Psychotherapy and (or) Medications for Depression in Youth?
An Evidence-Based Review with Recommendations for Treatment
This article reviews existing research pertaining to antidepressant medications, psychotherapy, and their combined efficacy in the treatment of clinical depression in youth. Based on this review, we recommend that youth depression and its treatment can be readily understood from a social-psycho-bio model. We maintain that this model presents an alternative conceptualization to the dominant biopsychosocial model, which implies the primacy of biological contributors. Further, our review indicates that psychotherapy should be the front-line treatment for youth with depression and that little scientiﬁc evidence suggests that combined psychotherapy and medication treatment is more effective than psychotherapy alone. Due primarily to safety issues, selective serotonin reuptake inhibitors should be initiated only in conjunction with psychotherapy and/or supportive monitoring.
Within the United States, psychiatric researchers and
practitioners currently formulate youth depression as a
medical illness (Vitiello 2008). This biomedical perspec-
tive extends adult neurochemical explanations for
depression to youth and emphasizes the safety and efﬁcacy
of antidepressant medications as a primary treatment
modality (Hughes et al. 2007). Indeed, the American
Academy of Child and Adolescent Psychiatry’s (AACAP)
latest youth depression practice parameter asserts that,
‘‘Depressive disorders are often familial recurrent ill-
nesses’’ (Birmaher et al. 2007, p. 1503).
Many psychologists and other mental health profes-
sionals also embrace the biomedical model, using it as a
guide for accurate diagnosis and treatment (Wyatt and
Livson 1994). Further, the view that depression is a chronic
medical disease—similar to diabetes or hypertension—is
provided in educational materials directed toward parents
(e.g., Evans and Andrews 2005). Depression is described as
a brain-based disease instead of a condition resulting from
psychological or social factors.
Despite its widespread acceptance, evidence supporting
an exclusively biomedical model of youth depression is
Speciﬁcally, there are no consistent biological
or genetic markers for clinical depression (Henn 2008).
Additionally, if depression results from known biomedical
mechanisms, then it should remit with targeted medical
treatment. However, even the most rigorous youth
depression treatment study to date observed remission
among only 37% of participants receiving somatic treat-
ment under optimal conditions (Brent 2006).
As discussed later, ﬁndings like these imply that biomedical models incompletely conceptualize youth depression and that alternative models might evidence equal or superior treatment utility.
In this article, we address the following questions: (a)
What is the safety and efﬁcacy of antidepressant medica-
tions used alone or in combination with psychotherapy? (b)
How does psychotherapy compare with antidepressant
medication treatment? (c) If the dominant model of youth
depression—which asserts biomedical primacy—is insuf-
ﬁcient, what alternative model might generate more
effective treatments and outcomes? (d) What treatment
guidelines for depression in youth should practitioners
A Brief History of Antidepressant Medication Treatment Research
Three relatively distinct periods characterize youth anti-
Pre-1987 Tricyclic Antidepressant (TCA) Efﬁcacy
Early conclusions about TCA safety and efﬁcacy were
generously optimistic. Kashani et al. (1984), for example,
claimed possible efﬁcacy for amitriptyline on the basis
minimal existing evidence and their own double-blind
study with nine prepubertal children, despite the fact that
their study lacked statistical signiﬁcance and 11% of the
treated sample developed hypomanic symptoms. This
tendency to inﬂate clinical signiﬁcance and minimize
safety issues is a common theme with regard to historical
and contemporary antidepressant treatments for adults and
youth (Turner et al. 2008).
1987–1994: Randomized Controlled Trials (RCTs)
with TCAs The years 1965–1994 witnessed publication of 13 TCA
RCTs (double-blind, placebo controlled trials), with most
studies appearing after 1987 (Sommers-Flanagan and
Sommers-Flanagan 1996). These studies conﬁrmed the
prematurity of Kashani and colleagues’ early hopeful
claims and raised concern about youth TCA treatment
safety. Indeed, no published study ever observed a
demonstrable advantage for TCAs over placebo and con-
sequently, subsequent research efforts began examining
1997-Present: RCTs with Selective Serotonin Reuptake
Inhibitors (SSRIs) Our PsychInfo and PubMed database searches and crossreferencing strategies identiﬁed 10 published RCTs of
SSRI efﬁcacy. In total, these studies compared 1,223 SSRI
treated patients to a similar number of placebo controls.
