Depression Symptoms Treatment

Psychotherapy

Table 1 outlines psychotherapeutic approaches to adolescent depression. The emphasis is on cognitive therapy and behavioural strategies that not only help to resolve the current episode but will also make enduring changes in social and cognitive behaviours in order to prevent recurrent depression in high-risk individuals.

Principles of cognitive therapy. Cognitive therapy has been proven as efficacious as, or better than, medication for mild and moderate depression among adults. While research on the efficacy of group cognitive therapy for adolescents and cognitive-behavioural therapy for anxiety and impulse control disorders exists, research protocols

for individual cognitive therapy for depressed adolescents have not been developed. However, cognitive distortions are well demonstrated in depressed adolescents. The appeal of cognitive therapy for adolescents is that they are still learning and their cognitive style is more flexible than adults. In my experience, teens acquire cognitive-behavioural skills more rapidly than adult patients with mood disorders. Furthermore, the skills help teens gain some control over their lives and counteract learned helplessness. Family physicians can readily undertake cognitive therapy; they have the advantage of an already established therapeutic alliance.

The principle behind cognitive-behavioural therapy techniques is that depression is exacerbated, and might even be caused, by "depressogenic" cognitions, ways of thinking that are self-defeating and promote depression. The learned helplessness model has demonstrated the behavioural consequences of this kind of conditioned attitude in animals. Animal models also demonstrate the associated biochemical changes in the brain that accompany this behaviour. Describing to adolescents the model of helpless rats is often a helpful starting point for them to see their behaviour as "logical" given their experience.

The individual who has succumbed to learned helplessness typically believes that "It’s no use trying; it never works out for me anyway; I never do anything right; everything always goes wrong" and so on. A negative interpretation of events reinforces these beliefs. For example, when classmates walk past in the school hallway without acknowledging the depressed adolescent, the adolescent assumes: "They don’t like me; no one likes me; I’ll never have any friends." Depressive behaviour reinforces this belief. Depressed adolescents do not smile, do not make eye contact, and look at the floor; inevitably others will be less likely to greet them in the hall. This then "proves" the belief that they will never have any friends or that it is no use trying. Cognitive therapy challenges this belief, reexamining the evidence and seeking alternative explanations for the classmates’ unfriendly actions. "Perhaps they had other things on their minds, were worried about a test, were shy, thought I didn’t want to talk because I was avoiding eye contact," and so on. This is followed by behavioural "experiments" to test out these other hypotheses.

The cognitive-behavioural approach for young people is reviewed in detail elsewhere, but the general approach can rapidly be mastered by family physicians and applied in a brief counseling approach outlined below.