with children under 6. These instruments
all have moderate to good inter-rater reliability [49, 50, 51, 52, 53, 54, 55, 56]. The mood
disorders module from these instruments may be used obtain a reliable diagnosis of
depression.
TREATMENT EFFECTIVENESS
Available information on the natural history of childhood and adolescent depression
provides a context for interpreting the results of treatment trials of psychological therapies.
The majority of youngsters recover from a depressive episode within a year; about a tenth
relapse during the following year; about a third relapse within 4 years; and inter-episode
intervals decrease as more episodes occur [10]. Depression often persists into adulthood
[8], and it is a risk factor for suicide [15]. Treatment with tricyclic antidepressants (TCAs) is
ineffective [57], and treatment with selective serotonin reuptake inhibitors (SSRIs) may be
associated with increased suicide risk in adolescents [58, 59], although there is some
evidence to the contrary [60]. There is clearly a strong case for the importance of
developing effective psychotherapies for depression in children and adolescents.
In selecting treatment outcome literature for review, priority was given to metaanalyses and systematic reviews, and in their absence to randomized controlled trials.
Where these types of evidence were not available, outcome studies that included a
matched control group or a single treatment group were included, but results of such
studies were interpreted with appropriate caution.
In the most comprehensive available meta-analysis of 35 randomized controlled
studies of psychotherapy for child and adolescent depression, Weisz et al. [61] obtained
an effect size of .34. This indicates that the average treated case fared better than 63% of
untreated cases and is equivalent to a success rate of about 58%. This modest effect size
is more valid than the larger effect size of .72 found by Michael and Crowley [62] in an
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earlier, smaller and less methodologically robust meta-analysis of 14 trials of
psychotherapy for child and adolescent depression. Weisz et al. [61] also found that there
were no significant differences in outcome between cognitive behavioural treatments and
other treatments, or between treatments conducted under optimal or routine clinical
conditions. Treatment gains were maintained at 6 months follow-up but not at 1 year
follow-up. This is not surprising giving the episodic and recurrent nature of major
depression. In addition to these omnibus reviews of the overall effectiveness of
psychotherapy for depression in young people, a number of reviews focusing on specific
forms of treatment, and a number of key outcome studies which have examined the
effectiveness of cognitive-behaviour, psychodynamic, interpersonal, and systemic therapy
deserve mention.
Cognitive behaviour therapy
There is evidence from three reviews for the effectiveness of cognitive behaviour therapy
in the treatment of child and adolescent depression. In a systematic review of 6 studies of
cognitive behaviour therapy for major depression in children and adolescents, Harrington
et al. [63] found a remission rate of 62% for treated cases and 36% for untreated cases.
In a meta-analysis of studies of cognitive behaviour therapy for depression in
adolescence, Lewinsohn and Clarke [64] found a post-treatment effect size of 1.27. They
also found that 63% of patients showed clinically significant improvement. In a metaanalysis of 6 studies of cognitive behaviour therapy for depression in adolescence,
Reinecke et al. [65] obtained a post-treatment effect size of 1.02 and a follow-up effect
size at 6-12 months of .61. Collectively these results indicate that just over 60% to just
over 70% of young people diagnosed with a depressive disorder benefited from cognitive
behaviour therapy.
