Developmental Neurorehabilitation, JanuaryMarch 2008; 11(1): 315

Depression in young people: Description, assessment and

evidence-based treatment

ALAN CARR
School of Psychology, College of Human Sciences, University College Dublin, Dublin, Ireland
(Received 22 March 2007; accepted 19 June 2007)
Abstract
Objective: The literature on depression in children and adolescents was reviewed to provide an update for clinicians.
Review process: Literature of particular relevance to evidence-based practice was selected for critical review. Meta-analyses
and controlled trials were prioritized for review along with key assessment instruments.
Outcomes: An up-to-date overview of clinical features, epidemiology, prognosis, aetiology, assessment and intervention was
provided.
Conclusions: Depression in children and adolescence is a relatively common, multifactorially determined and recurring
problem which often persists into adulthood. Psychometrically robust screening questionnaires and structured interviews
facilitate reliable assessment. There is growing evidence for the effectiveness of cognitive behaviour therapy, psychodynamic
therapy, interpersonal therapy and family therapy in the treatment of paediatric depression. There is also evidence that
SSRIs may be particularly effective for severe depression, although they may carry the risk of increased suicidality.

Keywords: Childhood depression

Objetivo: Se reviso la literatura sobre la depresion en ninos y en adolescentes con el proposito de brindar una actualizacion a
los medicos.
Proceso de la revision: Se selecciono la literatura que tuviera una relevancia particular en relacion a la practica basada en la
evidencia para su revision en forma crtica. Se dio prioridad a los Meta-analisis y a los estudios controlados en la revision,
junto a instrumentos claves de evaluacion.
Resultados: Se proporciono una vision general actualizada de temas clnicos, de la epidemiologa, del pronostico, de la
etiologa, de la valoracion y de la intervencion.
Conclusiones: La depresion en ninos y en adolescentes es relativamente comun, determinada multifactorialmente, siendo un
problema recurrente que generalmente persiste hasta la edad adulta. La aplicacion de cuestionarios de examenes
psicometricos y de entrevistas estructuradas facilita la realizacion de evaluaciones confiables. Existe evidencia creciente de la
efectividad de la terapia de conducta cognitiva, de la terapia psicodinamica, de la terapia interpersonal y de la terapia
familiar en el tratamiento de la depresion pediatrica. Existe tambien evidencia que SSRIs pueden ser particularmente
efectivos para el manejo de la depresion severa, aunque existe el riesgo de aumentar la tendencia al suicidio.
Palabras clave: Deopresion en la infancia

Clinical features
A major depressive episode in children and adolescents is characterized by a period of low mood of at
least 2 weeks duration, accompanied by other
cognitive and behavioural features. The primary
symptom of depression is low mood and/or loss of
interest in daily activities including those that
youngsters normally find enjoyable. There may be
diurnal variation in mood, with mood being lowest
in the morning. In adolescents, in some instances,
irritable, rather than low mood may be the central
feature. The principal cognitive features of

depression are poor concentration, poor attention

and indecisiveness; low self-esteem; pessimism;
suicidal ideation or intent; and feelings of worthlessness or guilt. Fatigue; psychomotor retardation or
agitation; and sleep and appetite disturbance are the
main behavioural features. The diagnostic criteria
for a major depressive episode from ICD 10 [1]
and DSM IV TR [2] and are given in Table I.
Major depression is an episodic disorder characterized by major depressive episodes and intervening
periods of normal mood. This is distinguished from
dysthymia, which is a milder but more persistent

Correspondence: Professor Alan Carr, School of Psychology, College of Human Sciences, John Henry Newman Building, University College Dublin, Belfield,
Dublin 4, Ireland. Tel: 353-1-716-8740 (Direct), 716-8120 (Secretary). Fax: 353-1-716-1181. E-mail: alan.carr@ucd.ie
ISSN 17518423 print/ISSN 17518431 online/08/01000313 2008 Informa UK Ltd.
DOI: 10.1080/17518420701536095

A. Carr
Table I. Criteria for a major depressive episode.

DSM IV TR
A. Five or more of the following symptoms have been present during
the same 2-week period nearly every day and represent a change
from previous functioning; at least one of the symptoms is ether
(1) depressed mood or (2) loss of interest or pleasure. Symptoms
may be reported or observed.
(1) Depressed mood. In children and adolescents can be irritable
mood.
(2) Markedly diminished interest or pleasure in almost all daily
activities.
(3) Significant weight loss or gain (of 5% per month) or decrease
or increase in appetite. In children failure to make expected
weight gains.
(4) Insomnia or hypersomnia.
(5) Psychomotor agitation or retardation.
(6) Fatigue or loss of energy.
(7) Feelings of worthlessness, excessive guilt.
(8) Poor concentration and indecisiveness
(9) Recurrent thoughts of death, suicidal ideation or suicide
attempt.
B. Symptoms do not meet criteria for mixed episode of mania and
depression.
C. Symptoms cause clinically significant distress or impairment
in social occupational, educational or other important areas of
functioning
D. Symptoms not due to the direct effects of a drug or a general
medical conditions such as hypothyroidism.
E. The symptoms are not better accounted for by uncomplicated
bereavement.

