Depression Treatments for Children and Adolescents

Introduction to CBT

CBT is a psychotherapy treatment that focuses on how thoughts, feelings and behaviors are intertwined in everyday functioning and how changes in any one domain can lead to improvement in the others. For example, altering a person’s unhelpful thinking can lead to healthier behavior and improved emotion regulation. CBT targets current problems and symptoms and is typically delivered over six to 16 weekly sessions.

CBT is recommended for the treatment of depression in adolescents.

How CBT can help treat depression in adolescents

CBT can teach adolescents how to differentiate between their thoughts and feelings and regulate their feelings by questioning their assumptions and beliefs. CBT might also address behavior patterns that contribute to withdrawal and lack of enjoyment with strategies such as helping adolescents identify activities they have enjoyed in the past and planning to engage in them regularly. Parents/guardians will also have an active role in treatment in that they will receive education about the possible causes of depression as well as strategies their adolescents can use in identifying and modifying negative thinking and behavioral patterns.

Using CBT to treat depression in adolescents

Treatment begins with the therapist educating the adolescent, often with their parent/guardian, on how thoughts, feelings and behaviors interact with one another. The therapist explains that there are ways the adolescent can modify their thinking and behavioral patterns that would benefit them emotionally and behaviorally.

Therapists might then ask the adolescent to complete a “mood diary” outside of session, in which they will note the situation that triggered the thoughts that then influenced the way they felt and behaved in that situation. For example, a teen who does poorly on an exam [situation] and jumps to the conclusion “I will flunk out of school” [automatic thought] might then withdraw socially due to perceiving themself as a failure [behavior] and end up sad and depressed [feeling]. The teen works with the therapist to identify common themes in the diary to begin to identify and address the unhelpful thinking and behavior patterns.

As common themes are identified, the adolescent will be encouraged to apply the behavioral component of CBT by identifying activities that they used to enjoy (like playing basketball or hanging out with friends) and then incorporate these into a schedule of pleasant activities (e.g., “When I feel sad or stressed, I will play basketball or hang out with my friend”). Homework is often assigned and encouraged to fully develop new skills and increase confidence in working through stressful situations.

References and resources

American Psychological Association, Div. 53: Society of Clinical Child & Adolescent Psychology. (2017). Cognitive behavioral therapy. Effective Child Therapy. https://effectivechildtherapy.org/therapies/cognitive-behavioral-therapy/opens in new window

Curry, J.F., Wells, K.C., Brent, D.A., Clarke, G.N., Rohde, P., Albano, A.M., Reinecke, M.A., Benazon, N. & March, J.S. (2005). Treatment for adolescents with depression study (TADS) cognitive behavior therapy manual: Introduction, rationale, and adolescent sessions. Duke University Medical Center. https://aaronkrasner.com/wp-content/uploads/2017/10/TADS_CBT.pdf (PDF, 1.10MB)opens in new window

Davis, J.P., Palitz, S.A., Knepley, M.J. & Kendall, P.C. (2019). Cognitive-behavioral therapy with youth. In K.S. Dobson & D.J.A. Dozois (Eds.), Handbook of cognitive-behavioral therapies (4th ed., pp. 349-). Guilford Press. https://www.guilford.com/books/Handbook-of-Cognitive-Behavioral-Therapies/Dobson-Dozois/9781462538584opens in new window

Kendall, P.C. (Ed.). (2011). Child and adolescent therapy: Cognitive-behavioral procedures (4th ed.). Guilford Press. https://www.guilford.com/books/Child-and-Adolescent-Therapy/Philip-Kendall/9781606235614/reviewsopens in new window

Hertfordshire Partnership University NHS Foundation Trust. (2016). Cognitive behavioural therapy (CBT) skills workbook. https://www.hpft.nhs.uk/media/1655/wellbeing-team-cbt-workshop-booklet-2016.pdf (PDF, 977KB)opens in new window

Rosselló, J. & Bernal, G. (2007). Treatment manual for cognitive behavior therapy for depression: Adaptation for Puerto Rican adolescents. University of Puerto Rico. https://i4health.paloaltou.edu/downloads/CBT_adolescents_individual_manual_eng.pdf (PDF, 2.01MB)opens in new window