In an important comparative trial Brent [66] and his team found that immediately
after treatment, more youngsters who received cognitive behaviour therapy (60%) were in
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remission compared with those who received family therapy (38%) or supportive therapy
(39%). However, at two years follow-up there were no significant differences between the
outcomes of the 3 groups. Recovery rates were 94% for cognitive behaviour therapy, 77%
for family therapy, and 74% for supportive therapy. In all three groups, a negative family
environment characterized by maternal depression and family conflict on the one hand,
and severe cognitive distortions and depressive symptomatology on the other, were
associated with poorer outcome. The positive effects of cognitive behaviour therapy arose
predominantly from changes in depressive cognitive distortions. Positive changes in family
functioning accounted for improvements in the family therapy group. In all three groups a
rapid improvement during the first couple of sessions occurred in just over a third of
cases, and was predictive of a positive outcome. Therapeutic factors common to all three
types of therapy, such as the quality of the therapeutic alliance, probably accounted for
this rapid improvement. All participants in this study received 12-16 sessions. During the
follow-up period 62% used other services for depression, 33% for family problems, and
31% for conduct problems. The results of the study suggest it may be worthwhile
combining individually-oriented cognitive behaviour therapy and family therapy to aim to
address both intrapsychic and interpersonal depression maintaining factors, and to extend
therapy beyond 16 sessions so that additional services are not required.
Cognitive behaviour therapy for depression rests on the hypothesis that low mood
is maintained by a depressive thinking style and constricted lifestyle that entails low rates
of response contingent positive reinforcement. Cognitive behaviour therapy programmes
for adolescents evaluated in treatment trials have two main components which target
these two maintaining factors: behavioural activation and challenging depressive thinking
[67]. In challenging depressive thinking, youngsters learn mood monitoring, and how to
identify and challenge depressive negative automatic thoughts and cognitive distortions
that accompany decreases in mood. With behavioural activation youngsters re-organize
their daily routines so they involve more pleasant events, physical exercise and social
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interaction. They also develop skills to support this process including social skills,
relaxation skills, communication and problem-solving skills, and relapse prevention skills.
Some cognitive behavioural programmes for depression in young people include
concurrent intervention with parents, which helps them understand factors that maintain
depression and support youngsters in following through on the behavioural activation and
cognitive components of the child-focused part of the programme. Cognitive behaviour
therapy usually spans 10-20 child-focused sessions and may be offered on an individual
or group basis. Where concurrent parent sessions occur, usually about 5-10 of these are
offered. Lewinsohn’s group-based programme [68, 69] and Brent’s [66] and Weisz’s [70]
individual cognitive behaviour therapy programmes are good examples of well-developed
North American evidence-based approaches in this area. In the UK, Stallard’s Think Good
- Feel Good programme offers a best practice approach to CBT with young people [71,
72]
Psychodynamic therapy
One randomized controlled trial and one non-random matched group trial provide
evidence for the effectiveness of psychodynamic psychotherapy with depressed children
and adolescents [73, 74]. In a randomized controlled study of 72 youngsters aged 9-15
assigned to psychodynamic or family therapy, Trowell et al. [73] found that about 75% of
cases in both groups were fully recovered after therapy. 100% of those who received
psychodynamic therapy and 81% of those who received family therapy were fully
recovered at 6 months follow-up (but this group difference was not significant).
Psychodynamic and family therapy also led to a significant reduction of double depression
(major depression with co-morbid dysthymia) and rates of other co-morbid conditions. In
this study psychodynamic therapy involved an average of 25 individual sessions and 12
concurrent parent sessions spanning 9 months, following a manual based on Malan [75]
and Davenloo’s [76] model of brief psychodynamic psychotherapy. In this model the focus
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is on interpreting the links between defences, anxiety and unconscious feelings and
impulses, within the context of the transference relationship with the therapist, the
relationship with significant people in the child’s current life, and early relationships with
parents or caregivers. Family therapy involved an average of 11 sessions spanning 9
months based on Byng Hall [77] and Will and Wrate’s [78] integrative model of family
therapy (discussed in more detail below).
In a non-randomized matched group study of 58 children aged 6-10 years, most of
whom had dysthymia, assigned to psychodynamic therapy or community-based treatment
as usual, Muratori et al [74] found that at two years follow-up, 66% of those who received
psychodynamic psychotherapy were recovered compared with 38% in the control group.
