18 Anxiety Worksheets for Adults, Teens & More
And yet, it can also be energizing, focusing our attention and preparing us for action — an evolutionary response to the unexpected, difficult, or downright dangerous (Workman & Reader, 2015).
It is not so much what happens but how we respond that matters the most (Joseph, 2013).
Therapists, counselors, and coaches can help by working with clients to change how they react to anxiety-inducing situations.
In this article, we introduce a collection of free worksheets for use by mental health professionals with their clients or as self-help activities.
Before you continue, we thought you might like to download our three Stress & Burnout Prevention Exercises (PDF) for free . These science-based exercises will equip you and your clients with tools to better manage stress and find a healthier balance in your life.
This Article Contains
5 best anxiety worksheets, 4 anxiety worksheets for teens, 3 social anxiety worksheets, 3 anxiety activities for adults, cbt worksheets for anxiety, positivepsychology.com resources, a take-home message.
We can learn to break free from anxiety. With the right approaches, the same situations can have different outcomes (Forsyth & Eifert, 2016).
The following five worksheets encourage clients to recognize that they are not alone in their experiences and can, indeed, learn how to cope with anxiety.
The activities work on their own or can be combined. They support clients by helping them identify situations that cause anxiety, using mindfulness and meditation to restore a balanced perspective, and recognizing that someone should not be defined by the extreme emotions they are experiencing (Forsyth & Eifert, 2016; Southwick & Charney, 2018):
1. Anxiety Hierarchy
Intense fears, phobias, and stressful situations can be highly anxiety provoking. It is helpful to establish a list of challenging situations that result in extreme upset or negative emotions for clients (American Psychological Association, 2016).
Use the Anxiety Hierarchy exercise to list situations that lead to anxiety and rate them on a scale from 1 (mild discomfort) to 10 (extreme emotions such as panic).
Once these anxiety-inducing situations are listed and sorted in order, the practitioner can use graded exposure practices as part of systematic desensitization.
2. Breath Awareness While Waiting
Waiting for an event can leave us excited, concerned, nervous, or anxious. We may notice changes to our physiology (increased heart rate, sweating, and faster breathing), cognition (erratic thinking, poor decision-making, and a failing memory), and emotions (fear, upset, and panic ; Peterson, 2018).
Work with the client to identify times they are waiting during the week — for example, waiting for the bus, at the school gates, at an appointment — and how they expect to feel.
Then use this breath awareness practice for mindful breathing: slowly breathing in through the nose, holding, and slowly breathing out through the mouth. As unhelpful thoughts enter the mind, direct attention back to breathing.
3. Creating a Mindfulness Anxiety Plan
Our behavior often follows patterns, and so does our anxiety. It is possible to anticipate when anxiety might show up, especially when we become more in tune with our bodies and the events around us (Peterson, 2018).
By creating a mindfulness anxiety plan , we can be ready with a list of actions to perform when we begin to recognize our anxiety taking shape and in advance of situations that can be difficult. These actions should aim to improve our wellbeing and leave us less anxious throughout the day
For example, “If my anxiety is getting away from me, I will call my best friend.” Or “Every day, I will go outside for a walk at lunchtime and try to be more mindful.”
4. Who Am I Beyond My Anxiety?
We are not our emotions, but when fearful or anxious, we spend a great deal of time and energy focusing on what is wrong with us, forgetting our strengths (Forsyth & Eifert, 2016).
In this exercise , the client mindful reflects on the following prompts (among others):
I am someone who … I really like … My most important relationship is … I feel my best when …
Reading through the answers helps remind us that anxiety does not define who we are.
5. Funeral Meditation
Often, we stop ourselves from taking on or embracing a challenge for fear of failure or experiencing anxiety.
Despite its foreboding name, the Funeral Meditation is used within Acceptance and Commitment Therapy to help free ourselves from the grip of anxiety (Forsyth & Eifert, 2016).
This powerful meditation helps us reflect on what matters to us, recognizing that, at any time, we can start living in line with how we want to be remembered.
After several calming breaths, we imagine what our funeral would be like, including:
How do people look? Who would be there? What would they say? What would we like people to say about us?
Recognizing our values can help us eliminate anxiety and begin living the way we want.
The following worksheets can also be adapted for adult populations, and mental health practitioners will find them valuable when working with adolescents coping with anxiety.
1. Best and Worst
Children and teens can benefit from stepping back from anxiety-inducing situations to reflect upon how, despite being scary, they can also be exciting.
For example, joining a new class, school, or social group can bring with it feelings of anxiety. When also recognized as exciting, it can be energizing, leading to positive emotions such as hope, curiosity, and gratitude.
Work with your teen client to:
- Identify and capture a situation that makes them feel nervous or scared.
- Use the diagram to capture what is exciting in the left-hand circle and what is scary about the situation in the right-hand circle.
- Write down aspects of the situation that are both scary and exciting in the intersection between the two circles.
Identifying how something fills us with fear while providing energy can help us have a more balanced view regarding how to approach what is ahead.
2. FLARE for Anxiety and Fear
This helpful worksheet helps teach acceptance of difficult feelings (rather than hiding from or rejecting them) through self-acceptance and self-compassion (Khazan, 2019).
The FLARE acronym directs the client to:
- Feel each sensation. Become aware of their heart rate, breath, and body temperature.
- Label the sensations. Do they feel worried, fearful, or anxious?
- Allow the experience to remain as it is. They can say to themselves, “It is OK to feel this way.”
- Respond by refocusing on breathing, taking each breath slowly and making the out-breath longer than the in-breath.
- Expand awareness of their environment and reflect on what they are grateful for that day.
By focusing on positive emotions, the approach builds toward a spiral of positive feelings (Fredrickson, 2010).
3. Radio Doom and Gloom
Teenagers are vulnerable to focusing on the worst events, situations, and outcomes. As a result, it can almost seem like an endless radio program playing in the background, broadcasting negative stories and songs all day long.
While it’s not easy to turn down the volume on the radio (or turn it off completely), we can attend to it less. By learning to treat such negative thinking as background noise and focusing more on current activities, its impact and ability to heighten anxiety are reduced.
4. When I’m Scared
Children and adolescents (and even adults) feel scared sometimes. And that’s OK. It’s a perfectly normal fight-or-flight response to a perceived — or actual — uncomfortable or dangerous situation.
Talking to an adult can help.
When I’m Scared can be used with individual youths or in a group setting.
They are asked to write down what makes them frightened, how it affects their thinking, how it feels physically, and one thing might be that makes them feel better.
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Social anxiety leads to persistent fear and the avoidance of social situations because of concerns about being evaluated by others (Schneier & Goldmark, 2015).
Therapy and the use of interventions enable clients to increase their social engagement and form deep, meaningful relationships (Schneier & Goldmark, 2015).
The following worksheets are valuable for mental health professionals helping clients identify what triggers their anxious thinking and manage them through visualization and mindfulness.
1. A Mountain of Worries
Our worries can mount up. Stresses, concerns, upsets, and things going wrong may seem never-ending, with even the most minor problems blown out of proportion, leaving our anxiety out of control.
This exercise captures situations that bother us and is particularly helpful for social anxiety, where we can begin to identify and reflect on unhelpful thought patterns and learn to expect and plan for how to handle them.
2. Event visualization worksheet
Visualization can feel as real to the mind as experiencing a situation first-hand — especially a social one — and offers a safe and controlled environment to explore and experiment with existing and future challenges (Clough & Strycharczyk, 2015).
Visualizing an event, especially one we are worrying about, can be a powerful and helpful way of reducing concern and anxiety and gaining confidence without the risk of failure or being overwhelmed.
Use the worksheet to:
- Identify an event likely to cause anxiety.
- Visualize the event in as much detail as possible using all the senses.
- Imagine the people and the situation.
- Reflect on how being successful might feel.
Clients can repeat the visualization exercise several times until they feel comfortable and less anxious.
3. The Documentary of You
Anxiety can arise from any environment and is particularly common in social situations (Schneier & Goldmark, 2015).
Mindfulness can help us think about ourselves and our situations with more compassion and forgiveness and less judgment (Forsyth & Eifert, 2016).
In this exercise , the client imagines their life playing out as a movie on a screen. They capture on paper, nonjudgmentally, situations that leave them feeling anxious.
Following a series of grounding breaths, the client considers each one mindfully without becoming too involved.
Finally, they reflect on how reading the story now makes them feel. What is their degree of anxiety?
Changing your relationship with it can help us take charge of our lives (Forsyth & Eifert, 2016).
Try the following three activities to create coping strategies, identify what we can control while learning to accept everything else, and become more comfortable with discomfort.
1. Anxiety Strategy Cards
Preparation is a crucial part of managing anxiety. This sheet contains a list of cards to help clients develop strategies for events and situations where they feel out of control and stressed, with their anxiety building.
Each card offers a valuable reminder of a powerful technique that will help them restore their physical, cognitive, emotional, and behavioral balance.
When I feel anxious, I could try … controlled breathing. When I feel anxious, I could try … visualization. When I feel anxious, I could try … a grounding technique.
Use them with psychoeducation and technique training to build confidence in the client’s ability to handle and overcome tough times.
2. Control–Influence–Accept Model
We can’t control every situation, so it’s helpful to recognize those that can be influenced by our behavior and those that cannot.
The Control–Influence–Accept Model can stop individuals from feeling overwhelmed and experiencing feelings of hopelessness, frustration, and anxiety when they experience a loss of control or indecision (Thompson & Thompson, 2018).
The client is encouraged to perform each of the following:
- Identify a potentially tricky situation.
- Capture what can be controlled or influenced.
- What cannot be controlled or influenced must be accepted.
- List what needs to be accepted.
Having performed each step, the client reflects on how they now feel about the situation and whether they are left wishing to control or influence anything they have accepted.
3. Interoceptive Exposure
Anxiety has a strong physical element that we can use to increase awareness of panic-related physiological symptoms .
Interoceptive exposure is built on the premise that exposure to such sensations can increase our familiarity with them and our preparedness for future anxiety-inducing situations.
The worksheet uses activities that induce physical, cognitive, and emotional discomfort to replicate the sensations of panic and anxiety.
Note: These should only be used under the guidance of a physician or health professional in a suitably safe environment.
Cognitive-Behavioral Therapy (CBT) treats anxiety by restructuring the client’s thinking, with the therapist exploring maladaptive expectations and worries related to upcoming events (Dobson & Dozois, 2021).
1. Anxiety Record
Reflecting on and sharing what makes us anxious can leave us feeling vulnerable, but it is essential. Understanding what leaves us feeling this way allows us to prepare for situations and learn appropriate coping skills.