Introduction to IPT-A

IPT-A aims to improve the person’s relationships with others by learning strategies to effectively communicate emotions and needs as well as problem-solve within a significant relationship. Therapists using IPT-A emphasize a biopsychosocial explanation of depression, which holds that negative or distressing events people experience can exacerbate feelings of sadness and worthlessness, both common symptoms of depression. As relationships with others improve, the depressive symptoms may subside, and the person will hopefully experience improved functioning in multiple areas of their life. On average, adolescents receive 12 to 16 weekly sessions of IPT-A.

IPT-A is recommended for the treatment of depression in adolescents.

How IPT-A can help treat depression in adolescents

IPT-A focuses on four problem areas that are intrinsic to the original model of IPT for adults: 

• Grief (e.g., mourning the death of a friend or loved one).
• Interpersonal role disputes (e.g., conflict in significant relationships including parents, siblings or friends).
• Role transitions (e.g., both expected and unexpected changes such as geographic moves, developmental changes, parental divorce, new school).
• Interpersonal deficits (e.g., social isolation). 

IPT-A helps adolescents improve their communication and problem-solving skills so that they will be better at interacting during normal and stressful situations with a friend, relative, teacher or any other relationship. Through psychoeducation and practice, the adolescent gains social confidence. As interpersonal functioning improves, the depressive symptoms will hopefully subside.

Using IPT-A to treat depression in adolescents

Treatment begins with a comprehensive evaluation of the adolescent’s social, emotional and academic functioning. The therapist educates both the adolescent and their parent/guardian on the theory of IPT. Then, the therapist works with the adolescent on defining their close relationships and the quality of those attachments by creating a “closeness circle.” This detailed review of significant relationships helps the therapist identify which relationship(s) may be contributing to or maintaining the adolescent’s current mood.

In the middle stages of treatment, the therapist and adolescent identify strategies to improve the relationships that will hopefully lead to a reduction in their depressive symptoms. This is done through role-playing, affect labeling (e.g., identifying and naming how the adolescent felt when their friend said X), effective communication strategies for difficult situations/relationships (e.g., using “I statements”), problem-solving strategies and creating interpersonal experiments for the adolescent to practice the skills outside of the session. The therapist also prepares the adolescent and their parent/guardian for the possibility of future depressive episodes by discussing how these strategies may be helpful in upcoming situations, reviewing the warning signs of depression so the adolescent can return to treatment sooner if needed, and offering additional “booster sessions” to prevent relapse or recurrence of depression.

References and resources

American Psychological Association, Div. 53: Society of Clinical Child & Adolescent Psychology. (2018, Sept. 6). Interpersonal psychotherapy. Effective Child Therapy. https://effectivechildtherapy.org/therapies/what-is-interpersonal-psychotherapy/opens in new window

Gunlicks-Stoessel, M. & Mufson, L. (2022). Interpersonal psychotherapy for depressed adolescents. In M.K. Dulcan (Ed.), Dulcan’s textbook of child and adolescent psychiatry (3rd ed., pp. 955-966). American Psychiatric Publishing. https://www.appi.org/Products/Child-and-Adolescent-Psychiatry/Dulcans-Textbook-of-Child-and-Adolescent-Psych-(1)opens in new window

Hall, E.B. & Mufson, L. (2009). Interpersonal psychotherapy for depressed adolescents (IPT-A): A case illustration. Journal of Clinical Child & Adolescent Psychology, 38(4), 582-593. https://www.tandfonline.com/doi/abs/10.1080/15374410902976338opens in new window

Jacobson, C.M., Mufson, L.H. & Young, J.F. (2017). Treating adolescent depression using interpersonal psychotherapy. In J.R. Weisz & A.E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (3rd ed., pp. 66-82). New York: Guilford Press. https://www.guilford.com/books/Evidence-Based-Psychotherapies-for-Children-and-Adolescents/Weisz-Kazdin/9781462522699opens in new window