In this study, psychodynamic therapy involved 11 conjoint parent-child sessions and
several additional individual sessions for children only, based on the Cramer and Palacio
Espasa’s [79] model. Within this model in the first phase, parent-focused work occurs
where parent-child interactions are interpreted in terms of their defensive functions. Playbased child-focused work occurs in the second phase, with the aim of helping the child
understand and articulate links between feelings, wishes and symptoms. In the final
phase, the core-conflictual theme that links the parent’s defensive style to the child’s
symptoms is explored. A core conflictual theme has three key elements: (1) the person’s
wish in a particular type of situation, (2) the person’s anticipated or imagined response of
the other person in that type of situation, and (3) the person’s actual defensive response
in that type of situation.
Taken together, the results of these two trials provide preliminary evidence for the
effectiveness of psychodynamic therapy with children and adolescents. Because
Muratori’s study was not a randomized controlled trial, caution is required in interpreting
the results. The exceptionally positive outcome of psychodynamic psychotherapy in
Trowell et al.’s [73] study is very impressive and requires replication.
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Interpersonal therapy
There is evidence from three controlled efficacy studies, a controlled effectiveness study
and a single group outcome study that interpersonal psychotherapy is an effective
treatment for adolescent depression which leads to recovery in more than 75% of cases,
and in two of these studies interpersonal therapy was found to be as effective as cognitive
behaviour therapy [80, 81, 82] Interpersonal therapy for adolescent depression targets
five interpersonal difficulties which are assumed to be of particular importance in
maintaining depression: (1) grief associated with the loss of a loved one; (2) role disputes
involving family members and friends; (3) role transitions such as starting or ending
relationships within family, school or peer group contexts, moving houses, graduation, or
diagnosis of an illness; (4) interpersonal deficits, particularly poor social skills for making
and maintaining relationships; and (5) relationship difficulties associated with living in a
single parent family. In interpersonal therapy the specific focal interpersonal factors that
maintain the youngster’s depressive symptoms are addressed within a series of childfocused and conjoint family sessions. Mufson et al.’s [83] manual provides detailed
guidance on this approach to therapy with depressed adolescents.
Family therapy
There is evidence from six studies for the effectiveness of family therapy for child and
adolescent depression and suicidality, two of which have already been mentioned [66,
73]. In a comparative study, Trowell et al. [73] found that 11 sessions of family therapy
was as effective as a programme which included 25 sessions of psychodynamic therapy
coupled with 12 adjunctive parent sessions. 75% of cases no longer met the criteria for
depression after treatment and 81% were recovered at 6 months follow-up. Byng Hall [77]
and Will and Wrate’s [78] integrative model of family therapy was used in this trial.
Therapy involved techniques from many schools of family therapy and helped families
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understand the links between the youngster’s depression, problematic family scripts and
insecure family attachment patterns. It also helped family members develop more secure
attachments to each other and re-edit problematic family scripts to form a more coherent
narrative about how to manage stress and life-cycle transitions.
In a controlled study of attachment-based family therapy for depression with 32
adolescents, Diamond et al. [84] found that after treatment 81% of treated cases no
longer met the criteria for depression, whereas 47% of the waiting list control group did. At
6 months follow-up 87% of cases were not depressed. Attachment-based family therapy
involves the following sequence of interventions which have been shown in process
studies to underpin effective treatment: relational reframing, building alliances with the
adolescent first and then with the parents, repairing parent-adolescent attachment, and
building family competency [85].
In another comparative study, Brent’s team [66], found that only 38% of depressed
adolescents were recovered immediately after family therapy, but at two years follow-up
77% no longer met the criteria for depression. Family therapy was less effective in the
short-term, but as effective in the long-term as cognitive behaviour therapy. Improvements
in family functioning accounted for youngsters’ recovery. A behavioural systems approach
to family therapy was used in this trial. This involved using family-based behavioural
interventions such as problem monitoring, communication and problem-solving skills
training, contingency contracting, and relapse prevention to reduce family conflict,
enhance family relationships and promote better mood management.
