Research Papers

The Effectiveness of Cognitive Behavioural Therapy (CBT) for the treatment of Adolescent Depression

Introduction

In Canada, clinically reported cases of mood disorders have been increasing in adolescent individuals (aged between twelve to nineteen years-of-age) affecting approximately 98 875 individuals in the year 2011, and increasing each year to an astounding 143 114 individuals in 2014 (Stats Canada, 2015). Additionally, mood disorders point toward dramatic gender imbalances with almost 70% of the total population of individuals with major depressive disorders and dysthymia being women; and- despite overall rates of this disorder varying around the globe- this seems to remain constant from country-to-country (Barlow, Durand, & Stuart, 2012; Fletcher, 2008). Stats Canada (2015) represents these gender differences further, and found that, of the 143 114 adolescents affected by mood disorders in 2014, 97 558 (or 68%) of these reported cases were females. Finally, depression rates increase substantially as children move into adolescence (Dopheide, 2006), and there is an “estimated prevalence of 2% to 6% of children and adolescents manifesting this disorder at any one time, and lifetime prevalence rates estimated at 20% by late adolescence” (Mahoney, Kennard, & Mayes, 2011, p. 307). With numbers such as these within this demographic, and a seemingly ever increasing growth rate, it works to highlight the importance of finding an appropriate and effective form of treatment to assist in reducing the prevalence of such a debilitating disorder.

This paper aims to analyze current writings with the intent of finding the most effective form of treatment in the field of depression thus far. What research has shown is that Cognitive Behavioural Therapy (CBT) is highly prevalent in current literature, and appears to be the best working model of therapy for the treatment of adolescent depression. To help solidify this point, this paper will first discuss each topic separately, starting with depression and finishing with CBT, in order to provide the reader with enough information about each area to make a connection between the two in the following section. In this next section, the literature that had been analyzed prior to completing this paper will be shared- this will include all the supporting evidence and even some contradictory evidence as well- with the intent of providing a clear explanation of how this conclusion was brought about. Next, relevance to the child and youth care (CYC) practice will be addressed and this writer will provide insights into how this topic relates to this specific profession. Finally, this paper will work to find the gaps in research that may have limited the results, as well as present ways in which this research can be expanded upon in future literature to improve the overall quality of the field.

Depression

Before the chosen evidence based treatment is discussed, it is important to provide an understanding of what depression is. Depression can typically be broken down into three classifications: (1) major depressive disorder (severe episode(s) with repeated incidents or lasting symptoms), (2) dysthymia (long-term unchanging symptoms of mild depression), and (3) double depression (alternating periods of both), (Barlow et al., 2012). The differences between each of these things are issues of timing, duration, or presumed etiology (American Psychiatric Association, 2013). There are a variety of factors that can leave individuals more susceptible to depression than others. Examples include: low levels of education, individuals living in high-poverty neighborhoods (Fletcher, 2008), genetics and physiology, background of previous disorders (Barlow et al., 2012; American Psychiatric Association, 2013), substance abuse, hormonal changes, and environmental influences (Dopheide, 2006).

When considering the diagnoses of depressive disorders, The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) explains that “the common feature of all of these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function” (American Psychiatric Association, 2013, Depressive Disorders section Para. 1). Apparent changes to behaviour can also occur and, to name a few, can include things like the onset of bullying, aggression, and social withdrawal (Dopheide, 2006). Symptoms of depression are oftentimes hard to pinpoint due to similarities they can have with most anxiety disorders such as: crying, guilt, hopelessness, etc. (Barlow et al., 2012). However, it does seem to present symptoms that are specific to only depression to help with differentiation. These symptoms are as follows: helplessness, depressed mood, loss of interest, lack of pleasure, diminished libido (sexual desire), and suicidal ideation (Barlow et al., 2012; American Psychiatric Association, 2013).

Cognitive Behavioural Therapy

CBT is a structured, short-term psychotherapy model that aims to address “the relationship between a person’s thoughts, feelings, and behaviours and their reciprocal influence on one another” (Mahoney et al., 2011, p. 308). To make this idea a little bit clearer: cognitive errors (e.g., negative thoughts), as well as maladaptive coping behaviours (e.g., avoidance), can lead to negative emotions as a result; and by targeting these thoughts and behaviours, one can begin to better control their emotions (Barlow et al., 2012; Bujoreanu, Benhayon, & Szigethy, 2011; Dopheide, 2006; Mahoney et al., 2011). One of the ways this is done is by replacing maladaptive thoughts with more realistic, controlled, and structured ways of thinking (Barlow et al., 2012; Ginsburg, Albano, Findling, Kratochvil, & Walkup, 2005; Mahoney et al., 2011). CBT is typically structured into twelve sessions with a specific breakdown of goals that need to be completed. The twelve weeks generally look as follows: between sessions 1 through 4 they focus on psychoeducation and the teaching of the rest of the “core skills”; between sessions 5 through 10 they practice these learned skills as well as tailor new skills based on the client’s needs; and between sessions 11 and 12 they consolidate, discuss, and review techniques important to relapse prevention (Mahoney et al., 2011).

