WASHINGTON, DC— Given the concerns regarding the safety of antidepressant drugs in children and adolescents, more clinicians may be considering psychotherapy for treating their patients with depression. The problem, however, is that few data are available concerning the long-term effectiveness of psychosocial treatments for depression, including the two most commonly used approaches—cognitive behavior therapy and interpersonal psychotherapy.

“The cognitive behavior therapy approach asserts that depression is either caused or maintained by an interaction between the way one perceives the world, called negative cognitions, and the way one moves through the world through his or her behavior,” said Laura Mufson, PhD, Associate Professor of Clinical Psychology in Psychiatry at Columbia University in New York City. “Cognitions can be about yourself or your relationships or the things that are happening to you. Then the presence of skills deficits that prevent the person from interacting effectively with the world may lead to more negative experiences. The goal of cognitive behavior therapy is to modify the negative thoughts to be more proactive and to learn skills to break the depressive cycle.” Dr. Mufson addressed the 51st Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP).

Interpersonal psychotherapy was originally developed as a brief treatment for depressed, nonbipolar, nonpsychotic adult outpatients, according to Dr. Mufson. “It’s based on the premise that regardless of whether you feel that depression may be biological in origin, it occurs in an interpersonal context,” she said. “When you are depressed, it affects your interpersonal relationships, and what is going on in your relationships in turn affects your mood. If you can intervene and improve those relationships, you can actually change the course of the depressive episodes. So the goal of treatment is to help educate the patients about the relationship between their mood and problems that may be occurring in their relationships and how improving their interpersonal skills and addressing those problems that are contributing to or are exacerbating their depression can actually lead to their recovery.”

COGNITIVE BEHAVIOR THERAPY

One of the first cognitive behavior therapy studies in adolescents was conducted in 1986 by Reynolds and Coats, who found that the treatment method was comparable to relaxation training, and both were better than a waiting list condition. A waiting list, explained Dr. Mufson, is psychosocial treatment’s “attempt to create a placebo control. What we struggle with in psychosocial studies is, What is a reasonable comparison condition that’s comparable to the medication placebo? There really isn’t one, because waiting list isn’t the same as being given an inert medication but, rather, is no treatment with the expectation of treatment in the future.”

Lewinsohn and Clarke found that group cognitive behavior therapy for adolescents was more effective than a waiting list condition and that including a parent-group component to the therapy did not add anything above and beyond results observed for adolescent group therapy alone. Other notable cognitive behavior therapy research was conducted by Brent, who found that the cognitive behavior therapy approach was more efficacious than were systemic behavior family therapy and nondirective supportive therapy for adolescent major depressive disorder in a clinical setting. The Brent study raised an important issue, noted Dr. Mufson—that is, how much does choice about treatment type influence the outcomes? Brent found that a number of the participants who were randomized to family therapy were not happy with that choice. “If you end up in something you don’t really want, are you less engaged?” asked Dr. Mufson. “Is that going to affect the outcome for that treatment?”

Not all studies with cognitive behavior therapy have been positive, however. Last year’s Treatment for Adolescents With Depression Study (TADS) had mixed results. Researchers found that treatment with fluoxetine and cognitive behavior therapy was superior to fluoxetine alone and cognitive behavior therapy alone. However, fluoxetine alone was shown to be superior to cognitive behavior therapy alone.

Overall, there have been five positive and one negative cognitive behavior therapy trials conducted in children, as well as six positive adolescent trials and one that was negative. “If you look at the studies comparing cognitive behavior therapy to alternative treatments, there are modest short-term advantages for cognitive behavior therapy over treatments such as relaxation training and supportive psychotherapy and the structural behavior family therapy,” stated Dr. Mufson. “At this point, there’s no study showing an advantage for parent involvement.”

INTERPERSONAL PSYCHOTHERAPY

Dr. Mufson conducted her own initial clinical trial that compared interpersonal psychotherapy with a clinical management group for adolescents with depression. She found that 75% of the adolescents who received interpersonal psychotherapy, versus 46% who received clinical management, met the recovery criteria of a Hamilton Depression Rating Scale score of 6 or less at week 12. “Adolescents who received interpersonal psychotherapy had a significantly greater decrease in their depressive symptoms on both the Hamilton and Beck Depression Inventory; significantly greater improvements in overall social functioning, in particular, with their peer relationships; and significantly better skills in positive problem-solving orientation and rational problem-solving orientation,” according to Dr. Mufson.