ICD 10
.

.
.

In a typical depressive episode the individual usually suffers

from depressed mood, loss of interest and enjoyment and
reduced energy leading to increased fatigueability and
diminished activity. Marked tiredness after only slight
effort is common. Other common symptoms are:
(1) reduced concentration and attention,
(2) reduced self-esteem and confidence,
(3) ideas of guilt and unworthiness,
(4) bleak and pessimistic views of the future,
(5) deas or acts of self-harm or suicide,
(6) disturbed sleep, and
(7) diminished appetite.
The lowered mood varies little from day-to-day and is
often unresponsive to circumstances and may show a
characteristic diurnal variation as the day goes on.
Some of the above symptoms may be marked and develop
characteristic features that are widely regarded as having
special significance for example the somatic symptoms which
are: loss of interest or pleasure in activities that are
normally enjoyable; lack of emotional reactivity to normally
pleasurable surroundings; waking in the morning 2 hours
or more before the usual time; depression worse in the
mornings; psychomotor retardation or agitation; marked
loss of appetite or weight; marked loss of libido. Usually
the somatic syndrome is not regarded as present unless at
least four of these symptoms are present.
Atypical presentations are particularly common in adolescence.
In some cases anxiety, distress and motor agitation may be
more prominent at times than depression and mood
changes may be masked by such features as irritability,
excessive consumption of alcohol, histrionic behaviour and
exacerbation of pre-existing phobic or obsessional symptoms or by Hypochondriacal preoccupations.
A duration of 2 weeks is required for a diagnosis.

Note: Adapted from DSM IV TR (APA 2000), ICD 10 (WH0 1992).

mood disorder, characterized by chronic low

mood for at least 1 year (in young people and 2
years in adults), accompanied by fewer additional
cognitive or behavioural symptoms than are
required for a diagnosis of major depressive disorder.
For a DSM diagnosis only two additional symptoms
are required and for and ICD diagnosis three
additional symptoms are required for a dysthymia
diagnosis.
In both DSM IV TR and ICD 10, children and
adolescents are diagnosed using almost the same
criteria employed as are used for adults. There are
some noteworthy minor differences. In DSM IV TR,
irritability and failure to make expected weight gain
count as symptoms of major depression in children,
but not adults; and the duration of symptoms in
dysthymia need only be 1 year for a diagnosis to be
made in children compared with a duration of 2
years in adults. In view of the evidence that
developmental changes in depressive symptoms

and the overall depressive syndrome occur during

childhood and adolescence, more extensive modifications to adult criteria have been proposed [3, 4].
Luby [3], in a series of studies aimed at revising
DSM IV TR criteria for pre-schoolers, found that
pre-school children express depressive symptoms in
thematic play and through loss of interest in play.
Also she has shown that a more valid definition of
the depressive syndrome in pre-schoolers requires
the presence of four (not five) symptoms, most of the
time (not all of the time) over a 2 week period, as
specified in DSM IV TR. Weiss and Garber [4], in
a meta-analysis of 16 studies of depressive symptoms
in children of different ages, found that anhedonia,
hopelessness, hypersomnia, weight-gain and social
withdrawal are rarer in younger children but become
more common as children mature. In clinical
practice, it is important to take account of these
developmental issues in assessing depression
in children and adolescents.

Depression in young people

Epidemiology

Sex differences

Depression in young people is not a rare condition.

In a review of 18 epidemiological studies of
community samples, Costello et al. [5] found
prevalence rates of major depression in youngsters
under 18 to range from 0.212.9%, with a median
of 4.7%. Depression is more common among
adolescents than children; more common among
teenage girls than boys; and very common
among clinical populations [6]. Community
studies of depression co-morbidity rates show that
high rates of co-morbidity occur with anxiety
disorder, conduct disorder and attention deficit
hyperactivity disorder in childhood and with eating
disorders and substance abuse in adolescence [5, 7].

In adulthood twice as many women have depression

as men. This sex difference in depression rates
begins after the onset of puberty. Hankin
and Abramson [7] have argued that multiple
constitutional, personal and contextual factors may
account for this and have drawn support for their
position from a review of a considerable body
of empirical evidence. What follows are some
key findings of their extensive review. Girls experience more independent and dependent stressful
life events than boys. Independent life events are
outside the individuals control, for example,
bereavement. Dependent life events are elicited
by the individuals behaviour, for example, interpersonal rejection. Girls also ruminate more and
have a more depressive inferential style in response
to these events. Girls have higher levels of
the personality trait neuroticism, which is a
vulnerability factor for depression and which is
partially genetically determined. Finally, genetic
factors may render teenage girls more vulnerable
to depression than boys. For example, in a study of
377 depressed and non-depressed adolescents
exposed to high and low levels of life stress, Eley
et al. [17] found that for girls (but not boys),
depression occurring during exposure to high stress
was associated with a specific molecular genetic
deficit, 5-HTTLPR, a short allele form of
the promoter region of the serotonin transporter
5-HTT. Collectively, the aggregation of these
factors, reviewed by Hankin and Abramson [7],
may partly explain the higher rates of depression in
teenage girls.

