Issues in the treatment of depressed children

Basic research into the cognitive, behavioral, familial, and physiological disturbances associated with depressive disorders during childhood is reviewed. Implications for the development of a treatment program are discussed and a comprehensive treatment model is proposed. The proposed model includes intervention strategies for the child, parents, family, and school. The child component consists of intervention strategies for the affective, cognitive, behavioral, and physiological disturbances that are evident from the existing research. The parent training component is designed to address disturbances in parenting due to cognitive disturbances and skills deficits. The family therapy component emphasizes changing interaction patterns that communicate schema-consistent maladaptive interactions. A school consultation component is proposed in which school personnel support the skills training through prompting use of the skills and reinforcement of the use of the coping skills.     

Family-Focused Treatment for Childhood Depression: Model and Case Illustrations

Although the evidence base for treatment of depressive disorders in adolescents has strengthened in recent years, less is known about the treatment of depression in middle to late childhood. A family-based treatment may be optimal in addressing the interpersonal problems and symptoms frequently evident among depressed children during this developmental phase, particularly given data indicating that attributes of the family environment predict recovery versus continuing depression among depressed children. Family-Focused Treatment for Childhood Depression (FFT-CD) is designed as a 15-session family treatment with both the youth and parents targeting two putative mechanisms involved in recovery: (a) enhancing family support, specifically decreasing criticism and increasing supportive interactions; and (b) strengthening specific cognitive-behavioral skills within a family context that have been central to CBT for depression, specifically behavioral activation, communication, and problem solving. This article describes in detail the FFT-CD protocol and illustrates its implementation with three depressed children and their families. Common themes/challenges in treatment included family stressors, comorbidity, parental mental health challenges, and inclusion/integration of siblings into sessions. These three children experienced positive changes from pre- to posttreatment on assessor-rated depressive symptoms, parent- and child-rated depressive symptoms, and parent-rated internalizing and externalizing symptoms. These changes were maintained at follow-up evaluations 4 and 9 months following treatment completion.     

Stress Sensitization and Adolescent Depressive Severity as a Function of Childhood Adversity: A Link to Anxiety Disorders

The goal of the present study was to determine whether exposure to adversity in childhood contributes to a differential threshold at which stressful life events provoke depressive reactions in adolescence. In addition, to address empirical and conceptual questions about stress effects, the moderating effect of anxiety disorder history was also explored. This examination was conducted in a sample of 816 children of depressed and nondepressed mothers, who were followed from birth to age 15. Information on adversities experienced in childhood was collected both from mothers during the first five years of their youth's life and from the youths themselves at age 15, and included information on the mother's relationship with her partner, maternal psychopathology, as well as youth-reported abuse. Results indicated that youths with both greater exposure to adversity in childhood and a history of an anxiety disorder displayed increased depressive severity following low levels of episodic stress compared to youths with only one or neither of these risk factors. The results are speculated to reflect the possibility that early anxiety disorders associated with exposure to adversity in childhood may be a marker of dysregulated stress responses, and may help to account for the comorbidity of depression and anxiety in some individuals.     

Effectiveness of Cognitive Behavior Therapy for Severe Mood Disorders in an Acute Psychiatric Naturalistic Setting: A Benchmarking Study

The current study examined the effectiveness of brief cognitive behavior therapy (CBT) for severe mood disorders in an acute naturalistic setting. The sample included 951 individuals with either major depressive disorder (n = 857) or bipolar disorder with depressed mood (n = 94). Participants completed a battery of self-report measures assessing depression, overall well-being, and a range of secondary outcomes both before and after treatment. We found significant reductions in depressive symptoms, worry, self-harm, emotional lability, and substance abuse, as well as significant improvements in well-being and interpersonal relationships, post-treatment. Comparable to outpatient studies, 30% of the sample evidenced recovery from depression. Comparison of findings to benchmark studies indicated that, although the current sample started treatment with severe depressive symptoms and were in treatment for average of only 10 days, the overall magnitude of symptom improvement was similar to that of randomized controlled trials. Limitations of the study include a lack of control group, a limitation of most naturalistic studies. These findings indicate that interventions developed in controlled research settings on the efficacy of CBT can be transported to naturalistic, “real world” settings, and that brief CBT delivered in a partial hospital program is effective for many patients with severe depressive symptoms.     