Using the researchers’ own efﬁcacy criteria, six studies
returned signiﬁcant results favoring SSRIs over placebo.
These included 3 of 4 ﬂuoxetine studies (Emslie et al.
1997,2002; Simeon et al. 1990; The TADS Team 2004), 1
of 3 paroxetine studies (Berard et al. 2006; Emslie et al.
2006; Keller 2001), 1 of 1 sertraline study (Wagner et al.
2003), and 1 of 1 citalopram study (Wagner et al. 2004).
Negative results were observed in the only escitalopram
study (Wagner et al. 2006).
Recently, Turner et al. (2008) critically analyzed the adult
antidepressant efﬁcacy literature by comparing published
results to published and unpublished results reported to the
US Food and Drug Administration (FDA). The authors
found that study publication was linked to outcome.
Whereas positive outcomes were nearly always published,
publication was exceptionally unlikely for studies with
equivocal or non-supportive results. Additionally, Turner
et al. also reported a discrepancy between published ﬁndings and ﬁndings reported to the FDA. For example, in
nearly 15% of reviewed studies, Turner et al. noted that
results were published in a way suggesting antidepressant
efﬁcacy even when ﬁndings reported to the FDA had been
questionable or negative. At a minimum, Turner et al.
(2008) suggest that selective publication practices breed
overestimation of SSRI efﬁcacy and underestimation of
adverse effects. Our brief review suggests a similar trend
with regard to SSRI efﬁcacy and adverse events among
children and adolescents diagnosed with clinical depression.
For example, despite the modestly positive results in 6
of 10 SSRI RCTs summarized previously, several meth-
odological problems favoring SSRIs should temper
optimistic conclusions. Speciﬁcally, (a) two positive ﬂu-
oxetine studies were characterized by unusually and
disproportionately high discontinuation rates within pla-
cebo conditions, which, when using intent-to-treat criteria,
advantage the medication condition; (b) all but one positive
study based conclusions exclusively on clinician rating
scales which have been shown as likely to be biased
(Greenberg and Fisher 1997); (c) despite multiple outcome
measures, no study made statistical adjustments for Type I
error; (d) the use of placebo washouts advantaged medi-
cations; (e) no procedures evaluated double-blind integrity
(Greenberg and Fisher 1997); and (f) despite inter-racial
differences in medication metabolism and responsiveness
(Lin et al. 1993), generalized conclusions failed to address
Side Effects and Adverse Events
SSRI-related medication safety issues for young patients,
in particular, deserve special scrutiny and articulation. For
example, Emslie et al. (1997) published the ﬁrst RCT to
claim that ﬂuoxetine is safe and efﬁcacious for treating
youth depression. Further inspection, however, uncovers
not only methodological problems (such as the fact that
psychiatrist ratings provided the sole outcome variable and
112 J Contemp Psychother (2009) 39:111–120:123
the possibility that intent-to-treat analyses conferred an
advantage for ﬂuoxetine due to a 46% discontinuation rate
in the placebo condition), but also, three (6.25%) ﬂuoxetine
patients developed manic symptoms, a ﬁnding that, when
extrapolated, suggests the possibility of 6,250 mania con-
versions for every 100,000 treated youth.
Similarly, in the much-heralded Treatment of Adoles-
cents with Depression Study (TADS), self-harming and
suicidal adverse events occurred among 12% of ﬂuoxetine
treated youth and only 5% of Cognitive Behavioral Therapy
(CBT) patients. Additionally, psychiatric adverse events
were reported for 21% of ﬂuoxetine patients and 1% of CBT
patients (March et al. 2006; The TADS Team 2004,2007).
Keller et al. (2001), authors of the only positive par-
oxetine study, reported similar data regarding SSRI safety.
In Keller et al.’s sample, 12% of paroxetine-treated ado-
lescents experienced at least one adverse event, and 6%
manifested increased suicidal ideation or behavior.
Interestingly, in the TCA and placebo comparison groups, no
participants evinced increased suicidality. Nonetheless,
Keller et al. claimed paroxetine was safe and effective.