One of the most powerful techniques is recognizing and, if possible, replacing unhelpful thinking.
Use the simple form in the worksheet to capture the following:
What does the anxiety feel like? When does it happen? What thoughts do you experience? How realistic are these thoughts? What thoughts could you replace them with? Are they more realistic?
Capturing our anxieties is an essential part of reducing them and bringing them under control.
2. Dealing with anxiety: Reverse the Rabbit Hole
The two words “what if?” can be anxiety- inducing, sending our thoughts racing down a rabbit hole of all that could go wrong.
What if I forget the words when I’m on stage? What if my date doesn’t like me?
Reframing an experience helps us experience it differently. We can turn a negative into a positive — reverse the rabbit hole.
In this exercise , we write negative outcomes in the left-hand column and then a corresponding reversed, positive outcome on the right.
What if I nail the speech? What if my date goes really well?
3. Tackling Anxious Thoughts
Anxiety can bias our thinking by making us buy into the likelihood of something terrible happening. As a result, it can be helpful to consider the following three points:
What is the worst potential consequence of this scenario? What is the best possible consequence of this scenario? What do you feel is the most likely consequence of this scenario?
Following these questions, the client thinks about how it would feel in a year’s time if the worst actually happened.
After all, even if the worst outcome becomes a reality, it may be less catastrophic than we imagine.
We have many resources available for therapists to support clients experiencing anxiety.
More extensive versions of the following tools are available with a subscription to the Positive Psychology Toolkit© , but they are described briefly below:
- Replacing Unhelpful Thoughts with Helpful Alternatives CBT is based on the premise that emotions and behaviors result from a person’s interpretation of a situation.
This exercise invites clients to examine the “helpfulness” of a thought they are having about a current challenging situation before formulating a more helpful alternative thought:
- Step one – Describe a challenging situation.
- Step two – Identify the automatic unhelpful thought.
- Step three – Rate the helpfulness of this thought.
- Step four – Come up with a more helpful alternative thought.
- Step five – Rate the helpfulness of this alternative thought.
- Step one – Visualize yourself in a relaxing environment.
- Step two – Add detail to the visualization by exploring all your senses.
- Step three – Enjoy the scene you have created and allow yourself to spend some time taking it all in.
- Step four – Close your eyes and continue taking slow, deep breaths as you visualize the stress leaving your body in waves with each exhale.
This exercise is valuable for stress reduction by connecting the sensations of relaxation with peaceful visual imagery during times of stress.
If you’re looking for more science-based ways to help others manage stress without spending hours on research and session prep, check out this collection of 17 validated stress management tools for practitioners. Use them to help others identify signs of burnout and create more balance in their lives.
Anxiety is a normal reaction to life events and can be beneficial in many situations, alerting us to dangers and increasing our attention and readiness for action.
It is often less about our environment or the challenges we face, but how we interpret them.
As a result, anxiety can dramatically impair our ability to function and perform in education, work, and social environments (American Psychological Association, 2016).
Its effects are widespread, impacting 30% of adults at some point in their lives and preventing them from living normally (American Psychiatric Association, 2021). They can find themselves avoiding opportunities and shying away from challenges due to intrusive thoughts or concerns.
Anxiety disorders are treatable. Therapists and counselors can help clients manage anxiety-inducing situations by changing how they view them and learning to cope with stressful conditions.
The anxiety worksheets in this article can be used independently or together as interventions for better managing anxiety. When combined with ongoing therapeutic assessment, it is possible to see how clients bring their feelings under control and return to the lives they wish to lead.
We hope you enjoyed reading this article. Don’t forget to download our three Stress & Burnout Prevention Exercises (PDF) for free .
Ed: Updated March 2023
- American Psychiatric Association. (2021). What are anxiety disorders? Retrieved March 17, 2023, from https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders
- American Psychological Association. (2016). Beyond worry: How psychologists help with anxiety disorders . Retrieved March 13, 2023, from https://www.apa.org/topics/anxiety/disorders
- Clough, P., & Strycharczyk, D. (2015). Developing mental toughness: Coaching strategies to improve performance, resilience and wellbeing . Kogan Page.
- Dobson, K. S., & Dozois, D. J. (2021). Handbook of cognitive-behavioral therapies . Guilford Press.
- Forsyth, J. P., & Eifert, G. H. (2016). The mindfulness & acceptance workbook for anxiety: A guide to breaking free from anxiety, phobias & worry using acceptance & commitment therapy (2nd ed.). New Harbinger Publications.
- Fredrickson, B. (2010). Positivity: Groundbreaking research reveals how to release your inner optimist and thrive . Oneworld.
- Joseph, S. (2013). What doesn’t kill us: A guide to overcoming adversity and moving forward . Piatkus.
- Khazan, I. Z. (2019). Biofeedback and mindfulness in everyday life: Practical solutions for improving your health and performance . W.W. Norton & Company.
- Khesht-Masjedi, M. F., Shokrgozar, S., Abdollahi, E., Habibi, B., Asghari, T., Ofoghi, R. S., & Pazhooman, S. (2019). The relationship between gender, age, anxiety, depression, and academic achievement among teenagers. Journal of Family Medicine and Primary Care , 8 (3), 799–804.
- Peterson, T. J. (2018). The mindfulness workbook for anxiety: The 8-week solution to help you manage anxiety, worry & stress . Althea Press.
- Schneier, F., & Goldmark, J. (2015). Social anxiety disorder. In D. J. Stein & B. Vythilingum (Eds.), Anxiety disorders and gender (pp. 49–67). Springer.
- Southwick, S. M., & Charney, D. S. (2018). Resilience: The science of mastering life’s greatest challenges . Cambridge University Press.
- Thompson, S., & Thompson, N. (2018). The critically reflective practitioner . Macmillan International Higher Education.
- Workman, L., & Reader, W. (2015). Evolutionary psychology: An introduction . Cambridge University Press.
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- CBT for Teens: How Cognitive Behavioral Therapy Works
- Mental Health
Cognitive Behavioral Therapy (CBT) is an evidence-based form of talk therapy that can be a particularly effective treatment modality for adolescents. Therapists or psychologists use CBT for teens to help them become aware of irrational or negative thinking so they can see situations clearly, process them, and respond to them in healthy ways.
CBT intervention for kids can be a powerful part of an integrated treatment plan for adolescent mental health disorders. Teen CBT helps with substance abuse, eating disorders, PTSD, anxiety, and depression, including seasonal affective disorder . Furthermore, teens can benefit from CBT even when they are not suffering from a specific mental health challenge. CBT activities for teens can help them form healthy habits that will support them as they enter young adulthood.
How Does CBT for Teens Work?
One of the central beliefs in CBT is that thoughts affect emotions, and emotions affect behavior. Following this logic, allowing distorted and negative thoughts to grow leads to difficult emotions and, subsequently, destructive actions. On the other hand, positive thinking leads to positive emotions, and thus to positive behaviors. Hence, the goal of Cognitive Behavioral Therapy for children and teens is to help them shift thoughts, feelings, and behaviors.
Let’s look at an example: A teen texts a friend and they don’t reply right away. A teen’s immediate response is to assume the worst, think of all the ways they may have upset the other person, and begin to panic and catastrophize: “Everybody will hate me now!” CBT skills help teens learn how to slow down and think logically about the situation. Maybe their friend is simply away from their phone or busy with an activity. Even if there is a misunderstanding, it can be worked out. Over time, with CBT skills in their toolbox, teens learn not to assume the worst.
How Thoughts, Emotions, and Behaviors Are Linked
A situation triggers a thought: an interpretation of the situation. For example, not hearing back from a text can trigger a teen to think “My friend is mad at me.”
The thought then triggers an emotion. In the texting example, thinking that a friend is angry with them can lead a teen to feel sad, worried, lonely, or bad about themselves.
Emotions influence behavior. Distressing teen emotions can manifest as anger and aggression toward parents or using self-harm or substances to numb the feelings.
How Do I Know if My Thinking Is Distorted?
Since thoughts are the first trigger for emotions and behaviors, according to CBT, interventions focus on identifying and shifting distorted thinking. Cognitive distortions, also known as “thinking errors,” are ways of thinking that don’t match up to the reality of what’s happening. Here are some common examples of cognitive distortions:
- Black-and-White (All-or-Nothing) Thinking: This is a way of thinking that categorizes people or situations at one extreme or the other. For example, if a teen who is struggling with distorted thinking has a disagreement with a friend, they might see that person as “bad” and become upset when mutual friends don’t take their “good” side in the conflict.
- Fortune-Telling (Jumping to Conclusions): This distortion refers to making assumptions without thinking about the whole picture. Remember a time you thought someone was mad at you, but later found out they had a bad day at work or school and their mind was elsewhere? That’s an example of jumping to conclusions.
- Magnification (Making a Mountain out of a Molehill): Do friends and family tell you that you often blow things out of proportion, seem to overreact, or are a pessimist? People who magnify mistakes and ruminate on the bad things also tend to minimize their achievements and the positive things in their life.
Teen CBT aims to help adolescents shift these patterns of distorted thinking, so that the emotions and behaviors that follow the thought are positive rather than distressing.
A List of CBT Interventions
CBT interventions for teens include the following approaches:
Cognitive Reconstruction (Thought Reframing)
Cognitive reconstruction is an exercise in which the therapist supports the client to look for the negative thought patterns they tend to fall back on, such as overgeneralizing or always assuming the worst. Once the client identifies this trend in their thought process, the CBT therapist can then teach them how to reframe the thoughts more positively.
For example, “Everyone in my friend group is constantly judging me” can turn into “Not all of my friends understand why I do the things I do, but they don’t have to. I understand why I do the things I do, and that’s good enough.”
In guided discovery, the therapist gets to know the client’s point of view. They ask questions that make the client think about how and why they think the way they do, which in turn broadens the client’s viewpoint. When an individual make assumptions, the therapist will ask them to give evidence that both supports and does not support their claims. This process can help them learn to see things from other people’s points of view.
While free-form journaling is a great way to get out repetitive or intrusive thoughts, cognitive journaling is structured so that clients can set goals and record their progress. A therapist or counselor may suggest making columns in a journal for
- Situation/trigger (who, what, when, where)
- Emotion/mood (assessing the intensity of a feeling from zero to 100)
- Physical sensation (feelings in the body, like becoming hot or tense)
- Thoughts (how strongly do you believe them?)
- Behavior (how action could help or hurt).
Using this process in stressful moments and social situations allows individuals to slow down, check the facts, and rethink their perspective.
Tools for Tapping into the Mind-Body Connection
Sometimes stressful thoughts also ignite physical reactions, as the nervous system reacts to the upheaval in the mind. Hence, it’s useful to combine CBT skills to improve thought patterns with self-soothing exercises for the body. This combination can be grounding and calming for children and adolescents who are struggling.
