Cbt manual for adolescent depression

Adolescents exhibited comparable reductions in suicidal ideation, regardless of whether they were randomized to a week group CBT program or care as usual. Suicidal ideation in depressed adolescents has also been examined in studies that evaluate the effectiveness of combined CBT therapy and medication. In this study, 73 adolescents age 12—18 years diagnosed with MDD, dysthymic disorder, or depressive disorder not otherwise specified, were randomized to 12 weeks of CBT, CBT and sertraline, or sertraline alone.

Results from the three treatment groups showed comparable, statistically significant improvement in suicidal ideation after acute treatment that was maintained at the 6 month follow-up. Suicidality was rated at baseline, 6, 12, and 28 weeks.

At each follow-up point, the number of participants experiencing suicidal symptoms and the frequency of these symptoms thoughts, ideation, attempts, and self-harm was lower in both groups in comparison to baseline. Treatment with fluoxetine and CBT was also examined in a study of 13—19 year old adolescents with major depression, behavior problems, and substance use disorders Each group had 16 weekly therapy and medication monitoring sessions.

Participant suicidality was assessed monthly and found to be comparable in both groups; however five participants were hospitalized during the course of treatment for increased suicidality 4 in the Fluoxetine-CBT condition.

For all five of these participants, suicide severity ratings decreased during the first month of treatment, but worsened during weeks 8 and 12 in response to psychosocial stressors. Thus, although suicidality showed an initial response to treatment, these adolescents did not respond well when additional psychosocial stressors arose.

However, given the small number of hospitalizations in this trial, it is difficult to draw conclusions. Rohde and colleagues 36 examined depressed adolescents, ages 13—17, with comorbid conduct disorder. Each treatment option offered 16 group sessions over 8 weeks. However, post-treatment, 6-, and month assessments revealed no significant difference in number of suicide attempts. Two large multisite studies examining combined pharmacotherapy and CBT for MDD, also examined the effects of their protocols on suicidality.

At 12 weeks, reductions in suicidality were greater for youth randomized to combination therapy than fluoxetine therapy, CBT only, and the placebo condition, though suicidal ideation was lower than baseline in all conditions.

Further, participants who received CBT 4. The authors concluded that there was a slight protective effect of CBT on both suicidal ideation and suicidal behavior. At 36 weeks of treatment, suicidal events were more common in patients treated with fluoxetine alone During the trial, suicidal ideation decreased from baseline to post-treatment for participants across all conditions. In summary, the majority of studies of CBT for depressed adolescents have found a reduction in suicidal ideation regardless of CBT format i.

It should be noted that reductions in suicidality have also been found in response to family therapy, 32 supportive therapy 32 and pharmacotherapy Only a few studies have used CBT to specifically treat suicidal ideation and behavior. One study 37 used a quasi-experimental design to compare the treatment efficacy of dialectical behavior therapy DBT , a treatment to approach that heavily employs cognitive behavioral techniques, to treatment-as-usual TAU , for suicidal adolescents.

The DBT protocol was designed to improve distress tolerance, emotional regulation, and interpersonal effectiveness. Though adolescents in the DBT condition reported more severe baseline symptomatology than those in the TAU condition, they had fewer psychiatric hospitalizations and higher rates of treatment completion than the TAU group at follow-up.

No differences were found on repeat suicide attempts. In another trial, 38 individual CBT was compared to an individual problem-oriented supportive therapy with adolescents immediately following a suicide attempt.

More than half of the sample reported at least one prior suicide attempt. The CBT condition focused on teaching adolescents problem solving and affect management skills. Each session included an assessment of suicidality, instruction in a skill, and skill practice both in-session and homework assignments. Participants were taught steps of effective problem solving and cognitive and behavioral strategies for affect management e. Homework assignments were given to assist in skill acquisition and generalization.

Participants in both conditions reported significant reductions in suicidal ideation and depression at 3 month follow-up but there were no between-groups differences.

At 6 months, both groups retained improvement over baseline but levels of suicide ideation and depression were slightly higher though not statistically significant than at 3 month follow-up. I-CBT included a 6 month active, 3 month continuation, and 3 month maintenance treatment phase. The protocol included individual, parent training, and family therapy sessions and used a two-therapist model. One therapist worked with the adolescent and a second therapist worked with the parents.