In a controlled trial involving the families of 31 adolescents, Sanford et al. [86]
evaluated the incremental benefit of adding psychoeducational family therapy to a routine
treatment programme involving predominantly supportive counselling and SSRI
antidepressant medication. Three months after treatment 75% of the family therapy group
and 47% of controls no longer met the criteria for depression, and parent-adolescent
relationships in the family therapy group were significantly better than in the control group.
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A 13 session, home-based adaptation of Falloon et al.’s [87] family therapy model was
used in this study. Treatment included psychoeducation about depression, communication
and problem-solving skills training, and relapse prevention.
In a single group outcome study for adolescents with co-morbid depression and
substance abuse, Curry et al., [88] found that after a combined programme of cognitive
behavioural therapy and family therapy, 50% of cases recovered from depression and
66% from substance abuse. The programme spanned 10 weeks, with weekly family
therapy sessions and twice weekly cognitive behaviour therapy group sessions. Robin and
Foster’s [79] model of family therapy for negotiating parent-adolescent conflict was used
in this programme.
Huey et al. [90] evaluated the effectiveness of multisystemic therapy – an
intervention programme that includes family therapy as its core component [81]– in a
randomized controlled study of a group of with 156 African American adolescents at risk
for suicide referred for emergency psychiatric hospitalization. Most of these youngsters
were depressed, but had multiple other co-morbid difficulties. Compared with emergency
hospitalization and treatment by a multidisciplinary psychiatric team, Huey et al. [80] found
that multisystemic therapy was significantly more effective in decreasing rates of
attempted suicide at 1-year follow-up.
Collectively these studies lend support for both attachment-based and
psyhoeducationally oriented cognitive-behavioural approaches to family therapy as
effective treatments for depressed adolescents, and multisystemic therapy as an effective
family therapy based approach to reducing suicidality.
Antidepressant medication
In a meta-analysis of 13 studies of the effectiveness of TCAs for depression in young
people, Hazell et al. [57] concluded that TCAs are ineffective with children and only have
a small impact on adolescent depression. In contrast, there is growing evidence that
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SSRIs may have a role in the treatment of depression in young people. In reviews of
controlled trials of SSRIs for child and adolescent depression, Cheung et al. [92] and
Vasa et al. [93] found a number of SSRIs, notably fluoxetine, alleviated the symptoms of
depression in about two thirds of children and adolescents and led to complete remission
in about a third of cases. However, because there is some evidence that SSRIs may lead
to increased suicidal ideation and behaviour [58, 59], caution in required in using them in
the treatment of children and adolescents with mood disorders.
Results of the large USA multisite Treatment for Adolescent Depression Study
[TADS, 94] which involved 439 moderately depressed adolescents, showed that cognitive
behaviour therapy combined with fluoxetine (an SSRI) led to a significantly higher
improvement rate (71.0%) than medication alone (60.6%), which in turn led to a
significantly higher improvement rate that cognitive-behaviour therapy alone (43.2%).
Cognitive behaviour therapy combined with SSRis also led to the greatest reduction in
suicidal thinking, compared with the other two conditions. This may provide an evidencebased rationale for combining SSRIs with cognitive behaviour therapy in moderate
depression. In the TADS study the effectiveness of cognitive behaviour therapy alone
(43.2%) was low compared with other trials where the outcome has been about 60% [53].
This may have been due to the characteristics of the participants. In an analysis of factors
related to outcome in the TADS study, Curry et al. [95] found that cognitive behaviour
therapy combined with SSRIs was more effective than SSRIs alone for mild to moderate
depression and for depression with high levels of cognitive distortion, but not for severe
depression or depression with low levels of cognitive distortion.
