Psychotherapy and (or) Medications for Depression in Youth?

An Evidence-Based Review with Recommendations for Treatment

John Sommers-Flanagan Duncan G. Campbell

Abstract

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.

Efficacy

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

equivocal.

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

follow?

A Brief History of Antidepressant Medication Treatment Research

Three relatively distinct periods characterize youth anti-

depressant research.

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

serotonergic agents.

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).

Methodological Issues

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

racial/cultural specificity.

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

combined treatment.

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

adverse events.

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

settings.

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.

Research Conclusions

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-

mers-Flanagan 1995,2007).

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.

Social-Cultural Components

The following factors provide a sampling of social and

cultural factors that can drive depressive symptom

emergence.

Cultural support

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

model.

Child Trauma

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.

Psychological-Cognitive Components

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

expectations.

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

depressive episodes.

Biogenetic Components

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

effectiveness.

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

Team 2007).

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

recommendations:

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

treatment plan.

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

SSRIs.

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

administration.

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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