Mufson, L., Dorta, K.P., Moreau, D. & Weissman, M.M. (2004). Interpersonal psychotherapy for depressed adolescents (2nd ed.). Guilford Press. https://www.guilford.com/books/Interpersonal-Psychotherapy-for-Depressed-Adolescents/Mufson-Dorta-Moreau-Weissman/9781609182267opens in new window

Young, J.F., Mufson, L. & Schueler, C.M. (2016). Preventing adolescent depression: Interpersonal psychotherapy-adolescent skills training. Oxford University Press. https://www.oxfordclinicalpsych.com/view/10.1093/med:psych/9780190243180.001.0001/med-9780190243180opens in new window

Introduction 

Children:

• The current evidence base is insufficient to make a recommendation regarding pharmacotherapy for children with depression. 

Adolescents:

• For the treatment of depression in adolescents, the selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac) is recommended as a first-line medication over other medications, due in part to safety concerns with other medications. 

Please see Tables 1 and 2 in the full guideline document (PDF, 115MB)opens in new window as well as the evidence grid located in the supplement for more information.

Selective Serotonin Reuptake Inhibitors

The neurotransmitter serotonin is involved in the functioning of brain regions that underpin how we feel and behave. SSRIs help regulate the amount of serotonin that is active in the synapses between neurons.

For adolescents with depression, the following is the typical dosage range for the recommended first-line medication:

• fluoxetine (Prozac): 20-40 mg daily

Side effects and frequency of prescriber visits

While research has shown that adolescents may benefit from receiving fluoxetine for the prevention of relapse of depression, adolescents may report different responses to medication. Side effects of SSRIs range from mild effects that can be tolerated or managed through over-the-counter remedies (e.g., headaches, nausea, drowsiness) to severe side effects that may require altering the dose or discontinuing the medication (e.g., suicidal ideation).

Upon initially being prescribed medication, the adolescent will likely see the prescriber at least a few times within the first eight weeks to check whether they are taking the medication as prescribed, as well as to determine whether the dose is optimal and whether the adolescent is experiencing any adverse side effects. Once the adolescent has a stable medication dosage and reports a decrease of symptoms, visits to the prescriber will likely be less frequent.

References and resources

American Psychological Association. (2010). Talking with your child’s pediatrician about behavioral problems and medication. https://www.apa.org/helpcenter/children-medication

American Psychological Association, Div. 53: Society of Clinical Child & Adolescent Psychology. (2018, Oct. 12). Therapy or medication? https://effectivechildtherapy.org/therapies/therapy-or-medication/opens in new window

Cipriani, A., Zhou, X., Del Giovane, C., Hetrick, S.E., Qin, B., Whittington, C, Coghill, D., Zhang, Y., Hazell, P., Leucht, S., Cuijpers, P., Pu., J., Cohen, D., Ravindran, A. V., Liu, Y., Michael, K. D., Yang, L., Liu, L. & Xie, P. (2016). Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: A network meta-analysis. The Lancet, 388(10047), 881-890. https://doi.org/10.1016/S0140-6736(16)30385-3opens in new window

Emslie, G.J., Heilgenstein, J.H., Hoog, S.L., Wagner, J.D., Findling, R.L., McCracken, J.T, Nilsson, M.E. & Jacobson, J.G. (2004). Fluoxetine treatment for prevention of relapse for depression in children and adolescents: A double-blind, placebo-controlled study. Journal of the American Academy of Child & Adolescent Psychiatry, 43(11), 1397-1405. https://doi.org/10.1097/01.chi.0000140453.89323.57opens in new window

Kaiser Permanente. (2018). Adult & adolescent depression screening, diagnosis, and treatment guideline. https://wa.kaiserpermanente.org/static/pdf/public/guidelines/depression.pdf (PDF, 253KB)opens in new window

Before taking any medications, over-the-counter drugs, supplements or herbs, consult a health care provider for a thorough evaluation. American Psychological Association does not endorse any medications, vitamins or herbs. A qualified health care provider should make a decision based on each person's medical history and current prescriptions. The medication summaries provided do not include all of the information important for patient use and should not be used as a substitute for professional health care advice. The prescribing professional should be consulted concerning any questions that you have.