Dr. Mufson augmented that research with a study conducted in school-based health clinics in New York City, which were staffed largely by social workers with varied backgrounds who were trained to deliver interpersonal psychotherapy. She found that adolescents who received interpersonal psychotherapy did “significantly better” than did those who received treatment as usual, which was defined as whatever psychotherapy treatment the adolescents would have received if the study had not been in place. “Treatment with interpersonal psychotherapy resulted in significantly greater reductions in depression symptoms both on the Hamilton and Beck Depression Inventory,” said Dr. Mufson. “We found significantly greater improvement in global and social functioning by week 8.... Interpersonal psychotherapy did significantly better among the more severely depressed. Our interpretation of that is that if you are mildly depressed, supportive psychotherapy may be sufficient for you, but if you are severely depressed, a targeted treatment that is specifically for depression is much more beneficial than just supportive psychotherapy.”

It is important to have study findings replicated by other research groups, commented Dr. Mufson. Rossello and Bernal, using their own adaptation of interpersonal psychotherapy for depressed Puerto Rican adolescents, compared cognitive behavior therapy and interpersonal psychotherapy in 71 depressed adolescents who had a DSM-III diagnosis of depression. The researchers found that both interpersonal psychotherapy and cognitive behavior therapy significantly reduced depressive symptoms when compared with a waiting list condition and that 82% of the adolescents in interpersonal psychotherapy and 59% in cognitive behavior therapy were functional after treatment. “They also found on other measures that interpersonal psychotherapy was superior to waiting list for improvements in self-esteem and social adaptation but not significantly better than cognitive behavior therapy,” said Dr. Mufson.

A GOOD FOUNDATION

Although both cognitive behavior therapy and interpersonal psychotherapy have demonstrated positive results in a handful of trials, their long-term benefits still need to be assessed. “I think both orientations have good foundations of efficacy and effectiveness,” said Dr. Mufson. “Our generalizability for both is limited due to fairly homogenous sampling, even in the school-based study, despite having very few exclusionary criteria in the community study.”

Still, a number of other questions remain unanswered concerning psychotherapy for depression. For starters, researchers do not know how long a patient should remain in psychotherapy once his or her depression has remitted. AACAP has recommended six months of continuation treatment and maintenance therapy. However, “there are little data to support it due to lack of studies on continuation and maintenance treatment,” noted Dr. Mufson. Furthermore, researchers and clinicians do not know how long psychotherapy should be used before adjunctive medication is needed.

Other issues, according to Dr. Mufson, are: “What should the role of therapy be for patients who have initiated treatment with medication first but are not necessarily getting a good response? When you are not getting as fast of a medication response as you would like, when should you perhaps consider adding one of these evidence-based treatments rather than increasing the dosage of medication? What psychotherapies are most effective for treating depressed adolescents who have comorbid disorders such as conduct disorder and posttraumatic stress disorder?

“Also, we still don’t know what the best treatment approach is for adolescents with dysthymic disorder,” Dr. Mufson remarked. They may not respond the same way to psychosocial treatments and may need a longer dose of treatment. They may be the ones who do better with the combination treatment; we don’t know enough about that. We don’t know much about effective psychotherapies for prepubertal children and preventing depression in at-risk populations.”

Some researchers have already begun studying the use of interpersonal psychotherapy as a preventive intervention for depression for at-risk teens with bipolar disorder and in those at risk for depression due to subsyndromal symptoms and teenage pregnancy. “More work is needed to further examine how effective these psychotherapies are when practiced by community clinicians in real-world settings,” said Dr. Mufson. “There is certainly enough work to be done in the field for a long period of time. I think we do have a nice groundwork laid for these two psychosocial interventions.”

—Colby Stong

Suggested Reading
Brent DA, Holder D, Kolko D, et al. A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Arch Gen Psychiatry. 1997;54:877-885.
Lewinsohn PM, Clarke GN. Psychosocial treatments for adolescent depression. Clin Psychol Rev. 1999;19:329-342.
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.
Mufson L, Dorta KP, Wickramaratne P, et al. A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 2004;61:577-584.
Reynolds WM, Coats KI. A comparison of cognitive-behavioral therapy and relaxation training for the treatment of depression in adolescents. J Consult Clin Psychol. 1986;54:653-660.
Rossello J, Bernal G. The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. J Consult Clin Psychol. 1999;67:734-745.

Return to table of contents