Nonsomatic treatment of depression

Joel T Sherrill, Maria Kovacs
Child and Adolescent Psychiatric Clinics of North America 2002, 11 (3): 579-93
There is solid evidence that active and goal-oriented cognitive-behavioral or relationship-focused therapies are generally superior to more generic therapies or to no treatment for clinically diagnosed and for undiagnosed but symptomatic youths. Between 50% to 87% of diagnosed youths who received a targeted treatment had recovered from their depressive episodes, in comparison to 21% to 75% of those who received some other generic therapy and 5% to 48% of wait-listed youths. The cognitive behavioral and relationship-oriented interventions that were tested tended to be even more successful in reducing depressive symptoms in school-based samples, possibly because the participants in the school-based studies may have been less disturbed than the clinically diagnosed cases. Although the targeted treatments generally yielded better results than the comparison conditions, the targeted interventions seem to be similarly successful in ameliorating depression. Determining which psychosocial therapy works best for a given depressed youngster remains problematic. As noted in recent reviews [30,46,47], little attention has been devoted to which interventions, or parts of an intervention, are likely to be effective with children with various characteristics. This issue acquires added importance because in some diagnosed samples half or more of the treated participants were still in a depressive episode at the end of the trial. Likewise, in intervention studies involving symptomatic, school-based youngsters, not all children improved, and gains were not uniform across domains of functioning (e.g., severity of depression, self-esteem, global functioning). Possibly, for some of the nonresponders, the participant's characteristics and relevant problems and the target interventions were mismatched. For example, a depressed youth with a long history of highly dysfunctional relationships may not respond optimally to a therapy focusing on negative cognitions; alternatively, interpersonal therapy may not be the most effective treatment for a youth dispositionally inclined to negative ruminations about the self and for whom relationship issues are not the most relevant. Empiric information about the relationship between the underlying processes presumed to account for the onset and maintenance of depression and recovery from depression is limited. Few studies of youths provide direct evidence tht cognitive-behavioral interventions change depressogenic cognitions, explanatory style, and pleasent events, among others, that relationship-focused approaches predictably alter relevant interpersonal processes, or that improvements in these domains relate to overall depression outcomes. Admittedly, the designs of extent studies typically preclude conclusions about the relationship between changes in target processes and improvement in depression or about treatment specificity. More compelling evidence linking changes in targeted mechanisms to decreases in depressive symptoms comes from a controlled prevention trial involving 10- to 13-year-olds that used cognitive restructuring, social problem-solving, or a combination intervention [48]. According to the results, changes in explanatory style were related to decreased depression and accounted for a significant portion of the variance in changes in depression even after controlling for treatment assignment. Further research along such lines may help identify which treatment may be most effective for a patient with a given set of characteristics. To improve patients' response rates to specific treatments, it also would be helpful to understand better the impact of other attributes, such as psychiatric comorbidity, and contextual factors, such as parental psychopathology, on the process of recovery. With few exceptions [25], however, such variable have not yet received sufficient attention. Recent reviews also have noted that researchers typically use multi-component interventions in treatmenttrials [46,47]. This design an make it difficult to identify which particular treatment ingredient is instrumental in general or among children with specific characteristics. Thus, empiric initiatives also are needed to determine the active ingredients of experimental therapies for depressed youths. Existing models include component-analysis or dismantling studies of multi-faceted treatments for depressed adults [49,50]. Once the improtant prognostic factors and active ingredients of therapies have been identified, it will be possible to conduct studies in which children are either "matched" or "mismatched" to treatment conditions. To achieve meaningful results and to enroll sufficient numbers of youths, collaborative, multisite efforts may be required. What treatment should be endorsed for depressed youths from the perspective of health services policy? When the criteria of the Task Force on Promotion and Dissemination of Psychological Procedures [1] are applied broadly, both cognitive behavioral and interpersonally oriented therapies can be deemed efficacious. Both approaches have been tested in different samples by two independent teams and thus may be regarded as well-established treatments for depression in youths. If the criteria are applied more stringently, so that exactly the same intervention is tested independently by two or more research teams, interpersonal therapy and cognitive behavioral therapy would be regarded as "probably efficacious". Namely, the two trials of interpersonal therapy apparently used somewhat different versions because of cultural differences in the samples. The complete CWD course has been tested and the results replicated only by its originators [20,21]. Other trials of cognitive behavioral therapy entail various different study-specific approaches and consequently cannot serve as replications [46,47]. A next step in psychotherapy research might therefore involve further independent replication of standardized, previously studies therapies. In their landmark meta-analytic study of the efficacy of psychotherapy for adults, Smith et al [51] concluded that all psychotherapies are about equally beneficial and that distinctions among them, although "cherished by those who draw them ... make no important differences: (p. 186). Likewise, the various psychotherapies for depresed youths that have been examined seem to produce similar rates of improvement ( or alternatively, similar limits in efficacy) across the tested therapies and the scant data regarding meaningful prognostic factors might indicate that at present it does not matter what type of brief, goal-oriented nonsomatic therapy is used to treat pediatric depression. Alternatively, one might conclude that patients who fail to respond may have been mismatched to a therapy that was not focused on their primary depression-related deficits. Thus, clinicians who treat depressed children and adolescents are faced with substantial challenges, and to date, results of controlled psychotherapy trials with depressed youths offer limited guidance regarding choice of treatment. Nonetheless, some general guidelines can be culled from the available data. For example, interventions of elements of therapies that are structured and directed towards cognitive, behavioral or relationship issues show promise for the treatment of juvenile depression. It also appears that group interventions may be used as profitably as the more traditional individual therapy formats. And although parental participation in empiric treatment trials of pediatric depression has been limited to either separate parent groups as an adjunct [20,21 or family therapy [7], it can be argued that for various practical and clinical reasons [30] direct involvement of parents may be a wise choice. Parents may be critical to the success of interventions with depressed children and should be regarded as potential important agents of change.

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