Prognosis
While the majority of youngsters recover from
a depressive episode within 1 year, they do not
grow out of their mood disorder [6]. Major depression is a recurrent condition and depressed
youngsters are more likely than their non-depressed
counterparts to develop episodes of depression as
adults, although they are no more likely to develop
other types of psychological problems [8].
Double depression: that is, chronic dysthymia
combined with major depressive episodes; severe
depressive symptoms; maternal depression; comorbid conduct disorder or drug abuse; family problems; and social adversity have all been shown in
longitudinal studies to be predictive of worse outcome [6, 8, 9].
In a large North American community study,
Lewinsohn et al. [10] found that 12% of adolescents
with depression relapsed within 1 year and 33%
within 4 years. Inter-episode intervals decrease as
more episodes occur. This may be due to the
neurobiological process of kindling [11] and the
cognitive process of rumination [12, 13]. According
to cognitive therapists, small stresses, which lead
to small negative mood changes, can give rise to
chronic rumination and catastrophizing and precipitate later episodes of depression. According to
neurobiological theorists, multiple episodes of
depression, through a process of kindling, probably
render the neurobiological systems that maintain
depression more vulnerable to depressogenic
changes in response to minor stresses.
Children and adolescents with depression are at
a higher risk of suicide than youngsters with other
disorders, so the assessment and management of
suicide risk is a priority when dealing with depressed
young people [1416].

Aetiology
Research on the aetiology of depression is converging in support of a diathesis-stress model [18, 19].
Children and adolescents are rendered neurobiologically vulnerable to depression by genetic factors
which interact with environmental factors to give rise
to mood disorders.
Neurobiological vulnerability to depression is
polygenetically determined [20]. The genes associated with this vulnerability are different in males
and females [21]. Genetic factors play an increasingly significant role in the aetiology of depression
with the transition to adolescence, particularly
in girls [22]. Genetic factors may render
young people vulnerable to depression by affecting
their temperament and personality and by
affecting neurobiological factors associated with
depression. Genetic factors influence the level of
the personality trait, neuroticism, which is a predisposing factor for depression [23]. Genetic factors

A. Carr

may also influence the functioning of the hypothalamic-pituitary-adrenal axis and the functioning
of the serotonin, cholinergic and noradrenergic
systems, which show deregulation under stress in
depression [24].
Environmental factors which place undue stress
on youngsters; which outstrip their coping capacities; and which occur in the absence of social
support, interact with genetic factors and
may initially render youngsters psychologically vulnerable to depression. Later they may precipitate the
onset of depressive episodes and prevent recovery
or precipitate relapse [25]. Loss of important
relationships, failure experiences, bullying, illnesses
and injuries and disruptive life transitions such
as moving house or the onset of puberty
all constitute stressful life events. There is some
evidence that stressful events are more likely
to precipitate depression when they occur in the
same domain as those that rendered the individual
vulnerable to depression earlier in their lives.
So youngsters who suffered interpersonal losses
in early childhood are more likely to have a
depressive episode later in their development precipitated by an interpersonal loss and those that
experienced significant achievement failures early
in life are more likely to become depressed when
they experience failure in academic and work
domains later in their development [26, 27].
Non-optimal early parenting environments are
particularly important sources of environmental
stress and deserve special mention. Non-optimal
parenting environments include those characterized
by lack of parental attunement, parental psychopathology (notably maternal depression and paternal
substance use), family conflict, stressful parental
separation, domestic violence and child maltreatment, all of which may be influenced by wider
sociocultural factors such as poverty and social
isolation [19].
Non-optimal parenting environments may render
youngsters psychologically vulnerable to depression
by contributing to the development of poor skills
for regulating negative emotional states and coping
with both minor daily stresses and larger stressful life
events [28]; self-criticism [26]; a low sense of control
over ones life [29]; a pessimistic cognitive style [30];
a negative and hopeless inferential style [31];
a ruminative response style [32]; insecure attachment styles [33]; and poor skills for developing
supportive social networks [19, 34].
Once an episode of depression occurs it may be
maintained at a psychological level by all of these
personal psychological factors; and also by neurobiological processes, life stresses and non-optimal
parenting environments mentioned earlier.