E-TAU included psychotherapy services through community providers. However, adolescents in both treatment conditions were offered medication management for free with the same study employed child psychiatrist. Comparable reductions in adolescent self-report of suicidal ideation, number of drinking days, and depressive symptoms were reported across groups.

Treatment assignment could be random or chosen by study participants. CBT-SP incorporated a risk reduction and relapse prevention approach to treatment and integrated CBT techniques, dialectical behavior therapy techniques, and other intervention techniques for depressed youth with suicidality. Participants could attend up to 22 sessions over the course of 6 months, including individual adolescent and conjoint parent-adolescent sessions. All participants showed a significant decrease in suicidal ideation from baseline to the end of treatment.

After controlling for baseline differences across treatment conditions, there was no differential effect of monotherapy versus combination therapy on suicide outcomes.

In all, treatment studies that target adolescent suicidality suggest that CBT results in improvements in suicidal ideation and depressed mood, though results are generally comparable to active comparison treatments.

Similarly, with one exception, 39 the incidence of suicide attempts rarely differs between CBT and other active interventions. In our studies and treatment manuals for suicidal adolescents, 38 39 individual CBT sessions follow a standard format. They begin with a medication adherence check, if applicable, followed by an assessment of suicidal thoughts or behavior as well as any alcohol or drug use since the last session.

If the adolescent does appear to be at significant risk for suicidal behavior, we conduct an assessment of current suicidality, and either review or negotiate a safety plan, adapted from other important work in this area A coping card is created in which the adolescent generates a list of strategies that he or she can use in stressful situations, as well as phone numbers to contact in an emergency. A copy of the coping card is given to the adolescent to place in his or her wallet for immediate access.

A typical cognitive-behavioral session that follows the format used in TADS 27 and TORDIA 29 is as follows: the adolescent is first asked to identify an agenda item that will be discussed in the session, homework from the prior session is reviewed, a new skill is introduced or a previously taught skill reviewed, the skill is practiced, the agenda item is discussed and whenever possible the newly taught skill or a previously taught skill is applied to the agenda item.

Worksheets and handouts for each skill taught are used to assist in the learning process. All individual sessions also include a parent check-in at the end and a personalized homework assignment is created. Below, we describe cognitive and behavioral techniques that can be used to address both depression and suicidality in the skill portion of a CBT session.

First, we present the approach our group uses to teaching cognitive restructuring and problem-solving, two key cognitive interventions with this population. More details on how to implement these techniques have been described elsewhere. In our studies we have modified techniques based on Rational Emotive Therapy 45 for children and adolescents 46 to teach cognitive restructuring.

We call our techniques the ABCDE method and introduce this method to adolescents as a skill that helps adolescents deal with negative beliefs or thoughts. The first step in changing negative thought is to identify the A , activating event, that is associated with negative thoughts. The last step begins with an E and stands for E ffect. Effecting something is presented as trying to change something.

Adolescents are taught that they may not be able to change the fact that a negative activating event happened but they can change negative beliefs and feelings surrounding the event.

When adolescents begin to use this method, the therapist helps the adolescent question the evidence that is used to support a negative view through Socratic questioning.

What is the evidence for or against this belief? This technique is based on findings that suicide attempters often selectively attend to a particular set of evidence which confirms their negative interpretation. Deficits in problem-solving include difficulty generating alternative solutions and identifying positive consequences of potential solutions.

We begin with generating a list of triggers for suicidality, typically two to five events, and then the therapist teaches the adolescent the SOLVE system. The therapist may need to model the skills necessary to progress through the problem-solving steps. Lastly, the adolescent is asked to evaluate how well the process works. If it appears the option will work out well, then this option is selected. The adolescent does this until a solution to the problem is generated. When working with adolescents who have attempted suicide, the therapist reframes the suicide attempt as a failure in problem solving.

This explanation helps provide adolescents with a better sense of control over future problems that arise. The therapist points out that many teenagers who attempt suicide pick the only option that they think that have, which is to hurt themselves.

One contentious aspect of problem-solving is whether to have a suicidal individual include suicide as an option during the brainstorming portion of SOLVE. Some therapists feel that allowing suicide as an option facilitates the problem-solving discussion. Others fear that a cognitively restricted suicidal individual will not be able to generate other options beside kill oneself.

