CBT Techniques for Depression

• Depression stems from a diathesis-stress model, where personal vulnerabilities interact with stressful life events, leading to mood disruption.
• Negative cognitive and behavioral processes maintain depression, and are targets for therapy.
  • Examples of processes include depressogenic thinking, low reinforcement, negative life events, and skill deficits.

Cognitive Techniques

• CBT aims to align reactions with events, not to unrealistically perceive negative events as positive.
• Example: If someone cancels plans, CBT helps consider alternative, more probable reasons other than personal rejection.

Behavioral Techniques

• Track mood and activities to identify correlations.
• Create a list of rewarding activities that produce pride or pleasure, like running or talking with friends.
• Gradually modify habits, addressing environmental obstacles and skill deficits.
• Continuously monitor the impact of changes and refine the plan accordingly.

CBT Efficacy in Children & Adolescents

• A meta-regression analysis of 31 CBT trials with 4335 children and adolescents showed:
  • A 63% lower risk of depression at follow-up for sub-clinical participants at baseline.
  • A 45% lower risk post-treatment for those with clinical depression at baseline.
• Predictors of positive outcomes:
  • CBT combining behavioral activation and thought challenging.
  • Parental involvement in the intervention.

CBT in Low and Middle Income Countries (LMIC)

• A meta-analysis of CBT with adolescents in LMICs (e.g., Africa, Asia) revealed:
  • CBT reduced depression symptoms.
  • Economic interventions had moderate effects.
  • Interpersonal therapy had small effects.
  • Integrated approaches (CBT + other techniques) had non-significant effects.

Antidepressant Medication

• Many medications effective for adults aren't for children/adolescents, which is caused by brain development/metabolism differences.

Tricyclic Antidepressants

• Prevent norepinephrine and serotonin reuptake.
• There is no evidence of efficacy in youth.

Monoamine Oxidase Inhibitors (MAOIs)

• These inhibit the enzyme that breaks down neurotransmitters, increasing neurotransmitter levels.
• There is some mixed evidence of efficacy in teens.
• Potentially lethal side effects occur if taken with tyramine.

Selective Serotonin Reuptake Inhibitors (SSRIs)

• These inhibit serotonin reuptake, increasing its availability in the synapse.
• Fluoxetine (Prozac) has good evidence for use in teens.
  • Less likely to be fatal in overdose.
  • Side effects: agitation, jitteriness, anger, hostility, nausea, stomach cramps.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

• These block norepinephrine and serotonin reuptake, and are used for depression and anxiety.
  • Similar side effects to SSRIs
  • Fewer side effects than tricyclic antidepressants (TCAs)
  • Take 2-4 weeks to take effect.
  • Examples: venlafaxine (Effexor XR), duloxetine (Cymbalta), desvenlafaxine (Pristiq).

Antidepressants for Youth

• Some SSRIs show some efficacy.
• There is a suggestion of increased risk of suicide.
• The FDA issues black-box warnings on medication with serious adverse effects, named for the black border on packaging.

Black-Box Warning

• Sparked by concerns about paroxetine (Paxil).
• An FDA analysis of RCT data found higher suicidality in antidepressant-treated patients vs. placebos.
  • There were no completed suicides in the trials (+4000 patients).
  • Similar findings occurred in follow-up studies with more patients.
• Other studies show antidepressant use is associated with decreased suicidality.
• Increased antidepressant use correlates with decreased suicidality.
• Adolescent suicide rates in the US increased after years of decrease, possibly due to decreased treatment for depression.

Recent Studies

• Longitudinal data from Prozac RCTs and the Treatment for Adolescents with Depression Study (TADS) found no higher rates of suicidal ideation in youth treated with Prozac compared to placebo.
• Decrease in antidepressant use, sharp increase in suicide attempts (young adults).
• Decrease in antidepressant use, no change in suicide attempts or suicides (adults).

Antidepressant Use

• Evidence on whether SSRIs increase suicidal ideation in children is mixed.
• Balance the possible increase of suicidal ideation due to taking SSRIs with the risk of suicidal ideation if depression is left untreated.
• SSRIs (e.g., Prozac) may confer acceptable benefit-to-risk ratio for adolescents.

Treating Depression in Preschoolers

• Diagnosis of depression is very new in preschoolers.
• As of 2017, no large-scale studies had investigated the safety and efficacy of antidepressant meds in children younger than 7 years of age.
• There is limited data on psychiatric drugs with preschoolers.
• Parent-management training helps parents manage their children's moods.
  • Includes ways to help children experience positive affect.
  • Preliminary evidence suggests that this is a promising treatment.

Preschool Treatment

• Therapy is recommended as the first approach.
• If symptoms are severe and persist, fluoxetine has the best risk/benefit profile in older children and is recommended as the first choice in preschoolers.
• Medication must be closely monitored by a child psychiatrist.

Treatment Summary

• CBT and SSRIs are evidence-based treatments for depression in older children and adolescents.
• For youth, SSRIs may be associated with increased suicidal ideation, and this risk must be balanced against the potential clinical benefits.
• For preschoolers, there's is limited work examining efficacy and safety of antidepressant medications.
• Therapy is always recommended as the first approach.

Approaches

• Cognitive behavioral therapy (CBT).
• Antidepressant medications.

Emotional Spirals

• Depression may begin/deepen as part of a downward emotional spiral.
  • Negative events breed negative moods, moods lead to negative behaviors, and behaviors produce negative thoughts and expectations for the future.
• Upward emotional spirals include positive triggers can start a chain of pleasant feelings, events, and thoughts.

Cognitive Techniques

• Youths learn to observe their thoughts, feelings, and behavior.
• Youths can consider alternative explanations.
• Therapy encourages problem solving and facilitates rational decisions.
• It provides psycho education about the connection between thoughts, feelings, and behavior.
• Therapy is framed as observation and experiment.
• Match developmental level with concrete examples and cartoons.