Depression

ADULTS Ian H. Gotlib, Karen L. Kasch

CHILDREN AND ADOLESCENTS Judith Semon Dubas, Anne C. Petersen

Depression and Interpersonal Relationships

Depression in adults can often have a negative impact on interpersonal relationships. Depressed people evaluate their social skills negatively, reporting that they do not enjoy, and are not very adept at, socializing (Davis 1982; Lewinsohn et al. 1980). Independent observers have documented that depressed people have fewer social skills than nondepressed individuals (Segrin 2000). The relationships of depressed people are often characterized by low intimacy, poor communication, and withdrawal, characteristics that may lead to rejections and disappointments. Indeed, depression in individuals can lead others around them to feel irritability, anger, and fatigue; depressed people have been found to exhibit a high level of dependency on others, or to withdraw from others, both of which can put a strain on interpersonal relationships.

Late-twentieth-century research indicates that depression also adversely affects the quality of relationships with spouses and children. For example, investigators have found the interactions of married couples in which one spouse is depressed to be characterized by less cooperation and more angry exchanges than is the case among couples in which neither spouse is depressed (Davila 2001; Goldman and Haaga 1995). Not surprisingly, depression in marriage has been shown to be strongly associated with distress and disruptions in marital relationships; indeed, the rate of divorce among individuals who have experienced clinical depression is significantly higher than is the case among nondepressed individuals (e.g., Wade and Cairney 2000).

Given the high level of marital distress and discord associated with depression, it is not surprising to learn that the children of depressed parents have themselves been found to exhibit greater emotional and somatic symptomatology, and to have more school, behavioral, and social problems, than have children of nondepressed parents. Children of depressed parents have also been found to be at elevated risk for developing psychopathology (see Gotlib and Goodman 1999, for a review of these literatures). Several lines of research have emerged trying to understand the mechanisms underlying the elevated levels of psychopathology among children of depressed parents (Goodman and Gotlib 1999). Whereas a number of investigators have examined the genetic transmission of risk for depression from parent to child (e.g., Wallace, Schneider, and McGuffin 2002), other researchers have focused on aspects of the relationships between depressed parents and their children. For example, when they are depressed, adults are less effective at disciplining their children and are more likely to exhibit frustration and anger or withdraw and behave in a rejecting manner when they cannot achieve their desired outcomes with their children. Children of depressed parents may also model their parent's behavior and either act out and exhibit anger, or become isolated and withdrawn. They may feel unloved and find that they only get attention when they misbehave, which will tend to increase the amount of misbehavior. Depressed parents may come to rely to heavily on their children to perform tasks that they have become unable to carry out. Depressed parents may also rely too heavily on their children for emotional support when their marital relationship becomes strained. In this context, a depressed parent may share information that a child is unable to handle emotionally, such as thoughts of suicide or hopelessness.

Treatment of Depression

Depression is a treatable disorder. Because there are a variety of methods for treating depression, people who experience depression have several choices with respect to the type of treatment they choose to undertake. Treatments that focus on the depressed individual alone include pharmacotherapy (e.g., antidepressant medication) and psychotherapy (e.g., cognitive therapy, behavior therapy, or social skills training). Depressed people who are married may choose from these individual approaches to treatment, or they may undertake marital or family therapy for depression. Regardless of which form of treatment a depressed person chooses, it is important that the treatment has been demonstrated empirically to be effective in reducing depressive symptoms.

Although it may seem counterintuitive to treat marital problems in order to alleviate depression, there is evidence in support of the efficacy of this type of treatment, particularly in distressed marriages. Indeed, there are several different forms of marital and family therapy that are effective in the treatment of depression. For example, in maritally distressed couples, marital therapy has been found to be effective in treating depression in the context of marriage. K. Daniel O'Leary, Lawrence Riso, and Steven Beach (1990) asked wives in distressed marriages to identify which came first, the marital problems or their depression. In couples who reported that marital discord preceded the onset of depression, the wives reported that the marital distress was an important cause of their depression. This raised the possibility that marital therapy would be a way of targeting the perceived causes for depression. In fact, studies have demonstrated that marital therapy is as effective as individual cognitive-behavioral therapy in alleviating depressive symptoms of spouses in distressed marriages. Moreover, patients receiving marital therapy have been found to report higher marital satisfaction than do patients receiving cognitive-behavior therapy (Jacobson et al. 1991; O'Leary and Beach 1990). Steven Beach, Mark Whisman, and K. Daniel O'Leary (1994) suggest that behavioral marital therapy is an effective intervention for a specific subgroup of married depressed patients.

