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Cognitive Behavioral Therapy for Adolescent Depression

Cognitive Behavioral Therapy (CBT) for Adolescent Depression is a developmental adaptation of the classic cognitive therapy model developed by Aaron Beck and colleagues. CBT emphasizes collaborative empiricism, the importance of socializing patients to the cognitive therapy model, and the monitoring and modification of automatic thoughts, assumptions, and beliefs. To adapt CBT for adolescents, more emphasis is placed on (1) the use of concrete examples to illustrate points, (2) education about the nature of psychotherapy and socialization to the treatment model, (3) active exploration autonomy and trust issues, (4) focus on cognitive distortions and affective shifts that occur during sessions, and (5) acquisition of problem-solving, affect-regulation, and social skills. As teens frequently do not complete detailed thought logs, internal experiences such as monitoring cognitions associated with in-session affective shifts are used to illustrate the cognitive model. To match the more concrete cognitive style of younger adolescents, therapists summarize session content frequently. Abstraction is kept to a minimum, and concrete examples linked to personal experience are used when possible. The treatment program is delivered in 12 to 16 weekly sessions.

Descriptive Information

Areas of Interest	Mental health treatment
Outcomes	Review Date: November 2006 1: Diagnoses of major depressive disorder 2: Symptoms of depression 3: Achievement of clinical response 4: Achievement of remission
Outcome Categories	Mental health Trauma/injuries
Ages	13-17 (Adolescent) 18-25 (Young adult)
Genders	Male Female
Races/Ethnicities	White Race/ethnicity unspecified
Settings	Outpatient
Geographic Locations	No geographic locations were identified by the developer.
Implementation History	CBT for Adolescent Depression has been delivered as part of a comprehensive treatment program at the Services for Teens At Risk (STAR-Center), a research, treatment, and training center in Pittsburgh, Pennsylvania, for approximately 10 years. CBT has been evaluated and implemented in a multisite study in England.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Review Date: November 2006

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Outcomes

Outcome 1: Diagnoses of major depressive disorder
Description of Measures	A semistructured interview was used to ascertain participants' present episode and lifetime history of psychiatric illness according to DSM criteria.
Key Findings	At the end of treatment, 17.1% of youth receiving CBT showed evidence of major depressive disorder, compared with 42.4% of youth receiving nondirective support therapy (p = .02).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.6 (0.0-4.0 scale)

Outcome 2: Symptoms of depression
Description of Measures	Two measures of depression symptoms were used: (1) the Beck Depression Inventory, a 21-item self-report measure of depression, and (2) the School Age Schedule for Affective Disorders and Schizophrenia, Present and Lifetime Version (K-SADS-P/E), a 13-item depression inventory.
Key Findings	CBT showed more rapid treatment response than systemic behavior family therapy or nondirective support therapy, as measured by the rate of decline in interview-rated symptoms of depression (p = .05). Youth receiving CBT in a clinically representative community practice improved more slowly than youth receiving CBT in the clinical trial (p < .001).
Studies Measuring Outcome	Study 1, Study 2
Study Designs	Experimental, Quasi-experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Outcome 3: Achievement of clinical response
Description of Measures	Achievement of clinical response was defined as a Beck Depression Inventory score of less than 9 sustained for at least three consecutive sessions and until the end of treatment.
Key Findings	Youth receiving CBT had a higher rate of achievement of clinical response compared with youth participating in systemic behavior family therapy (p = .03).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Outcome 4: Achievement of remission
Description of Measures	Achievement of remission was defined as the absence of major depressive disorder. This outcome was determined using a semistructured interview designed to ascertain the participant's present episode and lifetime history of psychiatric illness according to DSM criteria and three consecutive scores on the Beck Depression Inventory of less than 9 sustained through the end of treatment.
Key Findings	CBT achieved a higher remission rate among youth (60%) than either systemic behavior family therapy (37.9%, p = .03) or nondirective support therapy (39.4%, p = .04).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.7 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	13-17 (Adolescent) 18-25 (Young adult)	75.7% Female 24.3% Male	83.2% White 16.8% Race/ethnicity unspecified
Study 2	13-17 (Adolescent) 18-25 (Young adult)	76.9% Female 23.1% Male	82.1% White 17.9% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