- Paired Muscle Relaxation: Start by flexing and relaxing the fingers and toes. Slowly move up through the next muscle groups, working toward the center of your body.
- Relaxed Breathing: Taking slow, deep breaths can slow the heart rate during a panic reaction, and reduce the “fight, flight, or freeze” response. Try inhaling four counts through the nose, then exhaling four counts out the mouth. Repeat until the wave of anxiety peaks and recedes. Notice when it passes, and express gratitude for your resilience.
- Temperature Change : Taking a warm shower or wrapping up in a cozy blanket can boost circulation and soothe the nervous system. Teens who are experiencing high levels of stress can try sipping on ice water to shift the nervous system.
What Are the Benefits of Teen CBT in the Short Term?
- CBT is known to have quick results. Both therapists and psychologists use CBT to help with several mental health challenges . On average, about 15 sessions are needed to acquire proficiency in practicing CBT skills.
- CBT activities for teens are highly engaging and interactive. The process of learning CBT skills keeps clients involved and interested throughout their sessions.
- CBT for teens holds them accountable by empowering them to take ownership of their life. By doing “homework” outside sessions, clients constantly reinforce the new principles they are learning.
What Are the Long-Term Benefits of CBT for Teens?
CBT for teens works best when they actively apply the skills until they become a natural “default setting.” While results vary, CBT for children and teens is very effective in increasing emotional intelligence and self-awareness over the long term. Moreover, practical CBT interventions for kids can stay with them for the rest of their lives, so they can turn to these reframing tools whenever they need them.
Over time, CBT interventions for kids can help them to:
- Shift negative thought patterns toward positive thinking
- Respond to stress in healthier ways
- Manage social situations and interactions more skillfully
- Be more self-compassionate
- Reduce unhealthy behaviors
- Talk themselves down from irrational anxiety, fears, and phobias.
CBT for Teens at Newport Academy
Searching for “Cognitive Behavioral Therapy for a teenager near me”? Newport Academy utilizes CBT for teenage anxiety disorders and CBT for teen depression as part of our individualized treatment plans. By addressing the underlying causes of adolescent mental health disorders, we help teens and their families move from struggling to thriving.
To learn more about how we use CBT and other modalities, such as Dialectical Behavioral Therapy (DBT) and Attachment-Based Family Therapy, contact us today.
- CBT intervention for kids can be a powerful part of an evidence-based treatment plan for adolescent mental health disorders, including substance abuse, eating disorders, PTSD, anxiety, and depression.
- The foundation of CBT is that thoughts affect emotions, and emotions affect behavior. Hence, the goal of CBT for teens is to shift negative thought patterns to more positive thinking, leading to positive emotions, and thus to positive behaviors.
- Therapists use CBT tools such as cognitive reconstruction, cognitive journaling, and relaxation techniques as part of the process of helping teens recognize and transform distorted thinking patterns.
- Teen CBT has both short-term and long-term benefits. Over time, CBT skills can help teens better manage emotions and social situations, and reduce anxiety, phobias, and irrational fears.
- At Newport Academy, teen CBT is an essential part of our individualized treatment plans for adolescents, alongside a variety of other clinical and experiential modalities.
Frequently Asked Questions About CBT for Teens
Yes, research shows that CBT for teens is highly effective in treating mental health disorders such as anxiety, depression, PTSD, and behavioral issues.
Cognitive reframing, journaling, and guided discovery are all tools used by a CBT therapist to help teens recognize and shift the negative thought patterns that lead to distressing emotions and unhealthy behaviors.
CBT is one of the most effective therapeutic modalities for teens because it is simple to use and provides practical solutions. In general, teens respond best to therapy that provides usable skills and tools. In addition, experiential therapy like art therapy, music therapy, and Adventure Therapy are useful for adolescents because they involve active engagement as opposed to a verbal conversation.
Yes. Research shows that CBT helps reduce depressive symptoms in teens. A 2019 review study found that teen CBT interventions resulted in a 63 percent less risk of being depressed at follow-up.
European Psychiatry. 2019 Apr; 57: 33–45.
Learn how treatment reduced teen suicide by 75%. Get the study .
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Psychological Treatments for Depression in Adolescents: More Than Three Decades Later
1 Department of Personality, Assessment and Psychological Treatment, University of Murcia, 30100 Murcia, Spain
2 Department of Developmental and Educational Psychology, University of Murcia, 30100 Murcia, Spain; [email protected]
3 Department of Psychology and Human Development, Vanderbilt University, Nashville, TN 37302, USA; [email protected]
José P. Espada
4 Department of Health Psychology, Miguel Hernández University, 03202 Elche, Spain; [email protected] (J.P.E.); [email protected] (M.O.)
Data sharing is not applicable to this article.
Depression is a common and impairing disorder which is a serious public health problem. For some individuals, depression has a chronic course and is recurrent, particularly when its onset is during adolescence. The purpose of the current paper was to review the clinical trials conducted between 1980 and 2020 in adolescents with a primary diagnosis of a depressive disorder, excluding indicated prevention trials for depressive symptomatology. Cognitive behavioral therapy (CBT) is the pre-eminent treatment and is well established from an evidence-based treatment perspective. The body of research on the remaining treatments is smaller and the status of these treatments is varied: interpersonal therapy (IPT) is well established; family therapy (FT) is possibly effective; and short-term psychoanalytic therapy (PT) is experimental treatment. Implementation of the two treatments that work well—CBT and IPT—has more support when provided individually as compared to in groups. Research on depression treatments has been expanding through using transdiagnostic and modular protocols, implementation through information and communication technologies, and indicated prevention programs. Despite significant progress, however, questions remain regarding the rate of non-response to treatment, the fading of specific treatment effects over time, and the contribution of parental involvement in therapy.
1. Depression in Adolescence: A Public Health Problem
Depression is a major public health concern; it is the most disabling single disorder, contributing to 7.2% of the overall burden of disease in Europe [ 1 ]. Depression is common, recurrent, sometimes chronic, and often comorbid with anxiety and substance and alcohol use problems.
Epidemiological studies of the prevalence of depression in adolescents differ depending on the diagnostic criteria used (e.g., Diagnostic and Statistical Manual of Mental Disorders, DSM; International Statistical Classification of Diseases and Related Health Problems, ICD; Research Diagnostic Criteria, RDC), the period covered (e.g., last month, last year, lifetime), the nature of the sample (e.g., school, pediatric, clinical), the age range (e.g., early, middle, late adolescence), the method of assessment (e.g., interview, questionnaires, rating scales), the informant (e.g., adolescent, parent, clinician), and other aspects such as country or research design. In the United States, the National Comorbidity Survey-Adolescent Supplement (NCS-A) found a lifetime and annual prevalence of 11.0% and 7.5%, respectively, with a representative sample of 10,123 adolescents, aged 13 to 18 years old [ 2 ]. The Saving and Empowering Young Lives in Europe (SEYLE) study, conducted in ten European countries plus Israel, with a sample of 12,395 adolescents, mean age 14.81 years, found that prevalence ranged from 7.1% to 19.4%. The percentage per country in increasing order was Hungary 7.1%, Austria 7.6%, Romania 7.6%, Estonia 7.9%, Ireland 8.5%, Spain 8.6%, Italy 9.2%, Slovenia 11.4%, Germany 12.9%, France 15.4%, and Israel 19.4% [ 3 ]. The Young Minds Matter, the second Australian Child and Adolescent Survey of Mental Health and Wellbeing study, with 6310 children and adolescents, found a prevalence of depression during the previous twelve months in youths 12 to 17 years old, of 5.0%; 4.7% if the informant was the parent or caregiver and 7.7% if the adolescent (aged 11–17 years) was the informant [ 4 ].
Depression is one of the main risk factors for suicide in adolescence. Among adolescents aged 15–19 years old, suicide is the third leading cause of death; in 2016, an estimated 62,000 adolescents died from self-harm [ 5 ]. In 2018, suicide was one of the three leading causes of death in Spain in the 15 to 19 age group: 18.2% traffic accidents, 17.7% tumors, and 17.0% suicide [ 6 ].
Comorbidity is common in adolescents with depression. In 1990, Fleming and Offord concluded “that ‘pure’ depression in children and adolescents is a rare entity” [ 7 ], p. 575. Clinical and epidemiological studies show that 40–80% of children and adolescents with depression have at least one other disorder and 20–50% have two or more comorbid disorders. Adolescent depression is associated with impairment in academic performance and family and peer relationships, and with a wide range of other disorders and problems, including anxiety, alcohol and drug abuse, risky sexual behavior, hyperactivity, oppositional behavior, antisocial behavior, delinquency, eating disorders, and self-injury [ 8 ].
Relapse and recurrence are common in adolescent depression. The Treatment for Adolescents with Depression Study (TADS) Team found that 88 of 189 adolescents (46.6%), who had recovered from depression, had a recurrence within 63 months, once (39.2%), twice (6.3%) and even three (1.1%) times. The mean time from recovery to first recurrence was 22.3 months, range 2–55 months, with the following cumulative rates every six months: 12.5% at half a year, 26.1% at one year, 40.9% at one and a half years, 61.3% at two years, 77.3% at two and a half years, and 84.9% at three years [ 9 ]. The recurrence rate in adulthood of depression that first appeared during adolescence is estimated at 60–70% [ 10 ].
Research on the efficacy of psychological treatments gained momentum in 1980, when the American Psychiatric Association settled the controversy about the nature of childhood and adolescent depression by clarifying that “the essential features of a major depressive episode are similar in infants, children, adolescents and adults” [ 11 ], p. 211. That year, the first trial on the treatment of childhood depression was published [ 12 ], and six years later, the first study of the treatment of depression in adolescents was published, involving 30 school children, mean age 15.65 years [ 13 ]. The authors argued that if adolescent depression is similar to adult depression, then treatment applied to the adult population, adapted to the level of adolescent development, would be effective in overcoming depression in adolescents. They considered cognitive behavioral therapy (CBT) the treatment of choice, which they compared with progressive relaxation training, and a wait-list (WL) control. Although relaxation is not a specific therapy for depression, they justified its inclusion as an active treatment because of the link between stress and depression. Contrary to their hypothesis, they found no differences between CBT and relaxation, with 83% of the CBT group and 75% of the relaxation group free of depression at the end of treatment, whereas all adolescents in the WL group continued to meet the criteria for depression.