Attachment-based family therapy for depressed adolescents: programmatic treatment development

Few effective psychosocial treatment models for depressed adolescents have been developed, let alone ones that use the developmentally potent context of the family as the focus of intervention. Attachment-based family therapy (ABFT) is a brief, manualized treatment model tailored to the specific needs of depressed adolescents and their families. Attachment theory serves as the main theoretical framework to guide the process of repairing relational ruptures and rebuilding trustworthy relationships. Empirically supported risk factors for depression are the primary problem states that therapists target with specific treatment strategies or tasks. Parent problem states include criticism/hostility, personal distress, parenting skills, and disengagement. Adolescent problem states include motivation, negative self-concept, poor affect regulation, and disengagement. Intervention tasks include relational reframing, building alliances with the adolescent and with the parent, addressing attachment failures, and building competency. A small, randomized clinical trial provides initial support for the model. Several process research studies, using both qualitative and quantitative methods, have helped refine the clinical guidelines for each treatment task. ABFT is a promising new treatment for depressed adolescents and more research on it is warranted.     

Presentation of Depression and Response to Group Cognitive Therapy with Older Patients

Concerned with response prediction, this research examines the relationships between pre-treatment components of depressive symptomatology and outcome of short-term group cognitive therapy for depression with older adults. Aspects of depressive symptomatology under examination were initial intensity of self-reported depressive symptomatology, profile of melancholic depression, perceived health status, perceived social support, and intensity of negative view of self. Findings indicate that perceived social support is not related to outcome but that a more intense depressive symptomatology, a more negative health evaluation, and a more negative view of self are variables associated with a less favorable outcome. Despite showing a sizable decrease in depressive symptoms over the course of intervention, severely depressed subjects still presented residual depressive symptoms at the conclusion of intervention. There was a tendency for subjects with a melancholic profile to show a poorer response to this intervention.     

The Benefits of Using Psychotherapy Skills Following Treatment for Depression: An Examination of “Afterwork” and a Test of the Skills Hypothesis in Older Adults

It has long been assumed that one of the reasons clients maintain improvement after psychotherapy is that they learn skills during the course of therapy and continue to apply them once therapy has ended. While research on homework completion and psychotherapy outcome provides support for this assumption, there has been no direct examination of “afterwork,” the use of skills learned in therapy after therapy has ended, or how those posttherapy skills differ across different theoretical approaches. The purpose of this study is to test a skills hypothesis of long-term psychotherapeutic benefit in a sample of 90 older adults who have completed psychotherapy for depression. Helpfulness of the techniques learned in therapy was negatively associated with depressive symptoms up to 2 years after treatment. The number of techniques used was positively correlated with depressive symptoms within 6 months of treatment once helpfulness was controlled, indicating that skills learned in therapy are used when symptoms return. There were also between-group differences in which skills were reported to be covered and used by patients after therapy ended. These findings support the expectation that the benefits of therapy are extended by continuing to use helpful skills learned in therapy.     

Metacognitive therapy in recurrent depression: A case replication series in Denmark

Metacognitive therapy (MCT) for depression is derived from the Wells and Matthews (1994) self‐regulatory model, in which a Cognitive‐Attentional Syndrome (CAS) is the cause of psychological disorders. MCT for depression focuses on identifying patients' CAS and helps them to stop it. The CAS consists of worry, rumination and dysfunctional coping strategies. The focus in MCT is on removing the CAS by challenging positive and negative metacognitive beliefs and eliminating dysfunctional behaviors. In this case series, MCT was delivered to four depressed Danes and treatment was evaluated in 5–11 sessions of up to one hour each. An A‐B design with follow‐up at 3 and 6 months was conducted and the primary outcome was Beck's Depression Inventory II (BDI‐II). We measured CAS processes with the Major depressive Disorder Scale (MDD‐S). The results of the case series showed clinically significant improvements in depressive symptoms, rumination and metacognitive beliefs and the effects were still present at follow‐up for all patients. The small number of patients and decreasing baselines observed in some cases limits the conclusions. However, the results suggest that this treatment is feasible and was associated with large improvements in symptoms when delivered away from its point of origin and in a Danish help‐seeking sample.     

