1. Chapter 10: Depressive Disorders in Adolescents Megan Jeffreys V. Robin Weersing

2. Overview One in five youths experience a depressive episode before reaching the age of 18 Depression is a leading cause of disability worldwide Adolescent depression predicts: Impaired educational attainment Deficits in social support Increased risk of suicide attempt Youths with a prior depressive episode experience: higher levels of anxiety, elevated depressive symptoms, impaired social functioning, and higher levels of substance use

3. Evidenced-Based Approaches CBT is the best-research intervention 14 out of 18 published clinical trials investigate CBT effects Depression is thought to arise from: Heightened intrapersonal sensitivity to stress Experience of stressful life events Maladaptive responses to stressors

4. Treatment Types CBT Therapists collaborate with youths to identify depressogenic thought patterns and behaviors Clients explicitly learn new skills for managing thoughts and mood when exposed to triggering events IPT-A Immediate interpersonal stressful life events that appear to have precipitated the current depressive episode General interpersonal stress management skills are taught and practiced

5. CBT CBT for depression often consists of: problem solving, parent management training, relaxation, social skills training, motivational interview, cognitive restructuring, behavioral activation Focuses on current problems and symptoms that can be corrected through cognitive and behavioral modification Five core CBT manuals have been tested in clinical trials with depressed adolescents

6. CBT Manuals Coping with Depression Most extensively tested treatment manual for depression in adolescence Skills taught: relaxation, behavioral activation, social skills training, problem solving/conflict resolution, and recognizing and challenging distorted thoughts Pittsburgh Cognitive Therapy Study Individual setting, twelve to sixteen sessions Three core techniques: cognitive restructuring, behavioral activation, and problem solving Brief CBT Includes emotion recognition and labeling, social skill building, challenging distorted cognitions Nine individual sessions delivered every other week over maximum of 6 months

7. Cumulative Evidence for CBT Delivered at high dose and intensity—weekly for at least 12 weeks—CBT appears efficacious in treating depression in adolescence Superiority of CBT compared to other treatments diminishes over follow-up Efficacy of CBT for clinically complicated youths and effectiveness of CBT when delivered in real- world settings are much less clear

8. Interpersonal Psychotherapy Treatment targeted at practicing and building skills to reduce current symptoms and impairment associated with depression Primarily focuses on the social context in which symptoms develop and are maintained Treats depressive symptoms and problematic social functioning using three primary treatment strategies: 1) Identification of a social problem area tied with onset of the depressive episode 2) Development of effective communication and problem solving skills for this problem area 3) Building and practicing skills taught in treatment

9. IPT-A Treatment IPT-A Interpersonal therapy manual for depressed adolescents Weekly treatment for 12 weeks Works though active skills building in and out of session Across treatment manuals, evidence to suggest the efficacy of IPT-A in treating depression in adolescence Rates of recovery from depression in youths receiving IPT-A (75%–82%) higher than in youths in no-treatment conditions (46%)

10. Parental Involvement Parental psychopathology involved in the development and maintenance of adolescent depression Offspring of parents with a history of depression experience two- to threefold increase in depressive illness Current parental depression at the time of intervention delivery predicts poor response for depressed teens and may moderate treatment effects, erasing positive impact of CBT Limited empirical exploration of the efficacy of family- based treatment for adolescent depression

11. Cultural Adaptations RCT for adolescent depression largely have included Caucasian majority or failed to provide information on the culture, race, and ethnicity of enrolled adolescents Rossello et al. (2008) used culturally adapted versions of CBT and IPT-A Adaptation included: translation of materials, development and use of culturally relevant metaphors, greater involvement of family members in treatment sessions, adjustment of therapy goals

12. Measuring Treatment Effects Utilizing standardized assessment provides a thorough assessment of a youth’s symptoms and functioning Assess the extent that an adolescent’s clinical presentation is likely to be a good fit to the evidence- based treatment program under consideration Can help in assessing improvement of symptoms over the course of treatment

13. Clinician-Rated Assessments K-SADS: research gold standard for psychodiagnostic assessment of depression; semi structured interview Children’s Depression Rating Scale–Revised: rating scale in which the clinician uses both youth and parent report as well as clinical observation to make summary ratings for each specific symptom of youth depression

14. Youth and Parent Report Useful for assessing change in depressive symptoms over the course of treatment, rather than establishing depressive diagnoses at intake Common measures include: CES-DC, DSRS, CDI, and short and long forms of the Mood and Feelings Questionnaire

15. Clinical Case Example: Cecilia 14-year-old female Diagnosis: first episode of major depressive disorder; comorbid social phobia Spending time home alone with less family support, withdrawal from social activities, negative thoughts, feeling hopeless, passing thoughts of death Treatment included: psychoeducation, behavioral activation, physical symptoms, cognitive restructuring Outcome: depressed mood and thoughts of burdensomeness were less frequent