According to Mahoney et al. (2011) in the treatment of depression there are typically five “core skills”, and three skills considered to be “other skills”. The five core skills include: (1) psychoeducation (introduce goals of therapy, and education around depression), (2) mood monitoring (identifying emotions and rating moods), (3) behavioural activation/activity scheduling (encouraging youth to engage in activities that promote success), (4) cognitive restructuring (noticing and modifying maladaptive thoughts), and (5) problem-solving (e.g., evaluating consequences), (Mahoney et al., 2011). The “other skills” would include things such as social skills, relaxation techniques (e.g., deep breathing exercises), and relapse prevention (e.g., teaching them to recognize lapses earlier).

Other Clinical Approaches and the Effectiveness of Cognitive Behavioural Therapy

            Although the primary focus of this paper will be on the effectiveness of CBT, it is important to briefly address some of the other clinical approaches that appeared more than a couple times in some of the research as well. Excluding CBT, there were three other approaches that came up frequently: pharmacotherapy (PT), interpersonal therapy (IPT), and combined treatments (CT).  To begin, PT refers to the use of medication(s) for the suppression of depressive symptoms (Barlow et al., 2012) and appeared in five of the eight sources used as the foundation of this paper. Despite yielding positive results in most cases, this form of treatment remains controversial for both children and adolescents and some parents remain hesitant to allow their children to begin PT because of the possible negative side effects that can be associated with medication use (Bujoreanu et al., 2011; Dopheide, 2006; Ginsburg et al., 2005).

Next, interpersonal therapy “focuses on problem areas of grief, interpersonal roles, transitions, and disputes” (Dopheide, 2006, p. 237). Interpersonal therapy has also been proven to be effective in many instances (Dopheide, 2006; Varley, 2006); while in some cases it has yielded very little positive results (Barlow et al., 2012). IPT can be used both clinically and in a school setting, and may, in some cases, be as operational as antidepressants in treating less severe cases of depression (Dopheide, 2006; Varley, 2006). However, despite both CBT and IPT being labeled as “efficacious” in the treatment of adolescent depression (Bujoreanu et al., 2011), not enough literature was found for IPT to assert any superiority over CBT. Finally, CT refers to combining psychosocial treatment with medication use, which, “with one exception, the results thus far do not strongly suggest any immediate advantage over separate drug or psychosocial treatment” (Barlow et al., 2012, p. 254). That being said, Bujoreanu et al. (2011) found that the speed in which CT began to take effect happened much quicker than the single approaches did, but as time passed the single approaches “caught up” to the CT approach and yielded similar results.

Regardless of all the drawbacks and successes that these other methods of treatment may have had, the literature still points more heavily toward the effectiveness of CBT; and it has been said to have the highest level of efficacy when it comes treating adolescents with depression (Bujoreanu et al., 2011; Dopheide, 2006; Ginsburg et al., 2005). Further, Dopheide (2006) found that “CBT is considered first line treatment for children and adolescents with depression, with efficacy rates of 60-70%” (p. 237). In clinical trials, CBT seems to have the most replicated success for youth depression than any other form of treatment, and is widely accepted by the professional community in this regard as well (Bujoreanu et al., 2011). In a study done to compare certain types of psychotherapy, CBT produced slightly better results when it was compared to IPT among Puerto Rican adolescents (Mahoney et al., 2011). “Additionally, depressed adolescents may experience a greater reduction in depressive symptoms and achieve remission more quickly when treated with CBT as compared with another psychosocial treatment or to wait-list controls” (Mahoney et al., 2011, p. 309). Similarly, Dopheide (2006) discovered that CBT is said to be superior to its counterparts in relieving depressive symptoms.

Conversely, although seven of the eight academic sources used in this paper highlight the importance of CBT in the treatment of adolescent depression in one way or another, small criticisms can be found throughout. For example, Ginsburg et al. (2005) mentions that although CBT is “useful” in the treatment of major depressive disorders, it is “most efficacious and safe” when it is paired with PT as well (p. 260). Dopheide (2006) feels the same way but takes it one step further by adding patient family education to CBT and PT to achieve what this article believes to be the most optimal results. Further, Shirk, Kaplinksi, & Gudmundsen (2009) found that although CBT has proven efficacious in less severe cases of depression, it produces diminished effects when used with “adolescents with greater symptom severity and suffiecient symptom duration and impairment” (p. 107). No treatment option is perfect for every adolescent in every situation, however, CBT is speculated to have provided the best results in current literature for the treatment of adolescent depression, and even when using CT, CBT is oftentimes the go to psychotherapy in the professional setting.