The first randomized controlled trial (RCT) in adolescents diagnosed with depression was conducted in 1990 [ 14 ]; since then, the number of clinical trials has multiplied, which has substantially improved our knowledge about the efficacy of psychological treatments of depression in adolescents. Nevertheless, although there are treatments of proven efficacy, “research-based treatments are rarely used in clinical practice” [ 15 ], p. 765, highlighting a gap between clinical science and clinical practice.
Depression is often underdiagnosed during adolescence. Moreover, although about 20% of adolescents experience an episode of major depression, only a few receive evidence-based treatments [ 16 ]. The objectives of the current review are, first, to analyze, from a historical perspective, the current state of psychological treatments for adolescent depression according to the criteria used to evaluate evidence-based psychological treatments for children and adolescents ( Table 1 ) [ 17 ]. The second aim is to provide health professionals with guidelines for choosing the most appropriate treatment based on the current evidence. Thus, this review addresses the question regarding the current evidence of the efficacy of various psychological treatments for depression in adolescents.
Review criteria used for evidence base updates in the Journal of Clinical Child and Adolescent Psychology.
2. Psychological Treatments for Depression in Adolescents
The criteria for including a trial in the present review were: (a) that the mean age of participants was between 12 and 18 years old; (b) a primary diagnosis of depression; (c) randomized controlled trial; (d) valid and reliable depression assessment measures; (e) comparison of at least one psychological treatment with another psychological, pharmacological, and/or placebo treatment, and/or waitlist (WL); and (f) publication in a peer-reviewed journal; (g) between 1980 and September 2020.
Exclusion criteria were: (a) mean age of participants was less than 12 or more than 18 years; (b) depressive symptomatology only, without a diagnosis of depression; (c) open trial or case study; (d) trials testing medication alone; (e) preventive interventions; and (f) publication in media other than peer-reviewed journals (handbooks, conference proceedings, etc.); (g) prior to 1980 or after September 2020.
We used several strategies to identify trials: (a) searches in the PsycINFO, PubMed, ERIC, Web of Science and CSIC-ISOC databases; (b) websites of institutions: Division 53. Society of Clinical Child and Adolescent Psychology, of the American Psychological Association (APA) (Retrieved 13 April 2021 from https://effectivechildtherapy.org/concerns-symptoms-disorders/ ); National Institute for Health and Care Excellence (NICE) (Retrieved 13 April 2021 from https://www.nice.org.uk/guidance/ng134 ); National Health System (Sistema Nacional de Salud, SNS) of Spain (Retrieved 13 April 2021 from https://portal.guiasalud.es/gpc/depresion-infancia/ ); and (c) the retrieval of primary studies from systematic reviews and meta-analyses.
We identified 123 potential trials, published between 1986 and 2020, of which 96 were excluded [ 13 , 16 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 ] (see Table 2 ). The main reason for exclusion was that they were prevention rather than treatment trials, mostly with indicated samples (adolescents with depressive symptoms, but without a diagnosis of depression). Other reasons for exclusion were the mean age of participants below 12 years (preadolescents) or above 18 years (youths), noncompliance with methodological standards (e.g., nonrandom assignment, open trial), and recruitment of heterogeneous samples with depression or other disorders. The 27 selected adolescent depression treatment trials [ 14 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 ] resulted in 46 studies in which a psychological treatment was compared with another psychological or pharmacological treatment, or with an active control or WL condition. CBT was the most investigated treatment with 22 trials (81%). Research on other treatments is rather scarce, with four trials of family therapy (FT), three of interpersonal therapy (IPT), and a single trial of psychoanalytic therapy (PT).
Trials excluded from the current review.
AADS = Asian Adolescent Depression Scale; AD = Anxiety Disorder; APAI = Acholi Psychosocial Assessment Instrument; ASQ = Ask Suicide Screening Questions; BDI = Beck Depression Inventory; BID = Bellevue Index of Depression; CBI = Computer-delivered Brief Intervention; CBT = Cognitive Behavioral Therapy; CDI = Children’s Depression Inventory; CDRS-R = Children’s Depression Rating Scale-Revised; CES-D(C) = Center for Epidemiological Studies-Depression Scale (for Children); CSR = Clinical Severity Rating; CWD-A = Coping with Depression Course for Adolescents; DD = Depressive Disorder; Dd = Dysthymic Disorder; EBP-D = Evidence-Based Practice for Depression; ED = Externalizing Disorder; FT = Family Therapy; GAD(-7) = Generalized Anxiety Disorder (Screener-7); HRSD = Hamilton Rating Scale for Depression; IPT = Interpersonal Therapy; KADS-11 = Kutcher Adolescent Depression Scale; KPDS = Kessler Psychological Distress Scale; MDD = Major Depression Disorder; MDE = Major Depression Episode; NOS = Not Otherwise Specified; PASCET = Primary and Secondary Control Enhancement Training; PEPT = Psychoeducational Psychotherapy; PHQ-8 = Patient Health Questionnaire-8-item version; PT = Psychodynamic Therapy; PRP = Penn Resiliency Program; RADS = Reynolds Adolescent Depression Scale; RCADS-P = Revised Child Anxiety and Depression Scale-Parent Form; SI = Shamiri Intervention; (S)MFQ = (Short) Mood and Feelings Questionnaire; SPARX = Smart, Positive, Active, Realistic, X-factor thoughts; ST = Supportive Therapy; STAT-ED = Suicidal Teens Accessing Treatment After an Emergency Department Visit; TAU = Treatment As Usual; TBI = Therapist-delivered Brief Intervention; UP-A = Unified Protocol for the Treatment of Emotional Disorders in Adolescents; WL = Wait-list Condition; YOQ = Youth Outcomes Questionnaire.
The 27 RCTs reviewed involved 3501 adolescents, mean age 15 years, 66.6% girls, from families with varied socioeconomic status and structure, and of diverse ethnicity (see Table 3 ). The adolescents had major depressive disorder (87.4%) and/or persistent depressive/dysthymic disorder (10%), unspecified depressive disorder (0.9%), or another depressive disorder (5%). In ten trials, with 1391 participants, suicidality was reported: 36.8% of adolescents had current suicidal ideation and/or 35% had a history of suicide attempts. In sixteen trials with 2483 adolescents, a wide range of comorbid disorders were reported: 43.1% anxiety disorders, 28.3% disruptive and conduct disorders, 17% attention deficit hyperactivity disorder, and 26.6% had other disorders. The trial by Szigethy and colleagues [ 130 ] departs from the above, because the comorbidity of the participating children and adolescents was inflammatory bowel disease, Crohn’s disease (75%) or ulcerative colitis (25%).
Sociodemographic and clinical characteristics of the participants in trials included in the current review.
a,b Data from a completers or from b intent-to-treat. AD = Anxiety Disorder; ADDM = Adjustment Disorder with Depressed Mood; ADHD = Attention Deficit Hyperactivity Disorder; AP = Agoraphobia; Ap = Attention Problems; BD = Bipolar Disorder; BN = Bulimia Nervosa; CD = Conduct Disorder; Cd = Crohn’s Disease; CSI = Current Suicidal Ideation; DB(D) = Disruptive Behavior (Disorder); DD = Depressive Disorder; Dd = Dysthymic Disorder; dD = Double Depression; DS = Depressive Symptomatology; ED = Externalizing Disorder; Ed = Eating Disorder; EDD = Endogenous Depression Disorder (RCD); GAD = Generalized Anxiety Disorder; HAS = History of Suicide Attempt; ID = Internalizing Disorder; IDD = Intermittent Depressive Disorder (RDC); MDD = Major Depression Disorder (DSM); mDD = Minor Depression Disorder (RDC); MDE = Major Depression Episode; NOS = Not Otherwise Specified; OAD = Overanxious Disorder; OCD = Obsessive Compulsive Disorder; ODD = Oppositional Defiant Disorder; PCRP = Parent–Child Relational Problem; PDD = Persistent Depressive Disorder; PTSD = Posttraumatic Stress Disorder; SA(D) = Substance Abuse (Disorder); SAD = Separation Anxiety Disorder; SP = Social Phobia; sP = Specific Phobia; SU(D) = Substance Use (Disorder); UC = Ulcerative Colitis.
2.1. Cognitive–Behavioral Therapy
Considering the large number of studies of CBT and the fact that definitions of evidence-based treatment emphasize the accumulation of positive findings, we focused on the analysis of trials with positive effects. Table 4 presents the RCTs that evaluated treatments for depression in adolescents included in the current review.
Adolescent depression treatment outcome of trials included in the current review.
A = Adolescent; ABM = Attention Bias Modification; BA = Behavioral Activation; BDI = Beck Depression Inventory; BPI = Brief Psychosocial Intervention; C = Clinician; CBCL-D: Child Behavior Checklist-Depression; CBT = Cognitive Behavioral Therapy; CDI = Children’s Depression Inventory; CDRS-R = Children’s Depression Rating Scale-Revised; CES-D = Center for Epidemiological Studies-Depression Scale; CGI = Clinical Global Impressions; CM = Clinical Monitoring; CMDE = Current Major Depressive Episode; EBP-D = Evidence-Based Practice for Depression; FL = Fluoxetine; FT = Family Therapy; HRSD = Hamilton Rating Scale for Depression; IPT = Interpersonal Therapy; K-SADS = Kiddie School Age Schedule for Affective Disorders and Schizophrenia; LST = Life Skills Tutoring; MDD = Major Depression Disorder; NDST = Non-Directive Supportive Therapy; P = Parents; PASCET = Primary and Secondary Control Enhancement Training; PAST = Parenting Adolescents Support Training; PL = Placebo; PT = Psychoanalytic Therapy; QIDS = Quick Inventory of Depressive Symptomatology; RADS = Reynolds Adolescent Depression Scale; RT = Relaxation Training; SER = Sertraline; (S)MFQ(-C) = (Short) Mood and Feelings Questionnaire (-Child); SSRI = Selective Serotonin Reuptake Inhibitor; TAU = Treatment As Usual; WL = Wait-list Condition.
The first trials compared CBT with another psychological treatment, with active controls, or WL. Approximately fifteen years ago, research began to investigate the effectiveness of CBT combined with antidepressants; additionally, WL was used less and was replaced by treatment as usual (TAU).
2.1.1. Cognitive–Behavioral Therapy Alone
Lewinsohn and colleagues [ 14 ] conducted a pioneering trial with two objectives: (1) to test the efficacy of the Coping With Depression Course for Adolescents (CWD-A) [ 138 ], the main components of which were social skills, pleasant activities, relaxation training, cognitive restructuring, conflict resolution, and relapse prevention; and (2) to test whether parental involvement enhanced treatment efficacy. Adolescents in CWD-A recovered significantly from depressive episodes and reduced their depressive symptoms, depressive cognitions, and anxiety significantly more than those in WL; improvement was maintained at a two-year follow-up. There was a trend in favor of the parent-involved group over the adolescent-only group; a significant difference between the two treatment groups was obtained on the depression, internalizing problems, and externalizing problems subscales of the Child Behavior Checklist [ 139 ] completed by the parents.
