What are depressive disorders? - Chapter 19

What is this chapter about?

3% of adolescents will experience a depressive period that meets the diagnostic criteria. Those who have experienced this are at greater risk of developing other disorders, often have recurrent depressive episodes, perform less well in school, use illegal substances earlier, are more likely to be involved in domestic violence crimes, have a greater risk of suicide, and more. According to Hyde and colleagues (2008), girls are at greater risk of depression than boys, and risk factors differ slightly between boys and girls. Some known general risk factors are an economic and/or social disadvantage, a family history in which depression is more common, recent interpersonal stressors, little social support, and conflicts within the family (Lewinsohn et al., 1999).

Symptoms of depression are similar in adults and in young people. It is important to always always screen for depression, because depression is a common comorbid disorder and it can re-occur.

What is a cognitive behavioural model of depression?

According to Beck and colleagues (1979), depression can be triggered by negative life events in individuals who already have a specific cognitive vulnerability. Then, the depression is maintained by cognitive and behavioural factors.

Young and depressed people often report that they have little on their hands. As a result, they end up in a vicious circle in which the biggest roles are assigned to avoidance, negative reinforcement and too much time to think about negative things – about themselves, the future and the world (see page 294, Figure 19.1 for an example of Sophie's vicious circle). A number of cognitive processes maintain depression. In this way, depressed people mostly remember the bad things that have happened; they pay more attention to the negative events; they make more negative judgments and predictions about the future, and they interpret the world and new information especially in a negative way.

According to Beck, people with depression are characterized by negative automatic thoughts (NATs). An example is "I will never get a good job", or "Everyone hates me". The CBT model states that NATs are the result of more general implicit assumptions, also known as life rules, that individuals themselves have developed over time. These are shaped by experiences that they had while growing up, the culture they grew up in, their family history and important life events.

How can CBT be used as a treatment for depression?

According to Bordin (1979), a therapeutic relationship consists of two main characteristics: an emotional connection and the task element. A positive emotional bond creates a secure context in which the person can share private information and in which new ways of thinking and doing can be performed. The task element refers to an agreement between the therapist and the person on the overall purpose of the therapy and specific sub-goals. Cooperation is encouraged by a number of specific activities:

• Identify the child's goals: what do they want to change?
• Help the child understand the basics of the CBT model.
• Develop a shared understanding of the situation by making a formulation.
• Make each session a collective agenda: what are you going to do today?
• Perform specific exercises or tasks in each session.
• Discuss explicitly the structure of the session and how many sessions there will be, working towards the end of therapy and progressing toward certain goals.

The therapeutic relationship provides a context in which the therapist and client follow 'collaborative empiricism'. This is a way of working with the aim of questioning the client's beliefs and assumptions, trying out alternatives, gathering information and continuously evaluating the evidence for the beliefs and assumptions.

What are the elements of CBT for depression?

Psycho-education is the first step to enter into a collaborative relationship. The CBT model (the relationship between thoughts, emotions and behaviour) – and how this model can help the client, is explained. Psycho-education is included in the formulation that is drawn up together. This incorporates the child's situation into their own CBT model. This model is not definitive: it is a set of hypotheses or ideas about how the problems arose and how they are maintained.

Very important in any CBT treatment of depression is to stimulate the activity level. Young people are often unmotivated and apathetic. By being inactive, the depressed mood remains present. The purpose of behavioural activation is to make the client engage in more enjoyable, rewarding activities. Extensive attention will have to be paid to what the person does every day. This is introduced in a session and then tracked between sessions in the form of a diary in which each hour is accounted for. This is called activity monitoring. In addition to recording their activities, they also record their mood/feeling. Activities are scheduled that the client has to perform between sessions. Although the increased activities often already promote (implicit) pleasurable feelings, it often also makes sense to put explicit rewards against activities (tangible or not tangible, determined by the client himself or by others, as long as it is appropriate to the age of the child).