1. Reliability of measures	4. Missing data and attrition
2. Validity of measures	5. Potential confounding variables
3. Intervention fidelity	6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Diagnoses of major depressive disorder	3.5	3.5	4.0	3.0	3.5	4.0	3.6
2: Symptoms of depression	3.5	3.5	4.0	3.0	3.0	4.0	3.5
3: Achievement of clinical response	3.5	3.5	3.5	3.0	3.5	3.5	3.4
4: Achievement of remission	4.0	4.0	4.0	3.0	3.5	3.5	3.7

Study Strengths

The randomized clinical trial was conducted with rigor. The analytical approach was solid and accounted for attrition; the developers demonstrated that the intervention was implemented with fidelity.

Study Weaknesses

Several potential confounding variables were introduced in the study comparing outcomes found in the randomized clinical trial to outcomes gathered from patient medical records from an outpatient treatment facility. Confounds included the lack of formal adherence ratings for senior counselors, limited measurement of intervention fidelity in the treatment facility, and differences in patient populations, including diagnoses, use of medications, and exclusion criterion, that were not controlled. Limited representation of suicide attempters and multiple attempters limits generalizability of overall findings. Study exclusion criteria may make the intervention difficult to utilize routinely in an outpatient setting. No evidence was presented indicating that the intervention produces outcomes sustained beyond treatment. Independent therapists would need specialized training in this modified version of CBT for adolescents to replicate the outcomes from these studies.

Readiness for Dissemination

Review Date: November 2006

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Brent, D., & Poling, K. (1997). Cognitive therapy treatment manual for depressed and suicidal youth. Pittsburgh, PA: University of Pittsburgh, Services for Teens at Risk.

Maher, M. (1997). Cognitive therapy for anxiety: Supplemental treatment manual. Pittsburgh, PA: University of Pittsburgh, Services for Teens at Risk.

Poling, K. (1997). Living with depression: A survival manual for families (3rd ed.). Pittsburgh, PA: University of Pittsburgh, Services for Teens at Risk.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
1.5	0.5	0.5	0.8

Dissemination Strengths

The treatment manual and supplemental treatment manual for therapists are clear and concise, provide a good overview of the therapy process, and include useful assessment forms. Each developmental phase of treatment, with its purpose and intervention techniques/strategies, is delineated. The survival manual for parents also provides a useful overview of causes and treatments for adolescent depression. The manuals also could provide a basis for training therapists. Some scales are provided that may be used to assess progress in treatment and thus provide some quality assurance.

Dissemination Weaknesses

Beyond the descriptions of the intervention, the materials do not address implementation in detail. Some readers may find the language in the manuals difficult to understand. Very little information is provided to directly assist a new therapist or therapy organization with program implementation. The materials do not provide measures of fidelity or mention how the outcome data can be collected, reported, and used.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Cognitive Therapy Treatment Manual for Depressed and Suicidal Youth	Free	Yes
Cognitive Therapy for Anxiety: Supplemental Treatment Manual	Free	No
Living with Depression: A Survival Manual for Families	Free	No
Training, technical assistance/consultation, and quality assurance materials	Contact the developer	No

Additional Information

The cost of CBT for Adolescent Depression is approximately $640, based on 16 hours of therapy with a social worker at $40 per hour.

Replications

No replications were identified by the developer.

Contact Information

To learn more about implementation or research, contact:
David A. Brent, M.D.
(412) 246-5596
brentda@upmc.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):

http://www.starcenter.pitt.edu/DownloadManuals/54/Default.aspx