Interpersonal therapy (IPT) for depression usually takes approximately twelve weeks and also focuses on the current marital distress. Although IPT bears some relationship to psychodynamic treatments that preceded it, its focus is different. Instead of dealing with past conflicts and unconscious material, this treatment emphasizes current problems and concerns. This form of treatment was adapted in the late twentieth century to work with geriatric populations by including certain kinds of concrete help in the treatment (e.g., obtaining transportation for the patient to attend sessions), flexibility in the length of sessions, and acknowledging the different life circumstances of older adults that may make some solutions less feasible or desirable (e.g., divorce after a long marriage; see Gotlib and Schraedley 2000 for a review of IPT for depression).

Another form of treatment for depression that has an interpersonal focus is behavioral family therapy. Like interpersonal therapy, behavioral treatment focuses on current problems. Behavioral treatment emphasizes concrete and specific behavior changes, along with skills training as needed. Early in the treatment, families in which a member is depressed are educated about depression's symptoms and consequences. The therapist underscores both the legitimacy of the disorder and the importance of treatment compliance, both for the person suffering from depression and for the family. In addition, families are taught better communication skills, including how to compromise, negotiate, manage anger, constructively express feelings, and listen empathically. Families are also provided with problem-solving skills training, and learn to concretely define their goals and generate more solutions to achieve those goals.

Finally, cognitive-behavioral family therapy has also been found to be effective in the treatment of depression. As with behavioral treatment, cognitive-behavioral family therapy also offers skills training in communication and problem solving as needed. In addition, the therapist models appropriate behavior: for example, parental discipline as part of skills training in parenting. Here, too, the focus is on current problems and concerns. Although cognitive-behavioral treatment is similar to behavioral therapy in its emphasis on current behavior and training of skills, this form of treatment is based on the notion that people's thoughts about events and actions lead them to make specific attributions about the event or action. This process may lead them to have overly negative expectations of their relationships and interpersonal interactions. Individuals with these negative cognitive schemas are also believed to filter their experience through the lens of their expectations, perceiving more of their interactions as negative than is actually the case. One of the therapist's primary tasks is to help the family identify attributions and the irrational beliefs that underlie them. The therapist demonstrates to the family how these thoughts and beliefs can affect their behavior and the behavior of those with whom they come into contact. Once the therapist has elucidated the relationship between the cognitions and behavior, cognitive restructuring can begin. Cognitive restructuring involves the therapist helping the family to understand the irrationality of the original maladaptive cognitions. According to cognitive-behavioral theory, by changing people's attitudes and beliefs, cognitive restructuring leads to behavior change.

Depression and Culture

Depression is a heterogeneous condition that may call for different types of treatment depending on the specific marital context in which the depressed person lives. Depression also occurs, of course, in many different cultural contexts. As with any disorder, depression can interact with culture and values; consequently, treatments need to be culturally sensitive and aware. Moreover, these different values mean that specific treatments or recommendations may be more useful and effective in some groups and, in fact, may even be contraindicated in others. For example, in African-American families, there is generally less of an emphasis on culturally defined gender roles than is the case in Caucasian families. Employment for women from African-American families has been found to be helpful to these women and their families, whereas employment showed fewer benefits for Caucasian women and their families, at least among older adults (Cochran, Brown, and MacGregor 1999). Therefore, clinicians may find that helping African-American women gain access to employment opportunities would be a useful intervention, whereas Caucasian women may receive fewer benefits from such help.