In a replication of the pioneering trial by Lewinsohn et al. [ 14 ], Clarke and colleagues [ 115 ] found that the recovery rate of treated adolescents was significantly higher than WL (66.7% versus 48.1%), an improvement confirmed by self-report of depression and clinician-rated global functioning. There were no differences, however, between the parent-and-adolescent group and adolescent alone group. Immediately after the post-treatment assessment, they introduced the novelty of randomly reassigning treated adolescents to three new conditions during the 24-month follow-up: (1) assessments every 4 months with booster sessions; (2) only assessments every 4 months; and (3) only assessments every 12 months. The booster sessions did not reduce the recurrence rate at follow-up, but they did appear to accelerate the recovery of adolescents who remained depressed at the end of the acute phase. A significant difference was also found for externalizing behaviors between adolescents who had received booster sessions and those who had only been assessed; participants who were evaluated quarterly outperformed those assessed annually on parental reports of depression and internalizing behaviors.
Rohde and colleagues [ 121 ] evaluated the effectiveness of the CWD-A course in depressed adolescents with comorbid conduct disorder, recruited from a juvenile justice department, compared with life skills tutoring (LST) that included current events review, life skills training (e.g., filling out a job application or renting an apartment), and academic tutoring. At the end of treatment, the rate of recovery from depression was significantly higher in CWD-A (39%) than in LST (19%), and depressive symptoms reduced more, according to adolescent self-report and clinician assessment. There also was an improvement in social functioning; the between-group difference in conduct disorder was not significant, however. The rate of recovery from depression was the same in both groups one year later (63%).
Clarke and colleagues [ 133 ] examined the feasibility of a brief CBT intervention in primary care with adolescents who had declined or discontinued treatment with antidepressants. In the first session of the acute phase, the adolescent and therapist together chose one of two program modules: cognitive restructuring or behavioral activation, which was implemented over four sessions. If, at the end of the first module, the adolescent was almost or completely recovered, they could end the intervention; if not, they were encouraged to continue with the other module. During the continuation phase, the adolescent had up to six optional treatment contacts. Recovery rates from depression in the follow-up period were significantly higher for CBT plus TAU than for TAU alone: 69.7% versus 43.4% (week 26), 79.8% versus 68.7% (week 52), 86.9% versus 75.8% (week 78), and 88.9% versus 78.8% (week 104). Median recovery time was 22.6 weeks for CBT plus TAU and 30 weeks for TAU alone. Compared with TAU alone, the reduction in clinician-rated and adolescent-reported depressive symptoms, reduction in dysfunctional thoughts and complaints, and improvements in global functioning and quality of life were superior for CBT plus TAU in the first year of follow-up, although not in the second year. The rate of psychiatric hospitalizations was also significantly lower for CBT plus TAU during the first year of follow-up.
In a replication of the initial trial of Reynolds and Coats [ 13 ] with depressed adolescents, Wood and colleagues [ 113 ] compared a program composed of Beck’s cognitive therapy [ 140 ], interpersonal problem solving, sleep hygiene, and pleasant activities, with another active treatment for depression and comorbid symptoms. Adolescents in the multicomponent program improved significantly more in depression and self-esteem and were more satisfied with the treatment than those who received only progressive relaxation training [ 141 ]. Both groups improved in anxiety, but not in antisocial behavior. At follow-up, the between-group difference narrowed, partly because of the high relapse rate in the CBT group and partly because the adolescents in the relaxation group continued to recover.
Brent and colleagues [ 114 ] tested the efficacy of a protocol that included Beck’s cognitive therapy [ 142 ], problem solving, emotion regulation, and social skills, with a mixed-modality of family therapy (FT) based on behavioral and systemic approaches, and with non-directive supportive therapy (NDST). Only 17.1% of the adolescents in the CBT group were still depressed at the end of treatment, whereas 32.3% and 42.4% of the FT and NDST groups, respectively, still had major depressive disorder (MDD); the difference was significant only with NDST. CBT showed significantly higher remission rates, defined as the absence of depression and a score < 9 on the Beck Depression Inventory [ 143 ] for at least three consecutive sessions, than the other treatments: 64.7% (CBT) versus 37.9% (FT) and 39.4% (NDST). CBT also outperformed the other treatments in the reduction in clinician-rated depressive symptomatology and in the credibility of the therapy. Finally, CBT was better than FT in adolescent-reported depressive symptoms.
Alavi and colleagues [ 127 ] evaluated the effectiveness of a CBT protocol for Suicide Prevention, developed by Stanley and colleagues [ 144 ], with the aim of decreasing suicidal ideation and hopelessness in depressed adolescents, who had had at least one suicide attempt in the previous quarter. In the initial phase of the treatment, which was conducted over three sessions, vulnerability factors and triggering events of suicidal crises were analyzed (i.e., chain analysis), coping strategies, and sources of support were provided (i.e., safety planning), the nature of suicide was explained together with the need to monitor potential lethal means (i.e., psychoeducation), the adolescent’s personal reasons for living were discussed (i.e., building hope), and a functional analysis of the problem was conducted (i.e., case conceptualization). The middle phase, sessions 4–9, included individual and family modules on behavioral activation, emotion regulation, cognitive restructuring, problem solving, and assertiveness. The three sessions of the final phase were devoted to relapse prevention. At the end of treatment, there were significant differences between youths in CBT versus those in the control condition on measures of depression, suicidal ideation, and hopelessness. Scores on these variables decreased between 54% and 77% in CBT, whereas they did not change in the condition that received only routine psychiatric intervention, including medication.
Charkhandeh and colleagues [ 132 ] compared CBT with the Reiki method of alternative medicine and WL. The goals of CBT were to modify distorted perceptions, learn problem-solving, acquire coping skills, and motivate behavior through enjoyable activities. At the conclusion of treatment, CBT had reduced depressive symptoms significantly more than either the Reiki method or WL.
Finally, we reviewed an RCT by Yang and colleagues [ 134 ] that compared active training in attentional bias modification (ABM) with placebo training. Although the treatment was very different from usual CBT, we included the trial because ABM is a specific target of cognitive therapy [ 142 ]. In the active condition, adolescents completed the neutral phase of ABM in eight sessions (320 trials per session), over two weeks, to shift their attention from sad words to neutral words. Nine weeks later, the positive phase of ABM took place in four sessions (480 trials per session), over two weeks, to redirect the attention from neutral words to positive words. The placebo condition used identical tasks but gave equal attention to sad and neutral words. After the neutral phase, a significantly higher proportion of adolescents in active ABM did not meet diagnostic criteria for MDD compared to placebo ABM (87% and 59%, respectively). The between-group difference was not maintained at the 7- or 11-week follow-ups, however. Active ABM also reduced clinician-rated depressive symptoms and attentional bias more than placebo ABM. At the 12-month follow-up, adolescents reported significantly fewer depressive and anxiety symptoms with active ABM as compared to placebo ABM.
2.1.2. Cognitive–Behavioral Therapy Plus Medication
The Treatment for Adolescents with Depression Study (TADS) Team [ 122 ] conducted one of the largest adolescent depression RCTs to assess the effectiveness of CBT and/or fluoxetine versus pharmacological placebo. The starting dose of fluoxetine and placebo was 10 mg/day, which was increased to 20 mg/day at week 1 and, if necessary, up to 40 mg/day at week 8. The initial phase of CBT (sessions 1–6) included psychoeducation, mood monitoring, pleasant activities, social problem-solving, and cognitive restructuring. The middle phase (sessions 7–12) addressed adolescents’ social skill deficits, including problems with social engagements, communication, negotiation, compromise, and assertion. In the final phase (sessions 13–15), two sessions were held with the parents alone to provide psychoeducation, and one to three sessions were held with the parents and the adolescent, focused on the concerns of both parties. The combined treatment of CBT plus fluoxetine significantly reduced depressive symptoms as assessed by the clinician more than separate psychological and pharmacological treatments and/or the placebo. Treatment response at week 12, defined as being much or very much improved, was more positive in the combined treatment (71%) and fluoxetine alone (60.6%) than in CBT alone (43.2%) or the placebo (34.8%). Suicidal ideation decreased in all four groups, although the reduction was greater in the combined treatment. The authors concluded that the combination of CBT with fluoxetine offered the best balance between benefit and risk and adding CBT to medication enhanced safety.
In another combined treatment trial, Clarke and colleagues [ 123 ] asked whether the adjunct of a brief CBT intervention based on cognitive restructuring and/or behavioral activation would increase the effectiveness of selective serotonin reuptake inhibitor (SSRI) administered as TAU in a health maintenance organization. The acute phase CBT program was the same as previously described [ 133 ] and its duration varied depending on the adolescent’s degree of recovery. During the continuation phase of CBT, the therapist made six brief check-in telephone calls to the adolescent at one, two, three, five, seven and nine months after completing treatment. Adolescents in the SSRI condition could receive any other treatment from the health maintenance organization and/or other outside services. Over one year, Clarke et al. conducted four follow-up assessments, at weeks 6, 12, 26, and 52, and found that CBT had significant benefits for mental health status. There was a reduction in outpatient visits and in the number of days on all types of medication and a marginally significant difference in depressive symptoms and externalizing problems as reported by adolescents.
Melvin and colleagues [ 124 ] compared the combination of CBT and sertraline with CBT alone and sertraline alone. CBT consisted of the CWD-A adapted for individual use in therapy. The initial dose of sertraline was 25 mg/day. After the first week, the dose was adjusted depending on clinical response. If adverse effects occurred, the medication was halved during several days for one week, after which time it was increased again to 25 mg/day. Conversely, if no adverse effects were observed during the first week, the dose was doubled (i.e., 50 mg/day). Subsequently, the dose was increased by 25 mg to a maximum of 100 mg/day, depending on clinical response and tolerance. The most frequent adverse effects of sertraline were fatigue (31.1%), difficulty concentrating (24.4%), and insomnia (22.2%). The highest response to treatment was obtained in the CBT alone group (86%), and the lowest in the sertraline alone group (46%). The probability of occurrence of depression at post-treatment was significantly lower in the CBT alone group than in the sertraline alone group, whereas the combined treatment did not differ from either treatment alone. At the six-month follow-up, there were no differences between the groups. Thus, in contrast to the short-term findings of the TADS Team [ 122 ], the advantage of the combined treatment in this study was less evident.