On the positive side, personal and contextual

protective factors may reduce the likelihood
of depression or contribute to recovery. These
include intelligence, problem-solving skills, an
active coping style, the capacity for self-reflection,
self-esteem, an internal locus of control and sense of
mastery, higher levels of physical activity, good social
skills, a supportive cohesive family, a positive school
environment, supportive peer relationships and
a supportive community [19, 35, 36].

Assessment
Assessment for depression should begin with a broad
screening for psychological difficulties. If this suggests that there are mood problems, a more detailed
assessment of depressive symptoms may be conducted. If appropriate, this may be followed
by structured interviewing about depressive syndromes. Then a wider interview covering risk
and protective factors mentioned in the previous
section along with suicide risk assessment should
be conducted. Guidelines for such broader interviews are given in Carr [15, 37] and elsewhere
[14, 16, 38, 39].
For screening school-aged children and adolescents for any type of psychological disorder, including
depression,
the
Achenbach
System
of Empirically Based Assessment (ASEBA) [40,
41] and the Behavioural Assessment System
for Children (BASC) [42] are very useful. These
are both reliable, valid and well standardized multiinformant assessment packs, which contain parent,
teacher and child report forms and which assess
a wide range of emotional and conduct problems
including depression. However, because these
instruments span a wide range of problems,
the depression sub-scales included in them contain
only a small number of items. If children screen
positive for mood disorders on BASC or ASEBA
depression scales, it is appropriate to conduct a more
detailed assessment of depressive symptoms.
The most widely used and best validated selfreport instruments for assessing depressive symptoms in children are the Childrens Depression
Inventory (CDI) [43], the Beck Depression
Inventory for Youth (BDIY) [44] and the Reynolds
Child and Adolescent Depression Scales (RCDS
and RADS) [45, 46]. The Mood and Feelings
Questionnaire [47] has parent and self-report
versions and is the most widely used and best
validated screening instrument with this feature.
For pre-school children, the parent-report Preschool
Feelings Checklist [48] is one of the very
few available measures for screening toddlers for
depression. All of these instruments have good

Depression in young people

internal consistency and testre-test reliability. They
also have strong criterion validity, distinguishing
between groups of cases with and without
a diagnosis of depression [4348]. These instruments are useful for evaluating symptom severity
and changes in symptom severity over time.
However, unlike structured interviews they do not
evaluate depressive syndromes as conceptualized
in DSM IV TR and ICD 10. Where young people
obtain elevated scores on depressive symptom
assessment instruments, it is appropriate to conduct
a structured interview to assess depression from
a syndromal perspective.
There are many structured interviews for assessing
depression (and other DSM IV TR or ICD 10
disorders), most of which have parent and childreport versions or which allow for data from multiple
informants to be combined. In the UK the most
widely used is the Development and Well-being
Assessment (DAWBA) [49]. In North America,
for school aged children, some of the most widely
used include the Diagnostic Interview Schedule
for Children (DISC-IV) [50], the Diagnostic
Interview for Children and Adolescents (DICA)
[51], the Child and Adolescent Psychiatric
Assessment (CAPA) [52] and the Schedule for
Affective Disorders and Schizophrenia for Schoolage Children (K-SADS) [53]. The Berkeley Puppet
Interview [54] may be used for assessing pre-school
children. The Young-Child DISC-IV [55] and the
Preschool Age Psychiatric Assessment (PAPA) [56]
are parent report interviews for use with children
under 6. These instruments all have moderateto-good inter-rater reliability [4956]. The mood
disorders module from these instruments may be
used to obtain a reliable diagnosis of depression.

psychotherapies for depression in children and

adolescents.
In selecting treatment outcome literature for
review, priority was given to meta-analyses and
systematic reviews and in their absence to
randomized controlled trials. Where these types of
evidence were not available, outcome studies that
included a matched control group or a single
treatment group were included, but results of such
studies were interpreted with appropriate caution.
In the most comprehensive available meta-analysis
of 35 randomized controlled studies of psychotherapy for child and adolescent depression, Weisz et al.
[61] obtained an effect size of 0.34. This indicates
that the average treated case fared better than
63% of untreated cases and is equivalent to a success
rate of
58%. This modest effect size is more
valid than the larger effect size of 0.72 found by
Michael and Crowley [62] in an earlier, smaller and
less methodologically robust meta-analysis of
14 trials of psychotherapy for child and adolescent
depression. Weisz et al. [61] also found that
there were no significant differences in outcome
between cognitive behavioural treatments and other
treatments or between treatments conducted under
optimal or routine clinical conditions. Treatment
gains were maintained at 6 months follow-up but
not at 1 year follow-up. This is not surprising given
the episodic and recurrent nature of major depression. In addition to these omnibus reviews of the
overall effectiveness of psychotherapy for depression
in young people, a number of reviews focusing
on specific forms of treatment and a number of key
outcome studies which have examined the effectiveness of cognitive-behaviour, psychodynamic, interpersonal and systemic therapy deserve mention.
Cognitive behaviour therapy

