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Research of Effective Treatments for Adolescent Depression, Anxiety Sorely Lacking

A few findings suggest that CBT is effective

Anxiety and depression are treatable, but according to the 2018 Children’s Mental Health Report, 80% of children with a diagnosable anxiety disorder and 60% of those with diagnosable depression are not getting treatment. More concerning: Most adolescents with mental health disorders never even begin treatment. And when they do get treatment, half don’t complete the course, whether it’s medication, psychotherapy, or both.

But when teens have positive expectations for treatment, they can be cooperative partners and get better, according to Harold Koplewicz, MD, president of Child Mind Institute, a national nonprofit organization focused on raising awareness of, and improving treatment for, mental health disorders in children.

A number of researchers have deplored the dearth of research on treatment for adolescents with depression and/or anxiety. Some have suggested ways adult therapies could be adapted for younger people. For instance, Positive Affect Treatment, which promotes positive emotion not by challenging negative thoughts, as in traditional cognitive behavioral therapy (CBT), but by identifying positive aspects of situations.

And it’s important to note that there are already treatments that can help. One trial for young people with anxiety disorders found that a combination of CBT and antidepressant medication was effective in 81% of patients after 12 weeks. CBT alone was effective in 60%, and medication alone (sertraline) was effective in 55%. A 12-week trial for adolescents with depression also found combination therapy was effective in the majority of patients: 71%, versus 43% for CBT alone and 61% for medication alone. 

A 2018 Cochrane review looked at 29 studies involving children with chronic physical conditions. The reviewers found therapies specifically designed to treat anxiety or depression, particularly those based on CBT principles, may be more likely to work in children and adolescents who have mild to moderate levels of symptoms, “at least in the short term.” Other research suggests older adolescents may benefit more from CBT because their cognitive and social skills are more developed.

Targeted CBT programs can be particularly effective. Dialectical behavior therapy, for instance, is an evidence-based form of CBT for adolescents who have significant trouble managing their emotions, thoughts, and behavior. Patients learn how to practice mindfulness and new problem-solving skills. DBT has been successfully adapted for young people with depression, anxiety, and suicidal behaviors. 

Psychological approaches improve symptoms in the short term, but maladaptive responses to negative mood, such as rumination, may become increasingly automatic and habitual—driving relapse. Noting that 20% to 40% of young people with depression and anxiety do not maintain their recovery into early adult life, Ford et al. also endorse mindfulness-based cognitive therapy as an option for those who only partially or briefly respond to first-line interventions. The absence of alternative psychotherapeutic approaches other than systemic behavioral family therapy is “striking,” they add.

Their suggestion is a group-based program that combines mindfulness practice with cognitive-behavioral elements, teaching participants the skills to recognize the early warning signs of relapse and how to respond in more adaptive ways. Research has shown, the authors say, that patients keep using the core skills learned after the actual intervention. Patients and their parents both have reported statistically significant reductions in rumination and improvements in self-compassion.

Other treatments drill down to the specific cause of the anxiety or depression. Researchers who studied 2,105 adolescents, for instance, found that being able to forgive the bully and having a best friend could be moderating agents for the depression, anxiety, and other debilitating psychological effects of bullying. In their study, adolescents who scored lower in forgiveness were more likely to be depressed and angry. Advising adolescents on forgiveness led to significantly lower levels of anger than did advice to exact revenge or avoid the bully. A bonus—studies have found that forgiveness is positively correlated with self-esteem, lower levels of mental health problems and effective coping strategies, and negatively associated with social anxiety.

A meta-analysis of 42 studies involving 7,310 adolescents found school-based mental health programs to reduce stress did not, overall, reduce stress symptoms, although targeted interventions showed greater reductions in stress than did universal programs. However, anxiety interventions significantly reduced anxiety symptoms and depression interventions significantly reduced depressive symptoms. The authors conclude that although school-based programs are effective, the effects are not long-lasting.

According to a Harvard report from the National Scientific Council on the Developing Child, “Emotional development is actually built into the architecture of young children’s brains …. [E]motion is a biologically based aspect of human functioning that is ‘wired’ into multiple regions of the central nervous system.” Significant and prolonged emotional distress can damage that emerging architecture, the report warns; interventions need to include attention to emotional development.

A report published in Brain Sciences described findings from self-report, behavioral, peripheral psychophysiological, and neural measures on the links between disrupted emotion regulation and depression/anxiety. The upshot: Teaching young people how to regulate emotion, often the guiding force of their lives, can be key.

Researchers who study “emotional intelligence” (EI)—which includes the ability to use emotional reasoning and understanding and the ability to regulate emotions—say teaching young people EI-type skills can give them a “potential buffer” against not only bullying, but stressful life events in general.

Meta-analytic data suggest that self-reported abilities predict subsequent diagnosis of anxiety or depression. For example, self-blame, catastrophizing, and rumination are connected to symptoms of depression. Anxious adolescents have been shown to have heightened emotional reactivity to negative images, but when they’re taught to generate adaptive techniques like reappraisal—considering a situation in a different way—they can effectively reduce their negative affect to a similar degree as non-anxious counterparts. Adolescents with greater EI, according to studies, are better adjusted psychologically, with better coping strategies and fewer internalizing problems, and they’re less likely to report symptoms of suicidal ideation and low self-esteem.

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