In the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) trial, Brent and colleagues [ 126 ] compared the combination of CBT and an SSRI or venlafaxine with these drugs given separately to adolescents who had previously failed to respond to SSRI treatment. All participants’ parents, regardless of treatment group, received family psychoeducation about depression. The CBT included cognitive restructuring, behavioral activation, emotion regulation, social skills, and problem solving. The alternative SSRIs were paroxetine, citalopram, or fluoxetine, with a daily dose of 10 mg per day the first week, 20 mg per day in weeks 2–6, with an option to increase to 40 mg per day if there was no improvement. The starting dose of venlafaxine was 37.5 mg, which was increased by that same amount over the next three weeks (i.e., 75, 112.5, and 150 mg), with the possibility of reaching a maximum dose of 225 mg daily in the sixth week. CBT plus any antidepressant showed a significantly higher response rate than any medications alone; the effects of the various medications did not differ from each other. There were no differences between treatments on clinician-rated or adolescent-reported depressive symptoms, suicidal ideation, rate of related harm, or any other negative events. Adverse effects of medication, such as increased diastolic blood pressure and pulse or skin problems, were more frequent with venlafaxine.
2.2. Interpersonal Therapy
In the late 1990s, Mufson and colleagues [ 116 ] adapted the therapy developed by Klerman and colleagues [ 145 ], used to treat depression in adults, for the treatment of adolescents. The modification addressed common developmental issues in adolescence such as separation from parents, conflict with parental authority, exploration of dyadic interpersonal relationships, experience of the death of a family member or friend, and peer pressure. A specific area was added for single-parent families. The control condition was clinical monitoring, in which the therapist was limited to checking depressive symptoms and school attendance, assessing suicide risk, and practicing active listening, refraining from counseling, or providing skills training. Adolescents in both groups could contact the therapist if they felt worse (“call-me-if-you-need-me”). At the end of treatment in the intention-to-treat sample, 75% of the IPT adolescents had recovered from depression, scoring 6 or less on the Hamilton Rating Scale for Depression [ 146 ], whereas only 46% improved in the control condition. In addition, for youth in the IPT, there was a significantly greater reduction in depressive symptoms based on the clinician ratings and adolescent’s self-report, better overall social functioning with friends and with their partner, and greater interpersonal problem-solving skills, compared to youth in the control condition.
Rosselló and Bernal [ 117 ] evaluated the effectiveness of IPT and CBT compared with WL. The IPT used in this study was also an adaptation of the original model of Klerman and colleagues [ 145 ]. IPT was carried out in three blocks of four sessions each. The goals of sessions 1–4 were to elicit information about the adolescent’s depression, present the therapy, assess interpersonal relationships, identify core issues such as grief, interpersonal disputes, role transitions, and interpersonal deficits, establish a treatment plan, and explain what was expected of the adolescent in therapy. In sessions 5–8, they worked on selected interpersonal issues, monitoring depressive feelings, facilitating a positive therapeutic relationship, and preventing parental interference in the treatment. Sessions 9–12 discussed feelings related to separation, the treatment was reviewed, and the adolescents’ interpersonal competence was acknowledged. The CBT was based on Lewinsohn’s behavioral therapy [ 147 , 148 ], and Beck’s [ 142 ] and Ellis’ [ 149 , 150 ] cognitive therapy, the main components being cognitive restructuring, pleasant activities, and social skills. At both post-treatment and the three-month follow-up, adolescents that received treatment showed significantly fewer depressive symptoms than those who did not; there was no difference between IPT and CBT; and self-esteem and social adjustment improved with IPT compared with WL. No differences in these variables were found between IPT and CBT, nor between CBT and WL.
In 2004, the Mufson team [ 120 ] evaluated the effectiveness of IPT compared with TAU, from school-based health clinic clinicians. IPT was implemented as described in the manual by Weissman and colleagues [ 151 ], similar to those in the earlier trial by the Mufson team [ 116 ]. Most of the adolescents in the TAU group received individual psychotherapy–supportive counseling. At the conclusion of treatment, youth in the IPT showed significantly fewer clinician-rated depressive symptoms, better global and social functioning, greater clinical improvement, and a greater decrease in severity than TAU.
2.3. Family Therapy
The trial by Brent and colleagues [ 114 ], described earlier, included an FT condition. In the first phase of treatment, based on Alexander and Parsons’ [ 152 ] functional FT, the therapist addressed the concerns raised by the family and reframed issues to optimize treatment engagement and identify dysfunctional behavior patterns. During the second phase, adapted from Robin and Foster’s [ 153 ] problem-solving model, family members focused on communication, negotiation, and conflict resolution skills, as well as on the modification of inappropriate family relationship patterns. The protocol included psychoeducation on depression and the developmental and educational aspects of depression, and emphasized skills building and positive practice in sessions and at home. FT was significantly inferior to CBT and did not differ from NDST in the remission rate of depression. There also was a smaller reduction in depressive symptoms, as assessed by clinician ratings and adolescent report, for those in FT compared to CBT; the latter treatment seemed more credible to parents.
Diamond and colleagues [ 119 ] contrasted attachment-based FT with a minimal contact WL control. The therapy consisted of five tasks aimed at repairing attachment and promoting autonomy. The Relational Reframing Task replaced a focus on “fixing” the adolescent with one of improving family relationships and addressing parental criticism and hostility with the aim of reducing blame and increasing mutual respect. The Adolescent Alliance-Building Task sought to create a bond to increase motivation and treatment engagement, explore family conflicts that damage trust, and prepare to discuss these issues with parents. The Parent Alliance-Building Task explored the parent’s current stressors and history of attachment failures, as well as promoted an authoritative educational style. The Attachment Task was initiated when the adolescent expressed anger about core conflicts, usually related to betrayal, abandonment, or abuse, such that parental remorse promoted adolescent forgiveness. The Competence-Promoting Task fostered the adolescents’ relationships and success outside the home (e.g., school, peers, work); with attachment recovered, the family became the secure base from which the adolescents could explore their emerging autonomy. At post-treatment, 81% of the adolescents who had received FT did not meet criteria for MDD, in contrast to 47% on the WL. FT also achieved a significantly greater reduction in depressive and anxiety symptoms and family conflict. Of the 15 cases evaluated at six-months follow-up, 13 adolescents (87%) were free of depression.
In a Norwegian pilot study with a small sample, Israel and Diamond [ 128 ] implemented the protocol of the previous trial [ 119 ]. The control condition was individually dispensed treatment in outpatient clinics. FT reduced depressive symptoms significantly more than TAU when assessed by the clinician, but not by adolescent self-report.
Pool and colleagues [ 136 ] compared the BEST MOOD program [ 154 ], which incorporates elements of attachment theory, such as parental sensitivity, grief responses, and understanding of frightening or stressful family environments, with the Parenting Adolescents Support Training (PAST) program [ 155 ], a control condition similar to TAU. The first four BEST MOOD sessions were held with parents only and included strategies for engaging the child in the program, stress reduction techniques, psychoeducation on family and adolescent development, family unity, parent–child communication, and parental self-care. The adolescent and siblings joined the therapy in the final four sessions devoted to clarifying the family roles, addressing loss and trauma, improving communication patterns, implementing behavioral activation techniques with the adolescent, and promoting positive family rituals. Improvement in depressive symptoms was similar in the two groups at post-treatment, d = 0.83 and d = 0.80, BEST MOOD and PAST, respectively, and at three-months follow-up, d = 0.46 and d = 0.51, BEST MOOD and PAST, respectively. There was no difference between the programs in the other variables including emotional symptoms, alcohol consumption, efficacy, dependence, and self-criticism. The only positive effect of BEST MOOD was the greater reduction in symptoms of depression and stress in the parents at the three-month follow-up.
2.4. Psychoanalytic Therapy
The IMPACT trial [ 135 ] is the only one psychoanalytic therapy (PT) compared to CBT and a brief psychosocial intervention control condition. The short-term PT was based on close observation of the relationship which the adolescent established with the therapist. The therapist approached therapy as the task of understanding the adolescent’s feelings and life difficulties. The therapist was nonjudgmental and non-inquisitive and conveyed the value of self-understanding. The CBT focused on modifying behaviors and information processing biases through collaborative empiricism between the therapist and the adolescent. The brief psychosocial intervention control condition emphasized the importance of psychoeducation about depression, in addition to goal-focused and action-oriented interpersonal activities but did not include either self-understanding or cognitive change. There was no significant difference in adolescent-reported depressive symptoms between short-term PT and CBT, or between short-term PT and CBT versus the control condition, at either the conclusion of treatment (week 36) or at follow-up (week 86).
3. Status of Psychological Treatments for Depression in Adolescents
The first review that applied the Criteria for Empirically Supported Treatments [ 156 ] to evaluate the efficacy of psychological treatments [ 157 ] identified seven trials on adolescent depression, and considered CWD-A to be the only treatment that had achieved probable efficacious status, based on the two trials by the research team of Lewinsohn [ 14 , 25 ], which demonstrated the superiority of CBT over WL. This paucity of results is understandable, considering that when the review was published in 1998, barely three years had elapsed since the development of the classification criteria for evidence-based therapy.
A subsequent review published in 2008 [ 158 ] revealed the growing number of adolescent depression trials produced in one decade. They examined 18 new trials plus two published in 1996 [ 112 , 113 ], which had not been included in the earlier review, and concluded that CBT and IPT were well-established treatments, because there were at least two RCTs showing that they were superior to another treatment or to an active control condition.
A third 2016 review [ 159 ], collected on the website of the Society of Clinical Child and Adolescent Psychology, Division 53 of the American Psychological Association, on evidence-based mental health treatment for depression (Retrieved 13 April 2021 from https://effectivechildtherapy.org/concerns-symptoms-disorders/disorders/sadness-hopelessness-and-depression/ ), re-evaluated the 27 trials from the previous reviews—of which it eliminated six trials mainly for methodological reasons—additionally, it identified 14 new trials, confirming the well-established treatment status of CBT and IPT. The novelty was the addition of FT as a possibly efficacious treatment, because in the two trials by the research team of Diamond, FT was superior to an active control [ 128 ] and WL [ 119 ].
These reviews included treatment trials with clinical samples and prevention trials with subclinical samples. In the current review, we focused only on trials involving adolescents with a diagnosis of depression; that is, 18 of the previous trials, to which we added 9 more that were new or were not included [ 127 , 128 , 131 , 132 , 133 , 134 , 135 , 136 , 137 ] in the aforementioned reviews.