In contrast to the results of the TADS study, Goodyer et al. [96] in the UK
multicentre Adolescent Depression Antidepressant and Psychotherapy Trial (ADAPT)
involving 208 adolescents with severe depression who had not responded to an initial
brief trial of psychotherapy, found that there was no significant benefit in terms of recovery
from depression or reduction in suicidal ideation associated with adding 19 sessions of
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cognitive behaviour therapy to routine outpatient consultations at a specialist clinic and
SSRIs. By 28 weeks 57% of trial participants showed clinically significant improvement
including reduced suiciality. The sample in this study included cases of severe depression
that would have been excluded from the TADS study because of suicidality, depressive
psychosis or co-morbid conduct disorder. Goodyer, concluded that for severe adolescent
depression, of the type typically referred to UK specialist services, the addition of cognitive
behaviour therapy to routine specialist care and SSRI treatment confers no additional
benefit. Two additional US studies have yielded similar results. In a randomized trial
involving 152 depressed adolescents, Clarke et al. [97] found that the addition of cognitive
behaviour therapy to routine treatment with SSRIs had a negligible impact on the course
of depressive symptoms. In a randomized multisite trial involving 73 moderately
depressed adolescents, Melvin et al. [98] found that treatment with SSRIs (sertraline),
cognitive behaviour therapy and both combined had similar outcomes 6 months after
treatment.
The results of the studies reviewed in this section support the use of SSRIs in severe
depression in young people, when they do not respond to a brief trial of psychotherapy.
However, because there is some evidence that treatment with selective serotonin
reuptake inhibitors (SSRIs) may be associated with increased suicide risk in adolescents
[58, 59], regular monitoring of this is essential.
Electro convulsive therapy
There are currently no data from controlled trials to support the use of electroconvulsive
therapy with adolescents, but some limited data from open trials, so its use remains
cautious and controversial [99, 100, 101, 102].
IMPLICATIONS FOR PRACTICE
Depression
21
The evidence reviewed in this paper has implications for assessment and treatment.
Assessment for depression should begin with a broad screening for psychological
difficulties with instruments such as those in the ASEBA or BASC evaluation packs. If this
suggests that there are mood problems, a more detailed assessment of depressive
symptoms may be conducted with depression-specific instruments such as the CDI, BDIY,
RCDS or RADS. Where elevated scores on these occur, it is appropriate to conduct a
structured interview to assess depression from a syndromal perspective with the mood
disorders module from instruments such as the DAWBA, DISC-IV, DICA, CAPA, or KSADS. If children are under 5 the Young-Child DISC-IV or PAPA may be used. These
structured interviews will yield DSM or ICD diagnoses. Then a wider interview covering
risk and protective factors mentioned in the previous section, along with suicide risk
assessment should be conducted.
With regard to treatment, the conclusions that can be drawn are limited by the
nature of available evidence. For example, only tentative conclusions may be made about
how to tailor treatment to match client characteristics because for all forms of therapy,
evidence is available for only a limited range of children in terms of age, socio-economic
status, family composition, depression severity, comorbidity and so forth. For example, in
Trowell et al.’s [73] trial of psychodynamic therapy, only children over 9 were included,
and this is the only randomized controlled trial of psychodynamic therapy. Also, actively
suicidal cases were excluded from most psychotherapy trials, with the exception of
Goodyer et al’s [96]. Tentative conclusions must also be drawn about how best to
combine child-focused and parent-focused interventions, since no treatment
deconstruction trials have been conducted in which child-focused, parent-focused and
combined treatment protocols have been compared. With these caveats in mind, the
following guidance is offered for clinical practice until more evidence becomes available.