Extensions and Mechanisms of Mindfulness‐based Cognitive Therapy: A Review of the Evidence

Mindfulness‐based cognitive therapy (MBCT) was originally developed to prevent depressive relapse and recurrence and has also been widely extended to new patient populations and target problems over the last 14 years. We provide a comprehensive review of this literature, examining the strength of the evidence base for specific populations and target problems and identifying questions for future research to address. Specifically, we review studies addressing the use of MBCT for depressive disorders (prevention of depressive relapse and treatment of residual and current depressive symptoms), the use of MBCT in the treatment or management of other mental disorders (bipolar disorder, anxiety disorders, mixed anxiety and depression symptoms, disordered eating, personality disorders, and psychosis), and the use of MBCT in behavioural medicine contexts. Additionally, we discuss the extension of MBCT during specific developmental periods, like childhood, pregnancy and post‐partum, and adult caregiving, and, finally, we address the use of MBCT among clinical health‐care providers. In the second section, we review hypothesised mechanisms of change in MBCT and reflect on implications for theories of how MBCT works in the application to various patient populations and target problems. We also consider research addressing active ingredients and what is known about the “dosage” of meditation practice. We conclude with a summary of recommendations for future research.     

Problem Solving Therapy

This paper describes how problem solving therapy (PST) would be applied to the treatment of Sylvia (I. Caro, 2001), a 27-year-old depressed wife and mother of three. PST involves training individuals in five major processes: problem orientation, problem definition and formulation, generation of alternatives, decision making, and solution implementation and verification. We briefly describe a problem solving model of depression that highlights the moderating nature of problem solving ability regarding the stress–depression relationship. Based on this model, we then delineate how PST can be specifically applied to Sylvia. This is followed by a brief overview of the research base supporting the efficacy of PST for depression.     

The Linguistic Therapy of Evaluation: A Treatment Plan for Silvia

This paper describes the treatment of a depressed woman, Silvia (I. Caro, 2001), treated with the linguistic therapy of evaluation. The linguistic therapy of evaluation is a type of cognitive psychotherapy developed from the theory of general semantics. The theory and the treatment are based on the use of language and the role this plays in the development of emotional problems such as anxiety and depression. We briefly describe the main conceptual and assessment issues of the therapy and the procedure followed in the case of Silvia. The aim of the therapy is to change patients' evaluations, that is, to help them to develop an extensional orientation instead of an intensional orientation, which is assumed to be at the core of emotional problems. The paper ends with a brief review of the process and outcome research that has demonstrated the efficacy and the clinical process of the linguistic therapy of evaluation.     

Continuity in childhood depression

It is only in recent years that childhood depression has received widespread attention from mental health specialists. Its status as a clinical syndrome of childhood remains unclear. Many controversies surround various facets of this condition, foremost among these are questions relating to the duration of depressive disorders, the likelihood of recurrence, and the long-term outcome of depressed children. In the course of addressing these issues, attention is devoted to the outcomes as well as the advantages and disadvantages of commonly used research designs (prospective, retrospective, and catch-up prospective), the level of diagnosis used (symptom, syndrome, disorder), the significance of the age of onset on severity, and specific areas in need of further research. Among the tentative conclusions, it is asserted that many depressive symptoms are transient, diminishing or disappearing with age and/or changing environmental circumstances, but that severe depressive disorders do persist, with periods of remission, at least into the early adult years.     