In Asian cultures, in which there is a greater focus on the interdependence of family members and connection with other people within the larger culture, depression may manifest in different ways than in the West and may therefore respond to different types of treatment. Because of Asians' greater cultural emphasis on social connection, what are viewed as symptoms of depression in the West may be interpreted more as interpersonal difficulties in these cultures. In addition, Asians may focus more on somatic difficulties than on emotional symptoms, perhaps in part because they make fewer mind/body distinctions in their culture than do Westerners. Therefore, "depression" in those cultures may be expressed and experienced more through physical than emotional symptoms. This may also be related to the fact that emotional problems are typically viewed as more stigmatizing in Asian cultures than they are in the West. Because of this greater stigma, Western treatments of discussing feelings and troubles are often contraindicated with Asian patients because this may exacerbate emotional pain and the shame, rather than alleviating suffering. Finally, Asians generally experience greater family and social connections and support than do people in Western cultures. This seems to be somewhat protective against depression and rates of depression in Asian countries such as Japan, China, and Taiwan are lower than in the Western world.

Latin/Hispanic cultures also place a greater emphasis on family than do many other Western cultures. Although the social support from family is protective, poverty and lack of resources continue to plague many Latino communities. Latino families living in the United States may find themselves relatively isolated from American culture and opportunities and, consequently, at greater risk for depression and other difficulties. Given the findings that lower acculturation is associated with more depression (e.g., Hovey 2000), it would seem important to aid less assimilated families in accessing resources and finding ways to become acculturated while maintaining their original cultural identity. In addition, it is crucial that clinicians attempt to remove the linguistic, cultural, and practical barriers to treatment faced by many minority populations. Finally, clinicians need to be sufficiently culturally knowledgeable to understand certain symptoms in context. For example, in Puerto Rican culture, dissociative states may be a normal part of spiritual practice, though these states would generally be considered psychopathological in mainstream U.S. culture (Tsai et al. 2001). Clinicians who can recognize culturally normative practices and differentiate them from pathology, and who develop culturally appropriate treatments, will be the most likely to be successful in alleviating their patients' distress.

Depression Classifications

The classification and investigation of depression typically focuses on: depressed mood, depressive syndromes, or clinical depression (or depressive disorders). Each approach reflects differences in assumptions concerning the nature of depression and denotes different levels of depressive phenomena (Petersen et al. 1993; Cicchetti and Toth 1998).

Depressed mood. Research on depressed mood has focused on depression as a symptom denoted by feelings of sadness, unhappiness, or the blues lasting for an unspecified period of time. It is differentiated from normal sadness by the absence of positive affect, a loss of emotional involvement with other persons, objects, and activities, and negative thoughts about oneself and the future (Fombonne 1995). Self-report measures are most often used with older children and adolescents; parent and/or teacher reports are typically used for younger children.

Depressed mood occurs in about one-third of all youth at any point in time, and ranges from 15 to 45 percent among adolescent samples. Results from the few studies that have charted depressed mood across the adolescent years suggest that it peaks around the ages of fourteen and fifteen and then attenuates slightly (Petersen, Sarigiani, and Kennedy 1991). Reliable gender differences do not exist until adolescence, when girls are more likely to experience depressed mood than boys.

Depressive syndromes. Depressive syndromes involve sets of symptoms that have been shown to occur together. Behavior problem checklists, completed either by children/adolescents or parents/teachers, are the main source of identification. These checklists usually include either severity or frequency ratings and consist of items such as sadness, moodiness, sleep disturbances, feelings of worthlessness, guilt, and loneliness. Most research examining depressive syndromes has used a cutoff score corresponding to the ninety-fifth percentile in nationally representative samples. In comparing the mean scores on the Anxious/Depressed Syndrome of the Child Behavior Checklist across twelve cultures (ages ranged from six to seventeen years), Alfons Crijnen and colleagues (1999) found Germany, the Netherlands, Sweden, and Thailand to be lower on average, whereas Greece, Israel, Puerto Rico, and the United States were above average, with Australia, Jamaica, Belgium, and China being average. Girls obtained higher scores than boys across all cultures.