Effective protocols for mild to moderate depression have been developed within the
cognitive-behavioural, interpersonal, psychodynamic and family therapy traditions. These
Depression
22
protcols should be flexibly applied in clinical practice, taking due account of clinical
formulations of clients’ unique profiles of personal and contextual predisposing,
precipitating, maintaining and protective factors. In light of such clinical formulations, a
case may be made for combining child and family based components of treatment
protocols that have been shown to be effective, to address specific elements within a
client’s formulation [37]. Extant evidence suggests that family-based intervention for child
and adolescent depression includes family psychoeducation; facilitating family
understanding and support of the depressed youngster; and organizing home-school
liaison to help the youngster re-establish normal home and school routines. Available
evidence suggests that child-focused interventions involves exploration of contributing
factors, some of which may be outside youngsters’ awareness; facilitating moodmonitoring; increasing physical exercise, social activity and pleasant events; modification
of depressive thinking styles, depression maintaining defence mechanisms and
depression maintaining patterns of social interaction; the development and use of social
problem-solving skills; and the development of relapse prevention skills. Extant evidence
suggests that a dozen family sessions and twice as many individual sessions are probably
necessary for treating mild to moderate depression in children and adolescents. With
severe depression, where clients show no response to a brief trial of psychotherapy, and
where they present with suicidality, psychotic features, or comorbid difficulties, a trial of
SSRIs combined with routine specialist clinical monitoring and support is the treatment of
choice. However, caution is warranted in using SSRIs with youngsters, since they may
increase suicide risk.
These conclusions are broadly consistent with international guidelines for best
practice [38, 39], but differ from UK NICE guidelines insofar as these do not recommend
the use of psychodynamic therapy for depression.
_____________
Depression
23
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Depression
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34
Depression
35
Table 1. Criteria for a major depressive episode
DSM IV TR
ICD 10
A. Five or more of the following symptoms have been
present during the same two week period nearly
every day and represents a change from pervious
functioning; at least one of the symptoms is ether (1)
depressed mood or (2) Loss of interest or pleasure.
Symptoms may be reported or observed.
In a typical depressive episode the individual usually
suffers from depressed mood, loss of interest and
enjoyment and reduced energy leading to increased
fatigueability and diminished activity. Marked tiredness
after only slight effort is common. Other common
symptoms are:
a. reduced concentration and attention
b. reduced self-esteem and confidence
c. ideas of guilt and unworthiness
d. bleak and pessimistic views of the future
e. ideas or acts of self harm or suicide
f. disturbed sleep
g. diminished appetite.
1. Depressed mood. In children and adolescents can be
irritable mood.
2. Markedly diminished interest or pleasure in almost all
daily activities.
3. Significant weight loss or gain (of 5% per month) or
decrease or increase in appetite. In children failure to
make expected weight gains.
The lowered mood varies little from day to day and is
often unresponsive to circumstances and may show a
characteristic diurnal variation as the day goes on.
4. Insomnia or hypersomnia.
5. Psychomotor agitation or retardation.
6. Fatigue or loss of energy.
7. Feelings of worthlessness, excessive guilt.
8. Poor concentration and indecisiveness
9. Recurrent thoughts of death, suicidal ideation or suicide
attempt.
B. Symptoms do not meet criteria for mixed episode of
mania and depression.
C. Symptoms cause clinically significant distress or
impairment in social occupational, educational or
other important areas of functioning
D. Symptoms not due to the direct effects of a drug or a
general medical conditions such as hypothyroidism.
E. The symptoms are not better accounted for by
uncomplicated bereavement.
Some of the above symptoms may be marked and
develop characteristic features that are widely regarded
as having special significance for example the somatic
symptoms which are:
loss of interest or pleasure in activities that are
normally enjoyable; lack of emotional reactivity to
normally pleasurable surroundings; waking in the
morning 2 hours or more before the usual time;
depression worse in the mornings; psychomotor
retardation or agitation; marked loss of appetite or
weight; marked loss of libido. Usually the somatic
syndrome is not regarded as present unless at least
four of these symptoms are present.
Atypical presentations are particularly common in
adolescence.
In some cases anxiety, distress, and motor agitation
may be more prominent at times than depression and
mood changes may be masked by such features as
irritability, excessive consumption of alcohol, histrionic
behaviour and exacerbation of pre-existing phobic or
obsessional symptoms or by Hypochondriacal
preoccupations.
A duration of two weeks is required for a diagnosis.
Note: Adapted from DSM IV TR (APA, 2000), ICD 10 (WH0, 1992).