Early Adversity and the Prospective Prediction of Depressive and Anxiety Disorders in Adolescents

The current study was a prospective exploration of the specificity of early childhood adversities as predictors of anxiety and depressive disorders in adolescents. Participants were 816 adolescents (414~males, 402 females) with diagnostic information collected at age 15; information on early adversities had been collected from the mothers during pregnancy, at birth, age 6 months, and age 5~years for a related study. Adolescents with pure anxiety disorders were compared with adolescents with pure depressive disorders (major depressive disorder, dysthymia), and these groups were compared to never-ill controls. Analyses controlled for gender and maternal depression and anxiety disorders. Results indicated that adolescents with anxiety disorders were more likely than depressed youth to have been exposed to various early stressors, such as maternal prenatal stress, multiple maternal partner changes, and more total adversities, whereas few early childhood variables predicted depressive disorders. Even when current family stressors at age 15 were controlled, early adversity variables again significantly predicted anxiety disorders. Results suggest that anxiety disorders may be more strongly related to early stress exposure, while depressive disorders may be related to more proximal stressors or to early stressors not assessed in the current study.     

Depressive realism and the effect of intertrial interval on judgements of zero, positive, and negative contingencies

In three experiments we tested how the spacing of trials during acquisition of zero, positive, and negative response-outcome contingencies differentially affected depressed and nondepressed students' judgements. Experiment 1 found that nondepressed participants' judgements of zero contingencies increased with longer intertrial intervals (ITIs) but not simply longer procedure durations. Depressed groups' judgements were not sensitive to either manipulation, producing an effect known as depressive realism only with long ITIs. Experiments 2 and 3 tested predictions of Cheng's (1997) Power PC theory and the Rescorla-Wagner (1972) model, that the increase in context exposure experienced during the ITI might influence judgements most with negative contingencies and least with positive contingencies. Results suggested that depressed people were less sensitive to differences in contingency and contextual exposure. We propose that a context-processing difference between depressed and nondepressed people removes any objective notion of “realism” that was originally employed to explain the depressive realism effect (Alloy & Abramson, 1979).     

Youth Depression in the Family Context: Familial Risk Factors and Models of Treatment

Research on parent risk factors, family environment, and familial involvement in the treatment of depression in children and adolescents is integrated, providing an update to prior reviews on the topic. First, the psychosocial parent and family factors associated with youth depression are examined. The literature indicates that a broad array of parent and family factors is associated with youth risk for depression, ranging from parental pathology to parental cognitive style to family emotional climate. Next, treatment approaches for youth depression that have been empirically tested are described and then summarized in terms of their level of parent inclusion, including cognitive–behavioral therapy, interpersonal therapy, and family systems approaches. Families have mostly not been incorporated into clinical treatment research with depressed adolescents, with only 32% of treatments including parents in treatment in any capacity. Nonetheless, the overall effectiveness of treatments that involve children and adolescents exclusively is very similar to that of treatments that include parents as agents or facilitators of change. The article concludes with a discussion of the implications of these findings and directions for further research.     

Sudden gains in interpersonal psychotherapy for depression

Sudden, precipitous improvements in depressive symptom severity have been identified as occurring among unipolar depressed individuals. These "sudden gains" have been associated with superior acute treatment outcome in several treatment modalities, including cognitive therapy. A better understanding of sudden gains may provide insight into the mechanisms of action in these and other psychotherapies. One efficacious therapy that has been overlooked in sudden gains research is interpersonal psychotherapy (IPT; Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. New York: Basic Books). The present research examined the rates and concomitant features of sudden, precipitous improvements in depressive symptomotology among 185 women receiving IPT for recurrent depression. Sudden gains, defined using extant criteria for the Beck Depression Inventory, were assessed over 12 weeks of acute IPT treatment for depression and occurred for 33.5% of the sample. Sudden gains were not associated with diagnostic and demographic characteristics or with differential likelihood of achieving depression remission with IPT monotherapy during active treatment. Further, those with sudden gains were no more likely to maintain their recovery through maintenance treatment. The lack of impact of sudden gains on eventual outcome is discussed in terms of potentially disparate emphases and mechanisms of change between IPT and cognitive-behavioral therapy (CBT).     

