ADOLESCENT DEPRESSION: Help your patient emerge from the darkness

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Applied Evidence

ADOLESCENT DEPRESSION: Help your patient emerge from the darkness

J Fam Pract. 2009 May;58(5):257-264

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References

1. Zuckerbrot RA, Cheung A, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care–GLAD PC – Part I. Pediatrics. 2007;120:e1299-e1312.

2. Richardson LP, Lewis CW, Casey-Goldstein M, et al. Pediatric primary care providers and adolescent depression. J Adolesc Health. 2007;40:433-439.

3. Myers SS, Phillips RS, Davis RB, et al. Patient expectations as predictors of outcome in patients with acute low back pain. J Gen Intern Med. 2008;23:1525-1497.

4. Aikens JE, Nease DE, Jr, Nau DP, et al. Adherence to maintenance-phase antidepressant medication as a function of patient beliefs about medication. Ann Fam Med. 2005;3:23-30.

5. Brent DA, Perper JA, Moritz G, et al. Psychiatric risk factors for adolescent suicide: a case-control study. J Am Acad Child Adolesc Psychiatry. 1993;32:521-529.

6. American Academy of Child and Adolescent Psychiatry. Summary of the practice parameters for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry. 2001;40:495-499.

7. Cheung A, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care–GLAD PC – Part II. Pediatrics. 2007;120:e1313-e1326.

8. Cheung AH, Zuckerbrot RA, Jensen PS, et al. Expert survey for the management of adolescent depression in primary care. Pediatrics. 2008;121:e101-e107.

9. Compton SN, March JS, Brent D, et al. Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review. J Am Acad Child Adolesc Psychiatry. 2004;43:930-959.

10. Mufson L, Weissman MM, Moreau D, et al. Efficacy of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 1999;56:573-579.

11. Mufson L, Dorta KP, Wickramaratne P, et al. A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Arch Genl Psychiatry. 2004;61:577-584.

12. Clarke GN, Rohde P, Lewinsohn PM, et al. Cognitive-behavioral treatment of adolescent depression: efficacy of acute group treatment and booster session. J Am Acad Child Adolesc Psychiatry. 1999;38:272-279.

13. Asarnow JR, Jaycox LH, Duan N, et al. Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial. JAMA. 2005;293:311-319.

14. Clarke G, Debar L, Lynch F, et al. A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication. J Am Acad Child Adolesc Psychiatry. 2005;44:888-898.

15. March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: treatment for adolescents with depression study (TADS) randomized controlled trial. JAMA. 2004;292:807-820.

16. Mufson L, Moreau D, Weissman M. Interpersonal Psychotherapy for Depressed Adolescents. New York: Guildford Press; 2004.

17. Olson AL, Kelleher KJ, Kemper KJ, et al. Primary care pediatricians’ roles and perceived responsibilities in the identification and management of depression in children and adolescents. Ambul Pediatr. 2001;1:91-98.

18. Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007;297:1683-1696.

19. Mayes TL, Tao R, Rintelmann JW, et al. Do children and adolescents have differential response rates in placebo-controlled trials of fluoxetine? CNS Spectr. 2007;12:147-154.

20. Birmaher B, Brent D. And the AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:1503-1526.

FAST TRACK

Only fluoxetine has been approved by the FDA for children and adolescents with depression.

The focus of CBT is to change patients’ perception of themselves, their world, and others. CBT treats depression by identifying behavioral and cognitive patterns associated with depressive cycles. Examples of such patterns include the propensity to withdraw from pleasurable activities, or irritability that alienates family and friends just when the teenager needs them most. CBT helps teens identify these self-defeating patterns, encourages them to take part in activities they enjoy, helps develop or reactivate social skills important for maintaining positive social interactions, and helps teens to develop problem-solving strategies for resolving stressful situations.

CBT also aims to correct maladaptive beliefs associated with the patient’s depression. If, for instance, a patient believes she is worthless if she’s not accepted by the “popular” group at school, she is likely to become depressed and stay depressed as long as she is having difficulty connecting with her peers. CBT would help her examine that belief and learn to feel worthwhile even if she is not accepted by the “in” group. In general, CBT sessions are scheduled on a weekly basis for 12 to 16 weeks. In each session, the therapist and patient complete specific tasks and exercises that are provided in a CBT manual. There are also tasks for the patient to complete between sessions and review later with the therapist. CBT has been used in primary care with preliminary positive results.^13,14 However, the results of a recent RCT conducted in psychiatric settings demonstrated superior efficacy of combination therapy (fluoxetine and CBT) vs CBT alone.¹⁵

IPT for adolescents (IPT-A) is like CBT in that it is time-limited and clinicians are guided by a manual.¹⁶ A course of therapy can last anywhere from 12 to 16 sessions with optional maintenance treatment. The theoretical basis for IPT-A is the observed negative impact of depressive symptoms on interpersonal relationships, and the effect poor relationships have in causing and perpetuating depression. In deciding whether a patient may be suitable for IPT-A, you need to find out whether she would be willing to share her experiences of ongoing relationship conflicts with a therapist or therapeutic group. The relationship difficulties IPT-A is designed to help with arise from 1 of 4 sources: grief, fights with peers or family members (interpersonal disputes), transitions from one social surround to another (role transition), and friendlessness (interpersonal deficits).

FAST TRACK

Families who know what to expect with antidepressants are most likely to stay with treatment for the duration.

IPT-A focuses on grief only when someone of significance to the patient has died. Therapy for teens who quarrel frequently with peers or family members is focused on interpersonal disputes, and this is the most common focus in IPT-A. A focus on role transition is called for when the teen’s social world has undergone a drastic change, such as a when a teen has moved to a new school or broken up with a boyfriend. Finally, therapy for a teen with no significant relationships outside the immediate family focuses on interpersonal deficits. In these cases, the goal of therapy is to increase social contact and help the patient build relationships. If your preliminary assessment identifies your patient’s difficulties as rooted in 1 of these 4 areas, IPT-A may be for her.

Because few family physicians are trained in CBT or IPT-A, most psychotherapy will be provided by mental health professionals. What you can provide is familiarity with available community mental health resources. To get to know the therapists in your community, you may want to reach out to a few of them and ask them the questions in TABLE 2. You may also want to share this list with parents who want to find their own therapist.

TABLE 2
6 questions to ask prospective therapists

1. What type of therapy can you provide—cognitive behavioral therapy (CBT), interpersonal therapy for adolescents (IPT-A), psychodynamic psychotherapy, supportive therapy, counseling, or eclectic (including elements of IPT-A and CBT)? The evidence suggests that CBT and IPT-A are the treatments of choice for teens with depression.
2. Have you received training in that therapy for adolescents with depression? Where and when? The therapist should have been trained in a clinical program (social work, nursing, psychology) that involved adolescents.
3. Have you received clinical supervision in that therapy? Where? For how long? How many cases? Generally, therapists should be supervised for at least 3 to 4 cases before they are considered pro? cient.
4. Are there specific tasks scheduled for each session? There should be for CBT, but not for IPT-A.
5. Is the therapy time-limited? CBT and IPT-A are both time-limited.
6. What are the goals of the therapy? The goals for both CBT and IPT-A should be the resolution of depressive symptoms.
Source: This list has been adapted by Amy Cheung, MD, from her contributions to the forthcoming book tentatively entitled Assessment and Treatment of Pediatric Depression: State of the Science; Best Practices (Editors: Peter S. Jensen, MD, Amy Cheung, MD, Ruth Stein, MD, and Rachel A. Zuckerbrot, MD), to be published by Civic Research Institute, Inc. All rights reserved.