Treatment effectiveness
Available information on the natural history of
childhood and adolescent depression provides a
context for interpreting the results of treatment
trials of psychological therapies. The majority
of youngsters recover from a depressive episode
within 1 year; about a tenth relapse during the
following year; about a third relapse within 4 years;
and inter-episode intervals decrease as more
episodes occur [10]. Depression often persists into
adulthood [8] and it is a risk factor for suicide [15].
Treatment with tricyclic antidepressants (TCAs)
is ineffective [57] and treatment with selective
serotonin reuptake inhibitors (SSRIs) may be
associated with increased suicide risk in adolescents
[58, 59], although there is some evidence to
the contrary [60]. There is clearly a strong case
for the importance of developing effective

There is evidence from three reviews for the

effectiveness of cognitive behaviour therapy in
the treatment of child and adolescent depression.
In a systematic review of six studies of cognitive
behaviour therapy for major depression in children
and adolescents, Harrington et al. [63] found
a remission rate of 62% for treated cases and 36%
for untreated cases. In a meta-analysis of studies
of cognitive behaviour therapy for depression in
adolescence, Lewinsohn and Clarke [64] found
a post-treatment effect size of 1.27. They also
found that 63% of patients showed clinically
significant improvement. In a meta-analysis of
six studies of cognitive behaviour therapy for
depression in adolescence, Reinecke et al. [65]
obtained a post-treatment effect size of 1.02 and a
follow-up effect size at 612 months of 0.61.
Collectively these results indicate that just over

A. Carr

60% to just over 70% of young people diagnosed

with a depressive disorder benefited from cognitive
behaviour therapy.
In an important comparative trial, Weersing and
Brent [66] and his team found that immediately after
treatment more youngsters who received cognitive
behaviour therapy (60%) were in remission compared with those who received family therapy (38%)
or supportive therapy (39%). However, at 2 years
follow-up there were no significant differences
between the outcomes of the three groups.
Recovery rates were 94% for cognitive behaviour
therapy, 77% for family therapy and 74% for
supportive therapy. In all three groups, a negative
family environment characterized by maternal
depression and family conflict on the one hand and
severe cognitive distortions and depressive symptomatology on the other were associated with poorer
outcome. The positive effects of cognitive behaviour
therapy arose predominantly from changes in depressive cognitive distortions. Positive changes in family
functioning accounted for improvements in the
family therapy group. In all three groups a rapid
improvement during the first couple of sessions
occurred in just over a third of cases and was
predictive of a positive outcome. Therapeutic factors
common to all three types of therapy, such as the
quality of the therapeutic alliance, probably
accounted for this rapid improvement. All participants in this study received 1216 sessions. During
the follow-up period 62% used other services for
depression, 33% for family problems and 31% for
conduct problems. The results of the study suggest it
may be worthwhile combining individually-oriented
cognitive behaviour therapy and family therapy to
aim to address both intrapsychic and interpersonal
depression maintaining factors and to extend therapy
beyond 16 sessions so that additional services are not
required.
Cognitive behaviour therapy for depression rests
on the hypothesis that low mood is maintained
by a depressive thinking style and constricted
lifestyle that entails low rates of response contingent
positive reinforcement. Cognitive behaviour therapy
programmes for adolescents evaluated in treatment
trials have two main components which target these
two maintaining factors: behavioural activation
and challenging depressive thinking [67]. In challenging depressive thinking, youngsters learn mood
monitoring and how to identify and challenge
depressive negative automatic thoughts and cognitive distortions that accompany decreases in mood.
With behavioural activation youngsters re-organize
their daily routines so they involve more pleasant
events, physical exercise and social interaction.
They also develop skills to support this process
including
social
skills,
relaxation
skills,