Clinical depression. Clinical depression is more severe and lasts longer than depressive mood or syndromes and has a major impact on daily living. Clinical depression is identified by categorical diagnoses, such as those described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association 1994) or the International Classification of Diseases (ICD-10) (World Health Organization 1996). Most often these diagnoses are made through individual interviews with a clinical psychologist. According to the DSM-IV, two forms of depression have been identified: Major Depressive Disorder (MDD) and Dysthymic Disorder (DD).

The diagnosis of MDD requires the presence of at least five of nine symptoms during the same two-week period, with one of the symptoms being depressed mood (dysphoria) for most of the day nearly every day or loss of interest and pleasure (Kolvin and Sadowski 2001). Irritable mood in children and adolescents may be substituted for depressed mood. The other possible symptoms include: significant weight change (in children, the failure to make expected weight gains), insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or inappropriate guilt, diminished ability to concentrate or indecisiveness, and recurrent thoughts of death, suicidal ideation, or suicide attempt. The symptoms are not due to direct psychological effects of a substance, a general medical condition, or bereavement. An episode of MDD in children lasts, on average, about eleven months, with recovery generally taking about seven to nine months (Kovacs and Sherill 2001). Estimates of the point prevalence of MDD range from 0.4 to 2.5 percent for children and from 0.4 to 8.3 percent for adolescents (Birmaher et al. 1996; Verhulst et al. 1997). The estimated lifetime prevalence of MDD for adolescents is 15 to 20 percent, a rate comparable to that for adults (Harrington, Rutter, and Fombonne 1996).

The diagnosis of DD requires the experience of depressed mood for most of the day, for most days for at least two years (Kolvin and Sadowski 2001). For children and adolescents irritable mood and a duration of at least one year are allowed as alternative criteria. Two of six additional symptoms (poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, poor self-esteem, difficulty concentrating or making decisions, and feelings of hopelessness) are also required.

There appears to be a trend for both an increased rate of depression across generations, and an earlier onset of major depressive disorder, with more onsets occurring during adolescence than previously (Fombonne 1995). A recent review of the gender differences in rate of clinical depression concluded that prior to puberty boys are anywhere from two to five times more likely to exhibit depression than are girls, whereas after age thirteen this difference shifts to girls with depression occurring at least twice as frequently in girls and women as in boys and men (Angold and Costello 2001)

Additional co-occurring problems with depression. Studies on both community and clinical samples report that anywhere from 7 to 51 percent of depressed children and adolescents have multiple psychiatric disorders, with anxiety and conduct or disruptive behavior disorders as the most common co-occurring disorders (Kovacs and Sherrill 2001). Anxiety disorders often precede depressive conditions. Eating disorders and drug and alcohol use often co-occur with depressive symptoms. Adolescents with affective disorders have a higher than normal risk of suicide.

Causes

There is no single cause for depression and any single risk factor rarely results in depressive outcomes. Rather, the structure of biological, psychological, and social systems over an individual's development need to be considered (Cicchetti and Toth 1998).

Heredity. Although there is no conclusive evidence that there exists a specific, single gene for depression, there is evidence that some families have an inherited vulnerability to depression. Close relatives of depressed people have a 15 percent chance of inheriting major depression. An identical twin with a depressed twin is 67 percent more likely to be depressed. A child having one depressed parent is six times more likely to develop depression than a child without a depressed parent and the risk for a child to develop depression increases to 40 percent if both parents are depressed. The parents and extended family members of depressed children are not only more likely to exhibit a higher incidence of depression but also found to have higher levels of anxiety, substance abuse, and antisocial behavior (Cicchetti and Toth 1998). Although this association is partially a result of heredity, the environment that family members share also contributes to depressive symptoms (Rende et al. 1993). The fact that many depressed children promptly recover when hospitalized, even when no other treatments are administered, lends additional credence to the role the family may play in a child's depression (Cicchetti and Toth 1998). Additionally, relapse of depression after being released from in-patient psychiatric care is confined primarily to children who return home to an environment characterized by high emotional overinvolvement, criticism, and hostility (Asarnow et al. 1993).