Relevance to the Child and Youth Care Practice

            The CYC field is very broad and oftentimes CYC’s are found on the frontline, in direct contact with young people on a regular basis. Because of this, it is not uncommon for CYC’s to be contacted first with concerns, questions, or information that may be relevant to a pending investigation, and we must be prepared to deal with all circumstances in stride. To begin this association, it is important to draw the reader’s attention back to the opening paragraph where the prevalence of depression in Canada was highlighted. A large number of Canadian adolescents suffer from debilitating mood disorders such as depression (Stats Canada, 2015), and, due to the nature of the disorder and the CYC field, these are the young people that they come in contact with on a regular basis (depending on their chosen field). For the CYC’s that do come in contact with individuals from this demographic, it is integral to the safety of the young person that professionals such as CYC’s have a good understanding of which treatments are most clinically effective because symptoms such as depressed moods, and/or suicidal ideation, can put them at immediate risk for harming themselves or others.

As mentioned previously, CBT has been viewed in recent literature as being the most efficacious form of treatment for adolescents with depression (Bujoreanu et al., 2011; Dopheide, 2006; Ginsburg et al., 2005), which is why it is important for a CYC to be well versed in this form of therapy. Further, some individuals that are hoping to take part in PT to relieve symptoms of depression are considered “treatment resistant” and require multiple models of treatment to help subdue the symptoms; CBT being one of them. However, what the research has shown us is that CBT is best when used with people aged thirteen or older (Bujoreanu et al., 2012), so it is important to be aware as a CYC that younger individuals may not benefit from CBT as well as some due to a lack in verbal and/or cognitive processing (Dopheide, 2006). The CYC practice is an ever expanding field and thus a variety of different skills and knowledge is required in order to give the best level of care possible to the youth we are working with. Therefore, by adding to your knowledge of depression, methods of treatment, and CBT skills, you become more equipped to deal with situations as they present themselves- or in the moment.

Limitations and future Directions

            Because a large majority of children with depression do not typically respond well to PT, and because children have difficulties benefiting from more complex treatments such as CBT (Dopheide, 2006), it seems rather important to provide more research into the treatment of depression in children by means of psychotherapy in the future. A common practice among the treatment of depression is to use medications to supress symptoms- and the same can be said for the research. The vast majority of the articles that can be found in the reference page compare the effectiveness of psychotherapies to the effectiveness of medication; although this is probably because most of these articles (five of the eight) are written by at least one individual that has ties to the medical field. It seems likely that it would be highly beneficial if more writings on this subject were to emerge from a more social work or CYC based perspective and worked to compare the results of various forms of therapy to see which presented the most desired results.

From what has been seen by reviewing the literature, one concern that comes to mind is that it seems as though there isn’t a whole lot of follow up for post treatment youth in most cases. Mahoney et al. (2011) agrees and found that a select “few studies have examined the long-term effects of acute, continuation, and maintenance treatments of depression” (p. 311) and one study in particular found that there was a 46.6% recurrence rate for symptoms of depression no matter which treatment method was used (PT, CBT, and CT). Providing more research to study the post treatment effects of various forms of clinical treatments could be beneficial in ensuring that the young people that we work with remain safe even after treatment is complete; and teaching effective skills to prevent the reoccurrence of depressive symptoms could potentially save someone’s life in the future. In conclusion, research has shown that CBT is the most effective way to treat adolescent depression in current literature, but more research needs to be done on psychotherapeutic approaches in order to continue creating clinically healthier futures.

References

American Psychiatric Association. (2013). Depressive Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). doi:10.1176/appi.books.9780890425596.744053

Barlow, D. H., Durand, V. M., & Stewart, S. H. (2012). Mood disorders. In Abnormal psychology an integrative approach (3rd ed., pp. 218-267). United States of America: Nelson.

Bujoreanu, S., Benhayon, D., & Szigethy, E. (2011). Treatment of depression in children and adolescents. Pediatric Annals40(11), 548-555. doi:10.3928/00904481-20111007-05

Dopheide, J. A. (2006). Recognizing and treating depression in children and adolescents.American Journal of Health-System Pharmacy63(3), 233-243. doi:10.2146/ajhp050264

Fletcher, J. M. (2008). Adolescent depression: diagnosis, treatment, and educational attainment.Health Econ17(11), 1215-1235. doi:10.1002/hec.1319

Ginsburg, G. S., Albano, A. M., Findling, R. L., Kratochvil, C., & Walkup, J. (2005). Integrating cognitive behavioral therapy and pharmacotherapy in the treatment of adolescent depression. Cognitive and Behavioral Practice12(2), 252-262. doi:10.1016/s1077-7229(05)80030-6

Mahoney, J. R., Kennard, B. D., & Mayes, T. L. (2011). Cognitive behavioral treatment of depression in youth. Pediatric Annals40(6), 307-313. doi:10.3928/00904481-20110512-06

Shirk, S. R., Kaplinski, H., & Gudmundsen, G. (2008). School-based cognitive-behavioral therapy for adolescent depression: A benchmarking study. Journal of Emotional and Behavioral Disorders17(2), 106-117. doi:10.1177/1063426608326202

Stats Canada. (2015, June 17). Mood disorders, by age group and sex. Retrieved February 6, 2016, from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health113a-eng.htm

Varley, C. K. (2006). Treating depression in children and adolescents. CNS Drugs20(1), 1-13. doi:10.2165/00023210-200620010-00001

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