communication and problem-solving skills and

relapse prevention skills. Some cognitive behavioural
programmes for depression in young people include
concurrent intervention with parents, which helps
them understand factors that maintain depression
and support youngsters in following through on the
behavioural activation and cognitive components of
the child-focused part of the programme. Cognitive
behaviour therapy usually spans 1020 child-focused
sessions and may be offered on an individual or
group basis. Where concurrent parent sessions
occur, usually about 510 of these are offered.
Lewinsohns group-based programme [68, 69] and
Brents [66] and Weisz et al.s [70] individual
cognitive behaviour therapy programmes are good
examples of well-developed North American evidence-based approaches in this area. In the UK,
Stallards Think GoodFeel Good programme offers
a best practice approach to CBT with young people
[71, 72].
Psychodynamic therapy
One randomized controlled trial and one nonrandom matched group trial provide evidence for
the effectiveness of psychodynamic psychotherapy
with depressed children and adolescents [73, 74].
In a randomized controlled study of 72 youngsters
aged 915 assigned to psychodynamic or family
therapy, Trowell et al. [73] found that
75%
of cases in both groups were fully recovered after
therapy;
100%
of
those
who
received
psychodynamic therapy and 81% of those who
received family therapy were fully recovered at 6
months follow-up (but this group difference was not
significant). Psychodynamic and family therapy also
led to a significant reduction of double depression
(major depression with co-morbid dysthymia) and
rates of other co-morbid conditions. In this study
psychodynamic therapy involved an average of 25
individual sessions and 12 concurrent parent sessions spanning 9 months, following a manual based
on Malan and Osimo [75] and Davenloos [76]
model of brief psychodynamic psychotherapy. In this
model the focus is on interpreting the links between
defences, anxiety and unconscious feelings and
impulses, within the context of the transference
relationship with the therapist, the relationship with
significant people in the childs current life and early
relationships with parents or caregivers. Family
therapy involved an average of 11 sessions spanning
9 months based on Byng Hall [77] and Will and
Wrates [78] integrative model of family therapy
(discussed in more detail below).
In a non-randomized matched group study of 58
children aged 610 years, most of whom had
dysthymia, assigned to psychodynamic therapy

Depression in young people

or community-based treatment as usual, Muratori
et al. [74] found that at 2 years follow-up, 66% of
those who received psychodynamic psychotherapy
were recovered compared with 38% in the control
group. In this study, psychodynamic therapy
involved 11 conjoint parentchild sessions and
several additional individual sessions for children
only, based on the Cramer and Palacio Espasas [79]
model. Within this model in the first phase, parentfocused work occurs where parentchild interactions
are interpreted in terms of their defensive functions.
Play-based child-focused work occurs in the
second phase, with the aim of helping the child
understand and articulate links between feelings,
wishes and symptoms. In the final phase, the coreconflictual theme that links the parents defensive
style to the childs symptoms is explored. A core
conflictual theme has three key elements:
(1) the persons wish in a particular type of situation,
(2) the persons anticipated or imagined response of
the other person in that type of situation, and (3) the
persons actual defensive response in that type
of situation.
Taken together, the results of these two trials
provide preliminary evidence for the effectiveness of
psychodynamic therapy with children and adolescents. Because Muratoris study was not a randomized controlled trial, caution is required
in interpreting the results. The exceptionally positive
outcome of psychodynamic psychotherapy in
Trowell et al.s [73] study is very impressive and
requires replication.
Interpersonal therapy
There is evidence from three controlled efficacy
studies, a controlled effectiveness study and a single
group outcome study that interpersonal psychotherapy is an effective treatment for adolescent depression which leads to recovery in more than 75%
of cases and in two of these studies interpersonal
therapy was found to be as effective as cognitive
behaviour therapy [8082]. Interpersonal therapy
for adolescent depression targets five interpersonal
difficulties which are assumed to be of particular
importance in maintaining depression: (1) grief
associated with the loss of a loved one; (2) role
disputes involving family members and friends;
(3) role transitions such as starting or ending
relationships within family, school or peer group
contexts, moving houses, graduation or diagnosis
of an illness; (4) interpersonal deficits, particularly
poor social skills for making and maintaining
relationships; and (5) relationship difficulties associated with living in a single parent family.
In interpersonal therapy the specific focal
interpersonal factors that maintain the youngsters

depressive symptoms are addressed within a series of

child-focused and conjoint family sessions. Mufson
et al.s [83] manual provides detailed guidance on
this approach to therapy with depressed adolescents.
Family therapy
There is evidence from six studies for the effectiveness of family therapy for child and adolescent
depression and suicidality, two of which have already
been mentioned [66, 73]. In a comparative study,
Trowell et al. [73] found that 11 sessions of family
therapy was as effective as a programme which
included 25 sessions of psychodynamic therapy
coupled with 12 adjunctive parent sessions; 75%
of cases no longer met the criteria for depression
after treatment and 81% were recovered at 6 months
follow-up. Byng Hall [77] and Will and Wrates [78]
integrative model of family therapy was used
in this trial. Therapy involved techniques from
many schools of family therapy and helped families
understand the links between the youngsters
depression, problematic family scripts and insecure
family attachment patterns. It also helped family
members develop more secure attachments to each
other and re-edit problematic family scripts to form a
more coherent narrative about how to manage stress
and life-cycle transitions.
In a controlled study of attachment-based family
therapy for depression with 32 adolescents,
Diamond et al. [84] found that after treatment
81% of treated cases no longer met the criteria
for depression, whereas 47% of the waiting list
control group did. At 6 months follow-up 87% of
cases were not depressed. Attachment-based family
therapy involves the following sequence of interventions which have been shown in process studies
to underpin effective treatment: relational reframing,
building alliances with the adolescent first and then
with the parents, repairing parentadolescent attachment and building family competency [85].
In another comparative study, Brents [66] team
found that only 38% of depressed adolescents
were recovered immediately after family therapy,
but at 2 years follow-up 77% no longer met the
criteria for depression. Family therapy was less
effective in the short-term, but as effective in the
long-term as cognitive behaviour therapy.
Improvements in family functioning accounted for
youngsters recovery. A behavioural systems
approach to family therapy was used in this trial.
This involved using family-based behavioural
interventions such as problem monitoring, communication and problem-solving skills training, contingency contracting and relapse prevention to
reduce family conflict, enhance family relationships
and promote better mood management.