Shortly after Keller et al. (2001) publication, regulatory
agencies in France, Canada, and Great Britain restricted
SSRI use among youth. In September of 2004, an expert
panel of the US Food and Drug Administration (FDA)
followed suit, voting 25-0 in support of an SSRI-suicide
link and 15-8 in favor of a ‘black box warning’ on SSRI
medication labels. The FDA warning and subsequent 2007
revision highlight the apparent increase of suicidal ideation
and behavior among children, adolescents and young adults
treated with antidepressants. The warning encourages close
clinical monitoring (weekly for the ﬁrst four weeks of
treatment and biweekly thereafter) and ongoing commu-
nication among providers, patients and their families.
When one considers the research closely, SSRI safety in
children appears far from guaranteed.
Combination Medication and Psychotherapy Treatments
The 2004 TADs study is viewed as the ‘state of the sci-
ence’ comparison of ﬂuoxetine with CBT and their
combination. This RCT represented the largest placebo-
controlled study comparing mono-therapy with combina-
tion therapy. To summarize the outcomes: at 12-week
follow-up 71% combination (ﬂuoxetine ?CBT) patients
evidenced ‘‘much’’ or ‘‘very much’’ improvement on a
single clinician-rated item. Fluoxetine produced a similar
outcome (60.6%), and CBT (43.2%) did not differ signif-
icantly from placebo (34.8%). Given the surprisingly poor
performance of CBT, several researchers and practitioners
noted critically that the form of CBT used in TADs
was suboptimal with multiple insufﬁciently developed
components (Brent 2006; Weisz et al. 2006). Interestingly,
in spite of these arguments, TADs CBT demonstrated
eventual effectiveness; there were no statistically signiﬁ-
cant differences between CBT and ﬂuoxetine at week 18
and no statistically signiﬁcant differences whatsoever
among the three groups on primary outcomes at week 36
(The TADS Team 2007).
Although ﬂuoxetine-based interventions evidenced a speedier antidepressant effect, TADs outcomes suggested that CBT, even a possibly inferior form of CBT, is equally effective over 36 weeks.
Other than TADS, only one other RCT has evaluated
combination SSRI and psychotherapy treatment for youth
with depression. Speciﬁcally, Melvin et al. (2006) directly
compared sertraline, CBT, and their combination. They
observed partial remission among 71% of CBT patients,
33% of sertraline patients, and 47% of patients receiving
Consistent with previously reviewed research, Sertraline patients evidenced signiﬁcantly more adverse events and side effects. Surprisingly and in con-tradiction with their own data, Melvin et al. recommended CBT and sertraline with equal strength.
Psychotherapy for Youth Depression
The paucity of direct comparisons between SSRIs and psy-
chotherapy make it difﬁcult to establish deﬁnitive
conclusions about the relative efﬁcacy of these two divergent
approaches in treating depressed youth. However, there is
also a separate body of literature focusing exclusively on the
efﬁcacy of psychotherapy in treating depression in youth.
We brieﬂy examine this literature to provide an indirect
comparison of medication and psychotherapy.
Numerous reviews and meta-analytic evaluations of
CBT for adolescent depression provide evidence of CBT
efﬁcacy (Klein et al. 2007). Generally, more recent studies
show less positive outcomes than earlier ones. Keeping in
mind Cohen’s (1977) anchor points for small (d=.20),
medium (d=.50) and large (d=.80) effect sizes, early
meta-analyses by Reinecke et al. (1998) and Lewinsohn
and Clarke (1999), were very positive (i.e., d=1.02–
1.27). In contrast, Weisz et al. (2006) more recent analysis
reported a small to moderate average effect size (d=.34)
and Klein et al.’s meta-analysis showed a medium effect
size (d=.53). As an alternative anchor point, these effect
sizes generally compare favorably with Greenberg and
colleagues (1994) analysis of ﬂuoxetine’s effect size
among adults (d=.40).
Similar to SSRI RCTs, CBT outcome studies are vul-
nerable to a wide range of methodological problems and so
these indirect comparisons are problematic.
Nonetheless, the data suggest a modest CBT effect and, consistent with direct SSRI CBT studies, very few side effects or adverse events are observed within CBT studies.
J Contemp Psychother (2009) 39:111–120 113: 123
Interpersonal psychotherapy (IPT) also enjoys empirical
support as an efﬁcacious treatment for youth depression.