3.1. Cognitive–Behavioral Therapy
The body of research generated by CBT is far superior to that of other therapies. Six trials [ 13 , 14 , 19 , 23 , 25 , 114 ] in the 1998 review [ 157 ] included at least one CBT group, which was the only probably efficacious treatment. However, CBT is the first psychological treatment that, as early as the 1990s, achieved the status of a well-established treatment, because two trials conducted by independent research teams revealed that CBT was more effective than progressive relaxation training [ 113 ], FT, and NDST [ 114 ]. The discrepancy in evaluation is explained by the fact that the 1998 review did not include the study by Wood and colleagues [ 113 ]. The 2008 review [ 158 ] added fifteen trials, ten treatment [ 112 , 113 , 115 , 117 , 118 , 121 , 122 , 123 , 124 , 125 ] and five prevention [ 27 , 28 , 34 , 36 , 38 ], corroborating the well-established treatment status achieved by CBT in 1997. The 2016 review [ 159 ] updated the review of evidence-based treatments, removing five of the twenty-one previous trials and adding ten trials published between 2008 and 2014. They assigned well-established treatment status to individual CBT and to group CBT, possibly efficacious status to CBT using bibliotherapy, and experimental status to technology-assisted CBT.
We identified 96 CBT trials, of which we included 22 ( Table 4 ) and excluded 74 ( Table 2 ). Independent research teams have shown that CBT, applied individually, is superior to FT and NDST [ 114 ], relaxation training [ 113 ], the Reiki method [ 132 ], TAU [ 127 , 133 ], psychological placebo [ 134 ], and WL [ 117 , 132 ]. With respect to medication, CBT is more effective than sertraline [ 124 ]; when combined with fluoxetine, it is more effective than fluoxetine or a pharmacological placebo [ 122 ]; when combined with SSRI, CBT is more effective than an SSRI or venlafaxine (an SNRI) [ 123 , 126 ]; and when combined with venlafaxine, CBT is more effective than an SSRI or venlafaxine [ 126 ], making CBT a well-established treatment. Three trials by the same research team of Clarke, Rohde, Lewinsohn, and colleagues have shown that CBT, applied in a group setting, is superior to life skills tutoring [ 121 ] and WL [ 14 , 115 ], making it a probably efficacious treatment.
In recent years, there has been an increase in CBT programs via the internet (iCBT), computer (cCBT), or other devices such as cell phones [ 49 , 55 , 56 , 58 , 59 , 70 , 75 , 82 , 95 , 101 ], although these have been prevention trials with universal or indicated samples. One study [ 134 ] used a computer to present the stimulus words of an attention redirection task, although such attentional bias modification training is not really comparable to the usual technology-assisted CBT, of which we found only one trial with depressed adolescents [ 131 ]. Although this online intervention achieved greater improvement on all measures, including depressive symptoms, the difference with TAU was not significant. Similarly, CBT trials using bibliotherapy [ 27 , 47 , 83 ] were with indicated samples for prevention; thus, these modalities remain in the experimental phase.
3.2. Interpersonal Therapy
The only study included in the 1998 review [ 157 ] was the open trial by Mufson and colleagues [ 21 ] which involved 14 adolescents with depression, making IPT an experimental treatment up to that date. The 2008 review [ 158 ] identified three RCTs of IPT applied individually and one applied in a group setting. In the trial by Rosselló and Bernal [ 117 ], IPT was equivalent to CBT; CBT had previously achieved well-established status and was superior to WL.
In the trials by Mufson’s team, IPT was superior to clinical monitoring [ 116 ] and TAU [ 120 ]. In another trial by Mufson’s team, group IPT was more effective than school counseling [ 39 ]. Thus, individual IPT was considered to be a well-established treatment, because in at least two trials, conducted by different research teams, it proved to be as effective as a well-established treatment and superior to other treatments, whereas group IPT remains an experimental treatment.
The 2016 review [ 159 ] added two new trials conducted by the same two research teams. In the second trial by Rosselló’s team [ 46 ], IPT was shown to be a robust treatment, both individually and in groups, although the reduction in depressive symptoms and internalizing and externalizing behaviors, as well as the improvement in self-concept, were significantly lower than with CBT. In a new trial by Mufson’s team [ 53 ], IPT was superior to school counseling in reducing depressive symptoms and improving global functioning. Thus, individual IPT was judged to be a well-established treatment and group IPT was a probably efficacious treatment.
We identified ten IPT trials, of which seven were excluded because they were indicated to be prevention [ 39 , 40 , 53 ] or open-label trials [ 21 , 29 ], or involved preadolescents [ 73 ]. The exclusion of the most recent trial by Rosselló’s team [ 46 ] could be debatable; one out of three adolescents was selected by the clinical interviewer’s judgment based on the degree of impairment and two out of three met the criteria for MDD; this exclusion, however, does not affect the evaluation of IPT because it was significantly inferior to CBT. Of the remaining three trials, the first RCT by Mufson’s team [ 116 ] compared IPT with clinical monitoring, an “ethical WL condition” (p. 574), which consisted of three monthly 30 min sessions, with an option for a second session within the month. In contrast, IPT included 12 weekly 45 min sessions, i.e., psychological attention time was up to six times longer in the active treatment than in the control condition.
Despite these concerns, individual IPT maintains the status of a well-established treatment for adolescent depression because there are at least two RCTs, conducted by independent research teams, in which it was as effective as CBT [ 117 ], a treatment of proven efficacy, and superior to TAU [ 120 ]. In contrast, group IPT would be in the experimental phase because the trials of Mufson’s team [ 39 , 53 ] were indicated prevention, as was that of Bolton [ 40 ], who selected adolescent survivors of war and displaced persons in northern Uganda.
3.3. Family Therapy
In the 1998 review [ 157 ], only the trial by Brent and colleagues [ 114 ] applied an FT protocol, which was inferior to CBT and did not differ from NDST; therefore, it was an experimental treatment. The 2008 review [ 158 ] included two new trials. In the first trial, attachment-based FT [ 119 ] was shown to be superior to WL, but in the second trial, psychoeducation-based FT [ 37 ] did not differ significantly from TAU; thus, FT was rated to be an experimental treatment. The 2016 review [ 159 ] incorporated two new trials [ 51 , 69 ], plus a third one [ 43 ] in which they analyzed childhood depression. The two adolescent trials, one by Diamond and colleagues [ 51 ] and one by Rohde and colleagues [ 69 ], failed to find a significant reduction in depressive symptoms between FT and control conditions; thus, it did not change the possibly efficacious status.
In the current review, we excluded seven of the ten FT trials identified because the samples did not meet our inclusion criteria. In the trial by Sanford and colleagues [ 37 ], not all adolescents met criteria for MDD; the trial by Trowell and colleagues [ 43 ] involved children and adolescents with a mean age of less than 12 years; the trial by Connell and Dishion [ 45 ] included high-risk adolescents based on parent and teacher reports of emotional or behavioral problems. Participants in the trial by Diamond and colleagues [ 51 ] had suicidal ideation and a major depressive episode, anxiety, attention deficit hyperactivity disorder, oppositional defiant or conduct disorders. Horigian and colleagues [ 62 ] included participants who were in substance use treatment and had symptoms of depression and anxiety. Rohde and colleagues [ 69 ] studied adolescents with comorbid substance abuse and depressive disorders. In the sample of Diamond and colleagues [ 104 ], participants were adolescents with suicidal ideation and depressive or anxiety disorders. Although in the trials by Sanford and colleagues [ 37 ] and Rohde and colleagues [ 69 ], a significant percentage of the adolescents had a depressive disorder 71% and 72%, respectively, there was no significant difference in depression measures between FT and the groups with which they were compared. Disparate results were obtained in the four trials included in the current review. In the two trials of Diamond’s team, FT was superior to TAU [ 128 ] and WL [ 119 ], although in the other trials no difference was found with TAU [ 136 ] or supportive therapy, and FT was inferior to CBT [ 114 ]; thus, the status of FT as possibly efficacious did not change.
3.4. Psychoanalytic Therapy
Of the three reviews prior to ours, only the most recent one, in 2016 [ 159 ], included a trial of PT [ 43 ], that focused on individual psychodynamic psychotherapy. PT did not differ from system integrative FT. Therefore, PT was judged to be an experimental treatment for child and adolescent depression. We excluded the study by Trowell and colleagues [ 43 ] from the present review because it included children and adolescents aged 9 to 15 years old, and therefore aligned better with other trials of treating depression in children. We did identify one new RCT [ 135 ], in which short-term PT was no more effective than either CBT, or a brief psychosocial intervention. The absence of significant differences in outcome suggests that short-term PT is only experimental treatment at this time.
4. Looking to the Future with Hope
In the more than thirty years since the 1986 Reynolds and Coats trial [ 13 ], a wealth of data has been accumulated on the treatment of depression in adolescents, which justifies moderate optimism about the future. In this review, we used the conservative criteria for selecting trials that involved adolescents diagnosed with depression and focused primarily on improvements in depression. Table 5 presents the categorization of each treatment for depression in adolescents based on these criteria. Thus, our results differed somewhat from previous reviews [ 157 , 158 , 159 ]. We confirmed that individual CBT and individual IPT are well-established psychological treatments for depression in adolescents; CBT reached level 1 in 1997 [ 113 , 114 ] and IPT did so years later in 2004 [ 117 , 120 ]. In contrast, group CBT, and especially group IPT, were repositioned at lower levels in our review because group application was more frequent in preventive trials. Rosselló and colleagues [ 46 ] analyzed the efficacy of individual and group formats of both therapies in a sample of 112 Puerto Rican adolescents with depressive symptoms. Both formats reduced depressive symptoms from pre- to post-treatment, 9.98 units on the Children’s Depression Inventory (CDI) [ 160 ] with the individual format ( d = 1.30) and 7.33 units ( d = 1.22) with the group format. Similarly, in CBT, the reduction in depressive symptoms on the CDI was 10.58 units ( d = 1.50), and for IPT it was 6.9 units ( d = 1.33). CBT showed significantly greater improvement than IPT in depressive symptoms, self-concept, and internalizing and externalizing problems. In contrast, there was no statistical difference between the individual and group formats in any of the outcomes assessed. Clinical improvement, defined as a cut-off score of 12 on the CDI, was similar for both therapies: 62% in CBT and 57% in IPT.
Evidence base for adolescent depression treatment.
CBT = Cognitive Behavioral Therapy; FT = Family Therapy; IPT = Interpersonal Therapy; PT = Psychoanalytic Therapy.
O’Shea and colleagues [ 161 ] conducted an IPT-only trial with a sample of 39 adolescents, aged 13 to 19 years old, from the metropolitan area of Brisbane, Australia. Intention-to-treat analyses indicated a significant improvement in depression with both individual and group modalities, which was maintained at 12-months follow-up, although there was no significant difference between individual and group administration. These data suggest that group CBT and group IPT may work well, but the paucity of trials with clinical samples prevents according them superior status.