Schneidman 50 described one way to include suicide as an option with a suicidal young adult who was pregnant.

After allowing his client to list suicide as an option to her problem, Schneidman had her write a list of alternatives without regard to their feasibility, e. Then he had her rank order the options from the least onerous to most onerous. Although she said that none of the options were good ones, this procedure helped her to see that there were other options besides suicide. Moreover, once she no longer ranked suicide as her first or second option, her suicidal ideation decreased significantly. A number of other techniques to address suicidal thinking have been outlined in detail elsewhere.

In this technique, the therapist asks the adolescent to scale the suicidal precipitant or anticipated future stressful event on a scale from 0 to Scaling the severity of an event provides a way for adolescents to view situations along a continuum rather than in a dichotomous fashion.

Affect regulation techniques, i. Below we describe our approach to affect management with suicidal adolescents. Another useful approach to affect management with these adolescents is Dialectal Behavior Therapy 51 a therapy designed to specifically target affect dysregulation in individuals with borderline personality disorder and self-injurious behavior. The reader is referred to the Klein and Miller chapter in this volume for a review of DBT with suicidal adolescents.

In our approach to affect management, we first review the rationale for managing emotions. Specifically, we relate the notion that when negative activating events trigger negative or untrue beliefs, these beliefs can cause depressed mood and anger. These negative feelings can also cause the body to start feeling out-of-control which can be experienced as muscle tightness, a faster heart rate, sweating, or shortness of breath. Therefore, it is important to learn ways to keep negative affect under control.

With suicidal adolescents, it is useful to focus on events that result in suicidal ideation or behavior. Relaxation training is often taught to the adolescent as a means of managing physiologic arousal. There are numerous approaches to relaxation training including progressive muscle relaxation, guided imagery, and autogenics which have been described elsewhere.

Anger is a very common emotion experienced by depressed youth who attempt suicide. There are some specific techniques for managing anger that may be useful when dealing with this population.

One anger management protocol for adolescents 54 integrates cognitive restructuring and affect regulation technique described previously. Modeling and behavioral rehearsal are used to help teach the adolescent how to use these skills in anger-provoking situations. In summary, considerable progress has been made over the past several years in the treatment of depression and suicidality in adolescence. CBT has emerged as a well-established treatment approach for children and adolescents.

According to diagnostic interviews with patients conducted at the end of treatment, The qualitative analysis showed that on the whole, the TADS-in manual is suitable for the inpatient setting. However, clinicians believed the effectiveness of TADS-in was limited by patient comorbidity and the fact that the inpatients were unable to practice incorporating techniques learnt into everyday life.

The sample of depressed adolescents showed reduced symptomology following treatment, although these findings require replicating in a randomized controlled trial before effects can be attributed to the TADS-in manual specifically.

This pilot study informs further development of the manual as well as representing an important first step in the evaluation of the inpatient treatment of adolescent depression. Availability and accessibility of the trained therapist 3. Special situations like children and adolescents, pregnancy, lactation, female in fertile age group planning for pregnancy, medical comorbidities, etc.

Inability to tolerate psychopharmacological treatments 5. Open in a separate window. There are many advantages of CBT in depression as given in table 2 Table 2 Advantages of cognitive behavioral therapy in depression. It is used to reduce symptoms of depression as an independent treatment or in combination with medications 2.

It is used to modify the underlying schemas or beliefs that maintain the depression 3. It can be used to address various psychosocial problems, for example, marital discord, job stress which can contribute to the symptoms 4. Reduce the chances of recurrence 5. Increase the adherence to recommended medical treatment. Number of sessions depends on patient responsiveness. A model for reference is given in table 3 Table 3 The use of cognitive behavioral therapy according to the severity of depression.

Table 4 Overview of cognitive behavioral therapy for depression. Mutually agreed on problem definition by therapist and client 2. Goal settings 3. Explaining and familiarizing client with five area model of CBT 4.

Application and consolidation of new skills and strategies in therapy sessions and homework sessions to generalize it across situations 7.

Relapse prevention 8. End of the therapy. CBT — Cognitive behavioral therapy. Figure 1. Table 5 Symptoms of depression and associated cognitions. Serial number Symptoms Automatic thoughts 1 Behavioral: lower activity levels I cants do it.