10

A. Carr

In a controlled trial involving the families of 31

adolescents, Sanford et al. [86] evaluated the
incremental benefit of adding psychoeducational
family therapy to a routine treatment programme
involving predominantly supportive counselling
and SSRI antidepressant medication. Three
months after treatment, 75% of the family therapy
group and 47% of controls no longer met the criteria
for depression and parentadolescent relationships
in the family therapy group were significantly
better than in the control group. A 13 session,
home-based adaptation of Falloon et al.s [87] family
therapy model was used in this study. Treatment
included psychoeducation about depression, communication and problem-solving skills training and
relapse prevention.
In a single group outcome study for adolescents
with co-morbid depression and substance abuse,
Curry et al. [88] found that, after a combined
programme of cognitive behavioural therapy and
family therapy, 50% of cases recovered from
depression and 66% from substance abuse.
The programme spanned 10 weeks, with weekly
family therapy sessions and twice weekly cognitive
behaviour therapy group sessions. Robin and
Fosters [89] model of family therapy for negotiating
parentadolescent conflict was used in this
programme.
Huey et al. [90] evaluated the effectiveness of
multisystemic therapyan intervention programme
that includes family therapy as its core component
[81]in a randomized controlled study of a group
of with 156 African American adolescents at risk for
suicide referred for emergency psychiatric hospitalization. Most of these youngsters were depressed, but
had multiple other co-morbid difficulties. Compared
with emergency hospitalization and treatment by
a multidisciplinary psychiatric team, Huey et al. [90]
found that multisystemic therapy was significantly
more effective in decreasing rates of attempted
suicide at 1-year follow-up.
Collectively these studies lend support for both
attachment-based and psyhoeducationally oriented
cognitive-behavioural approaches to family therapy
as effective treatments for depressed adolescents and
multisystemic therapy as an effective family therapy
based approach to reducing suicidality.
Antidepressant medication
In a meta-analysis of 13 studies of the effectiveness
of TCAs for depression in young people, Hazell et al.
[57] concluded that TCAs are ineffective with
children and only have a small impact on adolescent
depression. In contrast, there is growing evidence
that SSRIs may have a role in the treatment
of depression in young people. In reviews of

controlled trials of SSRIs for child and adolescent

depression, Cheung et al. [92] and Vasa et al. [93]
found a number of SSRIs, notably fluoxetine,
alleviated the symptoms of depression in about two
thirds of children and adolescents and led to
complete remission in about a third of cases.
However, because there is some evidence that
SSRIs may lead to increased suicidal ideation and
behaviour [58, 59], caution in required in using
them in the treatment of children and adolescents
with mood disorders.
Results of the large USA multisite Treatment for
Adolescent Depression Study (TADS [94]), which
involved 439 moderately depressed adolescents,
showed that cognitive behaviour therapy combined
with fluoxetine (an SSRI) led to a significantly higher
improvement rate (71.0%) than medication alone
(60.6%), which in turn led to a significantly higher
improvement rate than cognitive-behaviour therapy
alone (43.2%). Cognitive behaviour therapy
combined with SSRIs also led to the greatest
reduction in suicidal thinking, compared with the
other two conditions. This may provide an evidencebased rationale for combining SSRIs with cognitive
behaviour therapy in moderate depression. In the
TADS study the effectiveness of cognitive behaviour
therapy alone (43.2%) was low compared with other
trials where the outcome has been
60% [53].
This may have been due to the characteristics
of the participants. In an analysis of factors related
to outcome in the TADS study, Curry et al. [95]
found that cognitive behaviour therapy combined
with SSRIs was more effective than SSRIs alone
for mild-to-moderate depression and for depression
with high levels of cognitive distortion, but not
for severe depression or depression with low levels of
cognitive distortion.
In contrast to the results of the TADS study,
Goodyer et al. [96] in the UK multicentre Adolescent
Depression Antidepressant and Psychotherapy Trial
(ADAPT) involving 208 adolescents with severe
depression who had not responded to an initial brief
trial of psychotherapy, found that there was no
significant benefit in terms of recovery from depression or reduction in suicidal ideation associated with
adding 19 sessions of cognitive behaviour therapy to
routine outpatient consultations at a specialist clinic
and SSRIs. By 28 weeks, 57% of trial participants
showed clinically significant improvement including
reduced suiciality. The sample in this study included
cases of severe depression that would have been
excluded from the TADS study because of suicidality, depressive psychosis or co-morbid conduct
disorder. Goodyer et al. concluded that, for severe
adolescent depression, of the type typically referred to
UK specialist services, the addition of cognitive
behaviour therapy to routine specialist care and