RCTs of IPT suggest this treatment reduces depressive
symptoms and improves social functioning in adolescents
(Mufson et al. 1999). In a comparison of IPT to a waitlist
control condition in a sample of Puerto Rican adolescents,
Rossello and Bernal (1999) observed evidence for IPT’s
efﬁcacy for improving depression, self-esteem and social
adaptation. Other studies offer additional support for IPT’s
effectiveness in school-based treatment settings (e.g.,
Mufson et al. 2004) and culturally diverse samples such as
rural Uganda (Clougherty et al. 2006).
Finally, recent studies observed speciﬁc utility for interpersonal skill
treatments among high-risk adolescents with elevated
baseline depression (Horowitz et al. 2007) and among
depressed adolescents with comorbid anxiety (Young et al.
2006). Overall, these studies are promising, but particularly
because they are associated with little or no side effects or
Depression Treatment Prevalence
Somewhat surprisingly, mental health professionals rarely
represent the point of ﬁrst treatment contact for youth with
depression. Instead, it appears that increased antidepressant
treatment—and not increased psychotherapy—is driving
recent increases in depression treatment frequency (Ma
et al. 2005). Consistent with adult research that observes a
trend increasingly favoring primary over specialty clinic
depression care (Olfson et al. 2002), youth depression
treatment is also frequently provided in general medical
In a study of depressed youth HMO enrollees, for example, DeBar et al. (2001) found that most treated youth eligible for mental health specialist intervention did not receive it. In a suggestion that has since been echoed by others (e.g., Delate et al. 2004), DeBar et al. (2001) noted that health care system limitations might prohibit delivery of effective treatment options, like psychotherapy.
The limited availability and utilization of psychotherapy
raise concern for a number of reasons. First, the AACAP
practice parameter (Birmaher et al. 2007) demands that
youth depression treatment plans employ psychoeduca-
tional and supportive psychotherapeutic interventions
before other treatments (e.g., speciﬁc psychotherapies or
antidepressants). Second, research suggests that most
depressed youth prefer psychotherapeutic interventions
over medications (Jaycox et al. 2006). Given recent ﬁnd-
ings of improved treatment outcomes for depressed adults
who receive preferred treatments (Lin et al. 2005), it makes
sense for providers to accommodate youth preferences.
Finally, even after FDA warnings regarding the need for
close clinical monitoring, quantitative and qualitative
research suggest that medical providers fail to adhere to
follow-up treatment recommendations (Richardson et al.
2004,2007). Relative to treatment provided in general
medical settings, psychotherapeutic treatment provided by
mental health specialists would come closer to the FDA
and AACAP recommendations.
Our brief research review suggests that SSRIs may carry
potential beneﬁts for depressed youth, but these beneﬁts are
accompanied by signiﬁcant risks. Whereas beneﬁts may
outweigh risks in some cases, this is not necessarily the
case, and the opposite is also quite likely.
In sum, this biomedical treatment option does not enjoy uniform and robust empirical support.
CBT and IPT are the most studied psychotherapies for
youth depression. Despite indications that these psycho-
therapies work, the empirical data are difﬁcult to directly
compare with SSRI RCTs. Speciﬁcally, because psycho-
therapy studies often employ waitlist or treatment as usual
comparison groups, some have noted that psychotherapy
trials employ a lower standard than medication trials (Ryan
2005). In addition, unlike medication trials, which must be
reported to the FDA, it is not possible to examine how
many psychotherapy trials have remained unpublished due
to negative or ambiguous results.
Further, although not reviewed here, psychotherapy
outcomes research generally implies that theoretical
approaches grounded in common factors will likely show
efﬁcacy in treating youth with depressive symptoms. In
fact, given the dearth of research on the efﬁcacy of non-
CBT or IPT psychotherapies with this treatment popula-
tion, it is possible that therapies with a stronger affective
component than CBT or IPT might evidence better efﬁcacy
and common factors research would indicate that the spe-
ciﬁc techniques derived from CBT and IPT are only
minimally important (Lambert 2005; Wampold 2001).
Ultimately, we ﬁnd that psychotherapy offers advantages
over medication. Psychotherapeutic response matches
medication, and psychotherapy appears to reduce suicidal
impulses, and although perhaps slower to take full effect
(The TADS Team 2004), it provides a natural opportunity
for close clinical monitoring.