It is too much for me 2 Guilt I am letting everybody down 3 Shame What everyone must be thinking about me. Impact on functioning it is important to know the extent and effect of depression on the overall functioning and interpersonal relationships. Coping strategies Sometimes patients with depression might have adapted a coping strategies which make them feel good for short duration e.

Onset of current symptoms Patient's perception about the situation at the onset of symptoms might provide useful information about underlying cognitive distortions. Background information Detailed history of patient is necessary, including patients premorbid personality. Figure 2. Table 6 Session structure of cognitive behavioral therapy.

Starting treatment First treatment interview has mainly four objectives: To establish a warm collaborative therapeutic alliance To list specific problem set and associated goals To psycho-educate patient regarding the cognitive model and vicious cycle that maintains the depression Give the patient idea about further treatment procedures.

CBT can be explained in the following headings Starting treatment Behavioral interventions Working with negative automatic thoughts Ending session. Starting treatment The first treatment interview has four main objectives: To establish a warm, collaborative therapeutic alliance To list specific problems and associated goals, and select a first problem to tackle To educate the patient about the cognitive model, especially the vicious circle that maintains depression To give the patient first-hand experience of the focused, workman-like, empirical style of CBT.

Developing this list at the end of the first session helps in planning treatment goals Introducing cognitive model of depression:- In the first session at least a basic idea about how our cognitions affect our emotions and behavior is taught to the patient.

The data provided by patient can be used to give insight into behaviors Where to start:-Common treatment goal is agreed upon by patient and therapist, therapeutic alliance is of key importance in CBT.

Behavioural interventions Reducing ruminations It has been seen that depressed patients spend a significant amount of time and attention focusing on their shortcomings. Monitoring activities Loss of interest in day to day activities is central to the depression. Planning activities Once the patient learns to self-monitor activities each day is planned in advance.

Other important behavioral activities are:- Mindfulness meditation: Helps people stay grounded in the present by keeping away from ruminations Successive approximation: Breaking larger tasks into smaller tasks which are easy to accomplish Visualizing the best part of the day Pleasant activity scheduling. Working with negative automatic thoughts The main tool for this negative automatic thought record. Thought Record Thought Record — 2.

Identifying negative automatic thoughts Patients learn to record upsetting incidents as soon as possible after they occur delay makes it difficult to recall thoughts and feelings accurately.

They learn: To identify unpleasant emotions e. This is important since change is rarely all-or-nothing, and small improvements may otherwise be missed To identify the problem situation.

What are alternative views? What are advantages and disadvantages of this way of thinking? What are my thinking biases? Common cognitive distortions are Black— and— white also called all— or— nothing, polarized, or dichotomous thinking : Situations viewed in only two categories instead of on a continuum. Testing negative automatic thoughts: What can I do now?

Ending the treatment CBT is time-limited goal-directed form of therapy. Dysfunctional assumptions identification Consolidating learning blueprint Preparation for the setback. Dysfunctional assumptions identification Once the patient is able to identify negative automatic thoughts. If such advantages are not recognized and taken into account when new assumptions are formulated, the patient may be reluctant to move forward In what ways is the rule unhelpful?

Perfectionism leads to rewards, but it also undermines satisfaction with achievements and stops people learning from constructive criticism What alternative rule might be more realistic and helpful? This provides a new guideline for living, rather than simply undermining the old system What needs to be done to consolidate the new rule? Consolidating learning blueprint The patient should be able to summarize whatever he has learned throughout the sessions. The following questions might help to set the framework: How did my problems develop?

Preparation for the setback Since depression is recurring illness patient should be made aware about the possibility of relapse. Feelings, behaviors, and symptoms that might indicate the beginning of another depression are identified and listed If I notice that I am becoming depressed again, what should I do?

Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Beck J, Hindman R. Cognitive therapy. Fennell M. Cognitive behaviour therapy for depressive disorders. New Oxford Textbook of Psychiatry. New York: Oxford University Press; American Psychiatric Association.

Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression.

J Consult Clin Psychol. Combined pharmacotherapy and psychological treatment for depression: A systematic review. Arch Gen Psychiatry. Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy. Boyes A. Support Center Support Center. External link. Please review our privacy policy. It is used to reduce symptoms of depression as an independent treatment or in combination with medications.