Mechanisms of Change in Brief Couple Therapy for Depression

The goal of the present study was to investigate potential mechanisms of previously documented treatment effects for a brief, 5-session, problem-focused couple therapy for depression in a sample of 35 depressed women and their nondepressed husbands. The primary treatment effects were reducing women’s depressive symptoms and their husbands’ psychological distress and depression-specific burden. Secondarily, treatment resulted in increased relationship satisfaction for both partners. Given these significant treatment changes observed in 5 sessions, we sought to examine the mechanisms of change by testing the following three factors as potential mediators: (a) negative behaviors and attitudes toward depression, (b) support provision, and (c) empathic communication towards the depressed female partners. Women’s depression and husbands’ depression-specific burden were alleviated by positive changes in their illness-related attitudes and behaviors. Improvements in women’s marital satisfaction were also mediated by positive change in their illness-related attitudes and behaviors, along with perceptions of increased positivity and support from their husbands. Findings highlight the importance of targeting specific treatment agents in a brief couple therapy for depression such as psychoeducation about depression and support-building to increase partners’ understanding and acceptance of the illness, and teaching communication skills to reduce negative behaviors and criticism that are replaced by more empathic communication towards the depressed individual.     

Treatment Seeking for Anxiety and Depression Among Black Adults: A Multilevel and Empirically Informed Psycho-Sociocultural Model

Black adults with anxiety and/or depressive disorders underutilize outpatient psychotherapy and pharmacological treatment compared to White adults. Notably, anxiety and depressive disorders tend to be chronic and Black individuals with these disorders experience greater functional impairment than White individuals. Documented racial disparities in mental health treatment initiation indicate a need for research that addresses culture-specific barriers to treatment. This review paper critically evaluates existing theoretical models of treatment seeking among Black adults to inform a novel integrated, culturally contextualized model. This model extends previous ones by incorporating factors relevant to treatment seeking among Black adults (e.g., racial identity, perceived discrimination, medical mistrust) and critically examines how these factors intersect with key factors at three levels of influence of the treatment seeking process: the individual level, the community level, and the societal level. We posit interactions among factors at the three levels of influence and how these may impact treatment seeking decisions among Black adults. This model informs suggestions for enhancing interventions designed to support outpatient service use among Black adults.     

Depression und Paarbeziehung

The close relationship between depressive disorders and couple relationships has been well proved empirically.Conflicts and problems within the couples'relationship can be a significant trigger for depression. In additition, the quality of the relationship is often markedly impaired by depressive disorders, in many cases far beyond the depressive phase.The couples'relationship also influences significantly the course of depressions, especially when the disorders are not yet chronic.The link between depression and couples'relationship seems to be stronger and more evident for women than for men. Furthermore there seem to be patterns of interaction in couples with a depressed partner, which differ from those in healthy or other clinical comparison groups or distressed couples without depression.These patterns need further exploration with regard to different subgroups of depressed patients and phases of depression.Couples' therapy has been proved to be effective in the treatment of depression on the symptomatic and on the relationship level.Conjoint assessment and counselling sessions with depressed patients and their partners should be conducted regularly.For patients suffering from an ‘anaclitic’,‘sociotropc’form of depression couples' therapy in a more narrow sense is usually indicated. In the treatment of depressives of the ‘autonomous’ ‘introjective’ type partners should be included into treatment for the assessment and the working through of specific conflicts concerning the relationship.     

冠心病患者的抑郁和焦虑

许多临床研究表明,冠心病患者常发生抑郁及焦虑。而在严重精神症状（如抑郁或/和焦虑）者中有较高的冠心病发生率。抑郁增加冠心病患者的不良心血管事件发生率,影响预后。其机制有如下几个方面：对医疗措施及生活方式改变的依从性差、血小板功能异常、血管内皮功能紊乱以及心率变异性降低。选择性5-羟色胺再摄取抑制剂由于其较好的耐受性且无明显的心血管副作用而应用于冠心病合并抑郁及焦虑的药物治疗并改善患者的生活质量。但仍需要更大规模的临床研究以确定抑郁及焦虑对冠心病预后的影响。临床上应更加关注焦虑对冠心病的影响,进一步探讨焦虑能否作为冠心病的危险因素。