Trends of increased depression treatment suggest that
providers might be relying on pharmacological interven-
tions at the expense of psychotherapy. Although increased
treatment of depression in youth is likely to have positive
public health outcomes, current data and recent contro-
versies regarding SSRI medication safety suggest that the
treatment community should reconsider standing practices.
Speciﬁcally, providers might consider a range of inter-
ventions other than antidepressant monotherapy and should
consider whether treatment delivery systems could be
redesigned to increase the availability of nonpharmaco-logical interventions.
Reformulating Clinical Depression
The equivocal support regarding antidepressant efﬁcacy and
emergent safety problems lead us to assert that the biomed-
ical model might simply be one potential formulation among
many—and one that has not fared particularly well. It may be
time for researchers and practitioners to consider a paradigm
shift in the treatment of youth with depression.
In a call to medicine, Engel (1980) encouraged adoption
of a biopsychosocial model of health. Despite this recom-
mendation and the increasingly frequent use of
‘biopsychosocial’ language among non-medical practitio-
ners, medicine has demonstrated little movement toward
embracing Engel’s perspective (Alonso 2004). Although
we advocate the components within the biopsychosocial
model, our conceptualization of youth depression is
designed to avoid biological dominance.
Our call for reformulating how we conceptualize
depression in youth rests upon several factors. These
include the equivocal data regarding antidepressant medi-
cation effectiveness, developmental and medical dangers
associated with short- and long-term antidepressant use,
knowledge of the etiology and course of youth depression,
research on child development and trauma, and our own
child-clinical experiences (Sommers-Flanagan and Som-
In short, we believe a social-psychological-biological (Social-Psycho-Bio) approach to youth depression is equally consistent with current scientiﬁc and clinical knowledge and has greater potential to advance clinical treatment research and practice.
We recognize that the development, maintenance, and
remission of depressive symptoms are most likely com-
plex, non-linear processes involving many interactive
factors. However, for the sake of space and simplicity, we
present our model as primarily linear, with (a) social/cul-
tural factors activating (b) depressive psychological/
cognitive processes, which can sometimes (c) trigger
depressive biological processes.
The following factors provide a sampling of social and
cultural factors that can drive depressive symptom
US Census data for 2006 (DeNavas-Walt et al. 2007)
indicated that 12.8 million American children (17.4%) live
in poverty, and that the culture of poverty is much more
likely among single female parent households (42.1%) than
it is among married-couple families (8.1%). Single mothers
living in poverty may be depressed themselves and have
little community and governmental support (Goosby 2007).
Moreover, research by Hammen et al. (2004) suggests that
maternal depression might transmit intergenerationally to
children via interpersonal and social stressors. Considering
the protective value of the interpersonal environment, some
communal and supportive cultural settings place less par-
enting burden on individual mothers, thus possibly
decreasing depression. This possibility is supported by
research suggesting that among low income families child
mistreatment, a contributor to child maladjustment, is less
likely in the presence of high perceived social support
(Hashima and Amato 1994).
The likelihood exists, therefore, that cultural support can decrease relative risk for depressive experiences in children.
Research afﬁrms diverging cultural assumptions about
depression etiology (Vitiello 2008). In one study, South
Asian immigrants attributed depressive symptoms to social
and moral inﬂuences while European Americans attributed
depression primarily to biology (Karasz 2005). These cul-
tural formulations and expectations likely inﬂuence
medication or psychotherapeutic efﬁcacy. Although bio-
medical researchers emphasize depression as a family
medical illness, this narrow formulation ignores the fact
that an individual’s depressive predisposition and treatment
response may be strongly inﬂuenced by overarching cultural factors.
Early Caretaker-Child Interactions
Early caretaker-child interactions appear to stimulate
depression development in very young children. As
reviewed by Ashman and Dawson (2002) maternal
depression studies demonstrate that mothers’ depressive
behaviors inﬂuence their children’s own emotional expe-
riences and appear to initiate neurological changes.