Parental depression. As noted above, children having one or two clinically depressed parents are more vulnerable to developing depression than children without a depressed parent. In addition, more severe and chronic parental depression is associated with greater impairment in children (Goodyer 2001). Several possible mechanisms for the increased vulnerability to depression for children of depressed parents, besides direct hereditary transmission of depression, have been proposed. Most research in this regard has focused on mothers and how they interact with their children, although more recent work is including fathers. A parent struggling with his or her own depression may not be able to provide adequate responsiveness and care to children as the depression may interfere with the ability to react flexibly and creatively to the normative challenges that parenting entails (Kaslow, Deering, and Racusin 1994). Children of depressed mothers are at greater risk for an insecure attachment and for disruptions in emotional regulation (Cicchetti and Toth 1998; McCauley, Pavlidis, and Kendell 2001), which, in turn, increases a child's vulnerability for depression. Compared to nondepressed mothers, depressed mothers are more likely to use withdrawal, conflict avoidance, or overcontrolling strategies rather than negotiation to cope with child noncompliance (McCauley, Pavlidis, and Kendell 2001). Depressed mothers and fathers tend to be more hostile and irritable when interacting with their children, and the marital relationship itself often is characterized as dysfunctional and conflictive. Moreover, families with a depressed parent experience increased and persistent stressors, further taxing a parent's ability to cope constructively. Hence, not only is child nurturance disrupted but also a depressed parent serves as a role model for depressive thinking (McCauley, Pavlidis, and Kendell 2001). Moreover, the child becomes increasingly exposed to stressful life events that are not under his or her control, further increasing vulnerability to feelings of helplessness, hopelessness, and depression. Thus, children of depressed parents are at increased hereditary risk for depression, are more likely to experience disruptions in both physical and emotional relations with parents, have parental role models for depressive thinking, and are more likely to experience stressful life events and conflict. Together these findings underscore how children of depressed parents are exposed to a variety of risk factors that increase their vulnerability for depression.

Family context. Compared to families of nondepressed children, families of depressed youth have higher levels of marital and parent-child conflict, low levels of family cohesion, and diminished overall social support. Regardless of ethnicity, social class, or parents' marital status, parents who are accepting, firm, and democratic have adolescents who report less depression (Steinberg et al. 1991; Herman-Stahl and Petersen 1996). Longitudinal studies have also demonstrated that adolescents with warm family relations are less likely to become depressed several years later (Petersen, Sarigiani, and Kennedy 1991).

Dante Cicchetti and Sheree Toth (1998) propose that a vulnerability to depression may begin in infancy if there is an insecure attachment to primary caretakers. Infants who are insecurely attached are more likely to have less than optimal emotional regulation and expression, and as these infants grow into young children significant others are perceived as unavailable or rejecting while the self is perceived as unlovable. These perceptions may contribute to a proneness to self-processes that have been linked to depression (e.g., low self-esteem, helplessness, hopelessness, and negative attributional biases). When combined with additional environmental stressors these self-processes may contribute to a modification of hormonal and brain processes that further increase vulnerability.

Brain and hormonal processes. Research on biological disregulation during depression focuses on the hypothalamic-endocrine and neurotransmitter systems. As noted in the Surgeon General's report on mental health (1999), some of the primary symptoms of depression, such as changes in sleep patterns and appetite, are related to functions of the hypothalamus. The hypothalamus, in turn, is closely linked to the pituitary gland. Increased rates of circulating cortisol and hypo- and hyperthyroidism, each associated with pituitary function, are established features of adult depression. Research on the hypothalamic-endocrine link involved in childhood and adolescent depression focuses on the hypothalamic-pituitary-adrenal (HPA), hypothalamic-pituitary-gonadal (HPG), and hypothalamic-pituitary-somatotropic (HPS) axes, all of which are related to growth processes and pubertal change (Brooks-Gunn, Auth, Petersen, and Compas 2001). In each of these axes the hypothalamus secretes a releasing hormone that triggers the pituitary to release a stimulating hormone, which, in turn, then stimulates the secretion of an additional hormone by the particular gland in question (adrenal, gonadal, thyroid). This hormone is then released into circulation, inhibiting the hypothalamus and pituitary to produce more releasing and stimulating hormones (Brooks-Gunn et al. 2001). Variations from normal patterns of coritsol and dehydroepiandrosterone (both from the HPA axis), prolactin (from the HPG), and growth hormone (from the HPS axis), have been observed among depressed children and adolescents (Dahl et al. 2000; Schulz and Remschmidt 2001).