There is often little motivation of the child, which means that the therapist has to be creative. For example, in a world dominated by smartphones, it can be useful by sending an automatic text message to remind them of the homework. By letting the client write down their mood, the child is stimulated to discover the fluctuation in this (not everything is annoying and boring). They are also encouraged to think about naming and identifying moods and feelings and their intensity (by indicating the intensity of feeling on a scale of 1 to 10). This is called emotional recognition.

After monitoring and observing feelings follows the identification of NATs. This is the cornerstone of the CBT. These evaluation of NATs can be done in two ways: by collecting past evidence that serve as support for the NAT, or by conducting behavioural experiments to test the NAT. There will be evidence both for and against NATs and the therapist must adopt an open attitude. It can be useful to identify thoughts as hypotheses that need to be tested. The goal is not to prove that NATs are false, but to open the possibility that thoughts can be erroneous and can be changed.

A longitudinal formulation is a more complex formulation. This relates the person's history to their current thoughts, feelings and behaviours of underlying assumptions, beliefs and experiences (see page 301, Figure 19.3).

Cognitive restructuring is not an essential component of a CBT treatment for depression! A strong therapeutic relationship, behavioural activation, increased emotional recognition and the ability to question automatic negative thoughts (by evaluating the evidence or by conducting behavioural experiments) can already lead to sufficient improvement. When a young person has really persistent implicit negative beliefs about themselves, cognitive restructuring can help. The goal here is to reduce the impact of dysfunctional assumptions. This is done by examining the validity of the conviction through Socratic reasoning. The therapist provides alternative reasons for events. "Could it be that...?"

What are the challenges in using CBT for young depressed people?

CBT is developed for use in adults. In young depressed people, extra attention should be paid to developmental aspects and to their systems.

• Chronological age is not necessarily a good predictor of the psychological developmental age. So examine the person, not the age!
• Use psycho-education to assist and speed up the learning process.
• Be very collaborative.
• Be explicit about everything that happens in the therapy room (focus on the here-and-now and "live" emotions) and use current affairs to discuss abstract things.
• Include the family and other key systems (such as the school) in the formulation.
• Use concrete examples (a word can mean something different to the child than for an adult, for example the word "depressed").
• Don't engage in endless, philosophical discussions about abstract things like "good" or "bad".
• Encourage empiricism.
• Use yourself as an example.
• Involve the parents wherever possible, but accept that a conflict can make this problematic. Don't take sides. Look at parental factors that contribute to the problem.
• Encourage and support the autonomy of the child and use the sessions to give the child their own responsibility.

Is CBT effective for young people with depression?

For adults with depression, the effectiveness of CBT has been proven. Although CBT is also used successfully in young people with depression, there is not necessarily a proven superiority over other treatments. There has clearly been less research conducted on this than in adults, and the studies carried out are less clear in their conclusion. The TADS study (2007) showed that after 12 weeks of treatment, CBT in itself (treatment 1) was less effective than a drug treatment (treatment 2) or a drug treatment combined with CBT (treatment 3). However, after 36 weeks, all three of these treatments were effective in reducing symptoms (in 80%).

CBT based on mindfulness techniques has proven to be very effective in people experiencing recurrent depressive episodes. Suggestions have been made for some adjustments to mindfulness techniques when it comes to children with recurrent depressive episodes. Also, the cognitive bias modification (CBM) is a technique that significantly reduces depression in adults: because this can be easily offered via the computer and is therefore very accessible outside the clinical setting, this is also promising as a treatment for young people with depression.

3% of adolescents will experience a depressive period that meets the diagnostic criteria. Those who have experienced this are at greater risk of developing other disorders, often have recurrent depressive episodes, perform less well in school, use illegal substances earlier, are more likely to be involved in domestic violence crimes, have a greater risk of suicide, and more. According to Hyde and colleagues (2008), girls are at greater risk of depression than boys, and risk factors differ slightly between boys and girls. Some known general risk factors are an economic and/or social disadvantage, a family history in which depression is more common, recent interpersonal stressors, little social support, and conflicts within the family (Lewinsohn et al., 1999).