Because evidence such as this asserts the primacy of social
interaction, it offers further support for a social-psycho-bio
Garbarino’s (2001) statement, ‘‘Risk accumulates; oppor-
tunity ameliorates’’ (p. 362) articulates how trauma can,
without requisite support and opportunity, initiate cogni-
tive, emotional, and social pathology. Sufﬁciently intense
trauma may also produce lasting ‘‘psychic scars’’ (Terr
1990). Additionally, early childhood trauma drains victims
of meaningfulness and purposefulness in life (Garbarino
2001). There is little doubt about the powerful contribution
of trauma to the development of clinical depression and
other mental disorders.
Considerable evidence supports a cognitive model of
depression in adults, and to some extent, in adolescents and
children (Kazdin and Weisz 2003). Beck’s (1970) pio-
neering work emphasized that personal experiences lead
individuals to acquire speciﬁc negative beliefs about
themselves, the world, and the future (i.e., the cognitive
triad). Although empirical support for the cognitive triad’s
contributory and maintenance roles in depression is strong,
these belief systems do not rise autonomously. Instead, as
Beck notes, these deeply ingrained beliefs are learned vis-a-vis interpersonal experiences.
The Development of Schemata or Internal Working Models
Theorists spanning analytic, neoanalytic, cognitive, and
attachment perspectives have proposed concepts that can
be described as schemata or internal working models
(Ainsworth 1989; Morehead 2002; Young et al. 2003).
Although each theoretical perspective articulates the con-
cept somewhat differently, all involve development of a
psychological pattern of repetitive automatic beliefs and
These beliefs and expectations about the self, the world, and others generate repetitive behaviors and affect. A cognitive schema or internal working model arises from early social interactions and may contribute to depression and other maladies.
The internal working model concept forms the founda-
tion of many psychological interventions, including CBT
and IPT (Kazdin and Weisz 2003). As internalized repre-
sentations of early interpersonal experiences, internal
working models or schemata constitute a psychological
component of the social-psycho-bio model. When positive,
adaptive, and healthy early experiences predominate,
internalized working models buffer or immunize the indi-
vidual against stress and trauma. When critical, negative,
and maladaptive experiences predominate, schemata may
predispose individuals to acute, chronic, or recurrent
Researchers have identiﬁed neurological correlates of
depression and affective experience. These correlates
include neurochemical changes and neural activity, which
can be observed via brain imaging techniques (Davidson
et al. 2002).
Whereas imaging studies are typically presented as evidence that biomedical or biogenetic factors cause depression, the social-psycho-bio model suggests that neural changes are natural and inevitable correlates of internalized depressive life experiences.
The search for fMRI and PET scan differences between
depressed and non-depressed individuals represents a log-
ical development in our understanding of depression as it
exists within the whole person. Although neurochemical
changes might initiate or maintain depression in some
cases, these neurochemical changes are just as likely to be
consequences of depressive conditions. Based on this
depression re-formulation, we believe that it would be
appropriate to initiate antidepressant medication treatment
as an adjunctive approach if previously attempted experi-
ential interventions, including exercise, dietary
adjustments, and psychotherapy fail to achieve desired
Further, conceptualizing neurochemical changes as depressive correlates rather than causes, leads us to agree with others who maintain that medication treatment should be considered a palliative and not a curative treatment (Overholser 2006).
Conclusions and Recommendations
We have reviewed some relative beneﬁts and risks of TCA
and SSRI medications, individual psychotherapy, and their
combination in the treatment of depressed youth. We
believe that although SSRIs and psychotherapy appear to
provide equivalent antidepressant effects, safety issues
make psychotherapy the preferred initial treatment. Fur-
ther, there is no research available that demonstrates a clear
advantage for combined treatments over either medication
or psychotherapy alone (Melvin et al. 2006; The TADS
Based on the extant literature and usual initiation,
course, and outcomes of depressive disorders in youth, we
believe a social-psycho-bio conceptualization of depression
is appropriate. This approach asserts that social and cultural
factors are likely to initiate depressive processes. These
processes later become internalized as negative core beliefs
about the self, world and future. Eventually, after exposure
to stressful social experiences and the development of
negative cognitive schemata, neural correlates of depres-
sive conditions may develop and maintain depression in
some cases, even in the face of psychotherapy.