Depression in young people

SSRI treatment confers no additional benefit. Two
additional US studies have yielded similar results. In a
randomized trial involving 152 depressed adolescents, Clarke et al. [97] found that the addition of
cognitive behaviour therapy to routine treatment with
SSRIs had a negligible impact on the course of
depressive symptoms. In a randomized multisite trial
involving 73 moderately depressed adolescents,
Melvin et al. [98] found that treatment with SSRIs
(sertraline), cognitive behaviour therapy and both
combined had similar outcomes 6 months after
treatment.
The results of the studies reviewed in this section
support the use of SSRIs in severe depression in
young people, when they do not respond to a brief
trial of psychotherapy. However, because there is
some evidence that treatment with selective serotonin reuptake inhibitors (SSRIs) may be associated
with increased suicide risk in adolescents [58, 59],
regular monitoring of this is essential.
Electro convulsive therapy
There are currently no data from controlled trials
to support the use of electroconvulsive therapy
with adolescents, but some limited data from open
trials, so its use remains cautious and controversial
[99102].

Implications for practice

The evidence reviewed in this paper has implications
for assessment and treatment. Assessment for
depression should begin with a broad screening for
psychological difficulties with instruments such as
those in the ASEBA or BASC evaluation packs. If
this suggests that there are mood problems, a more
detailed assessment of depressive symptoms may be
conducted with depression-specific instruments such
as the CDI, BDIY, RCDS or RADS. Where elevated
scores on these occur, it is appropriate to conduct a
structured interview to assess depression from a
syndromal perspective with the mood disorders
module from instruments such as the DAWBA,
DISC-IV, DICA, CAPA or K-SADS. If children are
under 5, the Young-Child DISC-IV or PAPA may
be used. These structured interviews will yield DSM
or ICD diagnoses. Then a wider interview covering
risk and protective factors mentioned in the previous
section, along with suicide risk assessment, should
be conducted.
With regard to treatment, the conclusions that can
be drawn are limited by the nature of available
evidence. For example, only tentative conclusions
may be made about how to tailor treatment to match
client characteristics because, for all forms

11

of therapy, evidence is available for only a limited

range of children in terms of age, socio-economic
status, family composition, depression severity,
comorbidity and so forth. For example, in Trowell
et al.s [73] trial of psychodynamic therapy, only
children over 9 were included and this
is the only randomized controlled trial of psychodynamic therapy. Also, actively suicidal cases were
excluded from most psychotherapy trials, with
the exception of Goodyer et al.s [96]. Tentative
conclusions must also be drawn about how best
to combine child-focused and parent-focused
interventions, since no treatment deconstruction
trials have been conducted in which child-focused,
parent-focused and combined treatment protocols
have been compared. With these caveats in mind,
the following guidance is offered for clinical practice
until more evidence becomes available.
Effective protocols for mild-to-moderate depression have been developed within the cognitivebehavioural, interpersonal, psychodynamic and
family therapy traditions. These protcols should
be flexibly applied in clinical practice, taking due
account of clinical formulations of clients unique
profiles of personal and contextual predisposing,
precipitating, maintaining and protective factors.
In light of such clinical formulations, a case may
be made for combining child- and family-based
components of treatment protocols that have been
shown to be effective, to address specific elements
within a clients formulation [37]. Extant evidence
suggests that family-based intervention for child
and adolescent depression includes family psychoeducation; facilitating family understanding and
support of the depressed youngster; and organizing
home-school liaison to help the youngster
re-establish normal home and school routines.
Available evidence suggests that child-focused interventions involve exploration of contributing factors,
some of which may be outside youngsters awareness; facilitating mood-monitoring; increasing
physical exercise, social activity and pleasant
events; modification of depressive thinking styles,
depression maintaining defence mechanisms and
depression maintaining patterns of social interaction;
the development and use of social problem-solving
skills; and the development of relapse prevention
skills. Extant evidence suggests that a dozen family
sessions and twice as many individual sessions are
probably necessary for treating mild-to-moderate
depression in children and adolescents. With severe
depression, where clients show no response to a brief
trial of psychotherapy and where they present with
suicidality, psychotic features or comorbid difficulties, a trial of SSRIs combined with routine specialist
clinical monitoring and support is the treatment
of choice. However, caution is warranted in using

12

A. Carr

SSRIs with youngsters, since they may increase

suicide risk.
These conclusions are broadly consistent with
international guidelines for best practice [38, 39],
but differ from UK NICE guidelines insofar as these
do not recommend the use of psychodynamic
therapy for depression.
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