FT was upgraded from an experimental treatment to probably efficacious in 2013 [ 119 , 128 ], although this qualification should be scrutinized further in the future, because the only two trials of FT with a positive effect on adolescent depression were conducted with small samples by the same research team.
The present review is an important update due to the addition of the 2017 trial of short-term PT as an evidence-based therapy. In the IMPACT trial [ 135 ], conducted with the largest sample to date, at 36 weeks from baseline, short-term PT achieved an improvement of large magnitude ( d = 1.40), which was maintained at 86 weeks follow-up ( d = 1.77). Moreover, PT was not inferior to the improvement obtained with CBT at 36 weeks ( d = 1.70) or at 86 weeks ( d = 1.80). It will be important to replicate these findings in future randomized controlled trials, and demonstrate that the CBT and short-term PT, as conducted in this setting, are superior to an active control condition.
Thus, having treatments with demonstrated efficacy that work well for treating depression in adolescents, such as CBT and IPT, or that may be promising such as FT or short-term PT, is cause for cautious optimism. Several issues, however, limit total enthusiasm, but provide directions for continued progress in future research.
Firstly, in several trials, the improvement achieved with psychological treatments did not differ from that obtained with the control condition. An explanation for the absence of statistically significant differences could be, together with the high rate of response to placebo and spontaneous recovery from depression in adolescents, the nature of the control conditions used. For ethical reasons, WL is used less and less and, faced with the difficulty of finding a psychological placebo, TAU often is the control condition of choice. Over time, the quality of routine care provided in mental health clinics has improved considerably. Therefore, TAU should be considered more of an active treatment than a “no” or limited treatment control condition in RCTs on evidence-based therapy [ 162 ].
Secondly, a significant percentage of adolescents do not respond to treatment. Except for the trial by Esposito-Smythers and colleagues [ 137 ] with depressed adolescents with suicidal crises and concurrent risk factors, where flexible treatment was offered over one year, in the remaining 26 RCTs reviewed here, the response rate at post-treatment ranged from 27% to 29% in FT [ 128 , 136 ], to 86% to 89% in CBT and IPT [ 112 , 117 , 124 , 134 ], with an average of 60.9% across all studies. Why was a higher overall success rate not obtained? One salient predictor of poor response to treatment is comorbid anxiety disorders [ 163 , 164 , 165 ]. As such, transdiagnostic interventions are a possibly useful alternative. Ehrenreich-May and colleagues [ 91 ] implemented the Unified Protocol for the Treatment of Emotional Disorders in Adolescents (UP-A) with 51 adolescents with at least one primary diagnosis of generalized anxiety disorder (41.2%), social phobia (31.4%), major depression (21.6%) or other disorders (35.2%) and comorbid diagnoses. The core modules were: (a) knowledge of behaviors and emotions; (b) emotional awareness; (c) flexibility of thinking; (d) emotional exposure; and (e) maintenance of improvement. Additional modules included: (a) strengthening motivation; (b) coping with difficulties; and (c) parental education about the emotional adolescent. Transdiagnostic treatment significantly outperformed WL on all outcome measures at post-treatment. Sandín and colleagues [ 166 ] adapted the protocol for internet-based application (iUP-A), facilitating its implementation. Using the transdiagnostic protocol, Group Behavioral Activation Therapy (GBAT), based on live anti-avoidance exposure, Chu and colleagues [ 77 ] achieved a marginally significant reduction in the remission rate of the main diagnosis: 57.1% GBAT versus 28.6% WL.
Thirdly, specific treatment effects tend to fade over time [ 167 ]. Due to spontaneous recovery, most depressive episodes remit in 7–9 months in clinical samples [ 168 ], rather than worsening in treated adolescents. The course of depression is often chronic, with periods of remission; however, depression in adolescents is also recurrent between 46% and 63% [ 169 ]. Therefore, a relapse prevention component in the acute phase of treatment and booster sessions during the maintenance phase should be encouraged.
A fourth important question is to what degree should parents be involved in the treatment of depression in adolescents. Studies by Lewinsohn’s team [ 14 , 115 ] have not reliably shown the superiority of including parents. Spirito and colleagues [ 170 ] used a CBT protocol similar to that used in the TORDIA trial [ 126 ], with 24 dyads of adolescents with a suicidal history and a current major depressive episode and parents with a current or past major depressive episode. They hypothesized that treatment would be more effective if delivered jointly to the adolescent and parents than to the adolescent alone. The parent–adolescent group was significantly superior in reducing the depressive symptoms in both members of the dyad, especially the parents, at the end of the maintenance phase (24 weeks). There were no differences between groups at follow-up (48 weeks). Suicidal ideation was equally reduced in both groups during the acute and maintenance phases of treatment, and this improvement continued at follow-up. Interestingly, however, satisfaction with treatment was lower in the conjoint group; two adolescents were described by their therapist as oppositional and sessions with the family were needed to address parent–child conflict. Another adolescent reported abuse in the family and had to be hospitalized mid-treatment. In the absence of conclusive data and the higher cost of the involving parents in therapy, including parents in treatment of depression in adolescents needs further study and should be viewed with caution.
Additionally, the pharmacological treatment of adolescent depression is not without controversy. In 2006, Hammad and colleagues [ 171 ] conducted a meta-analysis with data from 4582 pediatric patients, who had participated in 24 trials—of which 16 dealt with MDD, including the multicenter TADS study—and reported that suicidality increased in pediatric patients treated with antidepressants by 1–3%. Consequently, the Food and Drug Administration (FDA) issued a “black box” warning about prescribing such medication to persons under 24 years of age [ 87 ]. Considering the concern raised and the response rate to antidepressants of approximately 60% [ 172 ], the first option for treating depression in adolescents will likely be psychological [ 173 ]. If the circumstances make combined treatment advisable, then the indicated drug is fluoxetine, in accordance with the indications of the U.S. FDA, the European Medicines Agency, and the Spanish Agency of Medicines and Health Products.
There is still a long way to go, but more than three decades of research have left us with two well-established and well-functioning psychological treatments for depression in adolescents: CBT and IPT. Other treatments, FT and short-term PT, require further RCTs to replicate the positive preliminary findings. Transdiagnostic protocols, delivery of therapy through information and communication technologies, and indicated prevention programs are currently expanding lines of research.
In conclusion, the first-line psychological treatments for depression in adolescents are individual CBT and individual IPT. The present review has been limited to adolescents with depressive disorders, excluding those with depressive symptoms; thus, it would be interesting to review the indicated prevention trials, especially considering that many of the excluded trials ( Table 2 ) obtained positive results.
Conceptualization, J.M., Ó.S.-H., J.G., J.P.E., and M.O.; methodology, J.M., Ó.S.-H., J.G., J.P.E., and M.O.; validation, J.M., Ó.S.-H., J.G., J.P.E., and M.O.; formal analysis, J.M., Ó.S.-H., J.G., J.P.E., and M.O.; investigation, J.M., Ó.S.-H., J.G., J.P.E., and M.O.; data curation, J.M., Ó.S.-H., J.G., J.P.E., and M.O.; writing—original draft preparation, J.M., Ó.S.-H., J.G., J.P.E., and M.O.; writing—review and editing, J.M., Ó.S.-H., J.G., J.P.E., and M.O.; visualization, J.M., Ó.S.-H., J.G., J.P.E., and M.O.; supervision, J.M., Ó.S.-H., J.G., J.P.E., and M.O.; project administration, J.M., Ó.S.-H., J.G., J.P.E., and M.O. All authors have read and agreed to the published version of the manuscript.
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Depression Reduction Workbook Student Workbook Counseling and Psychological Services University of Arkansas (479) 575-5276 health.uark.edu. Page 2 CAPS ... WORKSHEETS Page 7 CAPS Getting Unstuck Workbook (479) 575-5276 (24/7) Health.uark.edu SESSION 1: Understanding Anxiety/Depression Page 8 CAPS
CBT for depression includes techniques based on a variety of different theoretical models of depression. It incorporates behavioural theories of depression with the cognitive model of . DRAFT Feb 2010 Version 1 6 depression, as developed by Aaron Beck (Beck, 1967, 1978). From this initial focus on the
Behavioral Activation (BA) is a specific CBT skill. It can be a treatment all by itself, or can be used alongside other CBT skills such as cognitive restructuring. Behavioral activation helps us understand how behaviors influence emotions, just like cognitive work helps us understand the connection between thoughts and emotions.
get upset with you at first until depression is identified as the cause. This is called a Major Depression. Sometimes a person can be depressed for a long time and not realize it. This kind of depression is not as drastic and may have fewer symptoms than a Major Depression but it can cause you a lot of problems anyway because it lasts so long.
Anxiety and Depression Association of America, ADAA
Beck Depression Inventory (BDI) The Beck Depression Inventory (BDI) is widely used to screen for depression and to measure behavioral manifestations and severity of depression. The BDI can be used for ages 13 to 80. The inventory contains 21 self-report items which individuals complete using multiple choice response formats.
Client Resources. The following are resources for therapists to use with people during therapy sessions or to use as homework. This section includes readings, worksheets, forms and recommended reading. Activity Schedule (PDF in English) Activity Schedule (PDF in Spanish) Anger Cues and Control (PDF in English) Anger Cues and Control (PDF in ...
depression symptoms, the F.E.A.R. model (Kendall et al., 2002) was selected as an organizational framework for presenting the protocol outlined in this manual. Despite the fact that the F.E.A.R. model was originally presented as a means for treating anxiety in adolescents,
CBT for depression and anxiety. There are also formal adaptations of CBT to treat particular mental health problems, such as phobias, eating disorders, PTSD and OCD. ... diagrams or worksheets. With CBT you are often given work to do in your own time, so the end of each
CBT Worksheets for Anxiety. Cognitive-Behavioral Therapy (CBT) treats anxiety by restructuring the client's thinking, with the therapist exploring maladaptive expectations and worries related to upcoming events (Dobson & Dozois, 2021).. 1. Anxiety Record. Reflecting on and sharing what makes us anxious can leave us feeling vulnerable, but it is essential.
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Cognitive Behavioral Therapy (CBT) is an evidence-based form of talk therapy that can be a particularly effective treatment modality for adolescents. Therapists or psychologists use CBT for teens to help them become aware of irrational or negative thinking so they can see situations clearly, process them, and respond to them in healthy ways.
Treatment response at week 12, defined as being much or very much improved, was more positive in the combined treatment (71%) and fluoxetine alone (60.6%) than in CBT alone (43.2%) or the placebo (34.8%). Suicidal ideation decreased in all four groups, although the reduction was greater in the combined treatment.