Recommendations ﬂowing from a social-psycho-bio
model are surprisingly consistent with published practice
parameters in child and adolescent psychiatry and pediatric
medicine. Following decades of underwhelming research
on antidepressant medication efﬁcacy for youth depression,
many professionals agree that non-medical interventions
should precede antidepressant medications. If medications
are used at all, practice parameters and guidelines
recommend that they should be accompanied by psycho-
therapy or other supportive interpersonal interventions
(Birmaher et al. 2007).
Despite these practice directives, many depressed youth
receive treatment exclusively in primary care settings
where non-specialist practitioners rely on potentially dan-
gerous medications with tenuous empirical support.
Findings such as these are remarkable and concerning and
suggest that too many practitioners subscribe blindly to a
model of depression that asserts biomedical dominance.
Our preceding review, the social-psycho-bio formula-
tion, and existing practice parameters drive the following
1. Children and adolescents with signiﬁcant depression
should be offered psychotherapy in a manner appro-
priately sensitive to their cultural backgrounds and
acculturation. To be consistent with the youth depres-
sion treatment research literature, psychotherapists
should begin their case conceptualization using CBT
or IPT approaches. However, to be consistent with
psychotherapy outcomes research in general, psycho-
therapists should also recognize that many divergent
approaches to psychotherapy are evidence-based
(Lambert 2005; Wampold 2001). Additionally, family
therapy, parent consultation, in-session activities that
generate positive affect, and group counseling are all
appropriate depression interventions. Consistent with
CBT, homework assignments should emphasize plea-
sure-based experiences and thought monitoring/
modiﬁcation with relationship enhancement and par-
ticipation in personally meaningful social, recreational,
and culturally appropriate activities. Depending upon
the cultural acceptability and preference, family or
community members may be incorporated into the
2. Youth treated for clinical depression should be closely
monitored for suicidal thoughts and impulses, espe-
cially patients on SSRI medication. To maintain
appropriate balance, positive or strength-based cogni-
tive, social, cultural, and emotional experiences should
also be monitored and highlighted (Sommers-Flanagan
and Sommers-Flanagan 2007).
3. If acceptable symptom reduction has not occurred
within 8–12 weeks of psychotherapy, it may be reason-
able (but not necessary) for a properly-trained prescriber
who is knowledgeable about depression to offer SSRI
medications as an augmentation strategy. Additionally,
if psychotherapy fails to yield a signiﬁcant response and
if clients and family are amenable, it may be best to
transfer care to a different psychotherapist.
4. If SSRI medication treatment is initiated, weekly
psychotherapy should continue. This is especially
important because of evidence that concomitant psy-
chotherapy may reduce suicide risk and because of the
possibility of other adverse events associated with
5. The treating psychotherapist and treating physician,
physician’s assistant, nurse, or other health care
provider should communicate regularly regarding
clinical response and the potential side effects or
adverse effects associated with SSRI medication
6. All treatment team members should educate the client
and his/her parents that a pill is not a skill. Likewise,
the need for speciﬁc environmental, familial, and
individual efforts toward healthy and adaptive change
should be emphasized.
7. When youth present with severe depression, to facil-
itate a speedier initial treatment response, it may be
reasonable to simultaneously initiate psychotherapy
and SSRI medication. In such cases, monitoring and
communication is essential.
8. Some youth, their parents, caregivers, or physicians may
clearly prefer SSRI medication treatment without con-
comitant psychotherapy. Although positive outcomes
are possible with mono-SSRI treatment, we believe the
prevalence of adverse events among SSRI treated youth
(3–12%) confers risk of treatment that fails to abide by
the Hippocratic oath ‘‘do no harm.’’ Consequently, to
guard against harm, mono-SSRI treatment should
adhere to FDA recommendations for close and support-
ive weekly monitoring for the ﬁrst four weeks and
biweekly monitoring for the next four weeks. At a
minimum, patients with new antidepressant prescrip-
tions should be seen for supportive monitoring seven
times within the ﬁrst three months of treatment.
Overall, there is no argument about whether children
and adolescents experiencing clinical depression warrant
professional interventions. The need is real; depressed
children and their parents experience great distress, and the
cost to society is substantial (Mathers and Loncar 2006).
However, as mental health professionals, it is our challenge
to promote public awareness of psychotherapy as the
frontline treatment option for youth depression and to work
to develop even more efﬁcacious psychotherapeutic tech-
niques. Simply combining psychotherapy with medications
is not an adequate solution to this challenging problem.
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