At the neurotransmitter level, differences in serotogenic, cholinergic, noradrenic, and dopaminergic systems have all been associated with depression (Brooks-Gunn et al. 2001; Sokolov and Kutcher 2001). Whereas early research focused on deficiencies or excesses in neurotransmitter substances, current research now focuses on the functioning of the neurotransmitter systems with respect to the storage, release, reuptake, and responsiveness (Sokolov and Kutcher 2001). New research is examining the interaction between the hypothalamic-endocrine and neurotransmitter systems. However, as noted by Jeanne Brooks-Gunn and her colleagues (2001), less certain is whether changes and deficits in these systems are causes, correlates, or a result of depression. Nevertheless, once a depressive episode occurs, biological disregulation follows, further influencing behavior, thought, mood, and physiological patterns.

Cognitive factors. Attributional bias and coping skills are the two main cognitive factors investigated with respect to understanding depression. Considerable research has focused on the pessimistic attributional biases that are prevalent among depressed adults. A person with this bias readily assumes personal blame for negative events, expects that one bad experience will be followed by another, and that this pattern will endure permanently. Individuals who think this way have a tendency to cope with situations more passively and ineffectively than those without this bias. Among children, this attributional style is related to depression after the age of eight years; prior to this, childhood depression is primarily linked to negative life events (Nolen-Hoeksma, Girgus, and Seligman 1991).

Adaptive coping skills are important in order to regulate negative emotions when unpleasant and challenging events occur. Problem-focused coping refers to how an individual responds to the demands of a stressful situation in terms of active efforts to do something about the problem. Emotion-focused coping, in contrast, refers to the individual's attempts to control the emotion experienced. One form of emotion-focused coping is rumination: the tendency to focus repetitively on feelings of depression and their possible causes without taking any actions to relieve them. Another form is avoidant coping: the tendency to withdraw from or avoid stressors or to deny their existence. Emotion-focused coping such as rumination and avoidant coping have been linked to depression in adults, adolescents, and children (Herman-Stahl and Petersen 1999; Nolen-Hoeksma 1998).

Gender Differences

Most theories concerning gender differences have focused on explaining the female preponderance during adolescence and adulthood. Males and females appear to have different coping styles: males distract themselves, whereas females ruminate on their depressed mood and therefore amplify it (Nolen-Hoeksma 1998). Most young adolescents are faced with significant changes in every aspect of their lives: pubertal development, cognitive maturation, school transition, and increased performance pressures in academics. For many adolescents these events are stressful. Girls experience more challenges during adolescence compared to boys, including more negative life events, simultaneous changes in pubertal development and school transitions, making them more vulnerable to depression (Petersen, Sarigiani, and Kennedy 1991). Not only are differences in challenges and coping important but the hormonal changes that accompany pubertal development may also make girls more vulnerable (Angold, Costello, and Worthman 1998). Thus, it now appears that a combination of factors, including less effective coping styles, more challenges, and hormonal changes, may help to explain the gender differences in depression during adolescence.

Treatment

Treatments for depression in children and adolescents generally include three forms: pharmacological, psychotherapy, and a combination of the two. Unlike studies on adults, methodologically sound investigations on the relative effectiveness of each type of therapy on youth are only just beginning to be conducted. Thus, most findings are based on a few studies and therefore need to be interpreted cautiously.

Pharmacological. The drugs most commonly used for treating depression in children and adolescents are available in three major types: the monoamine oxidase inhibitors (including phenelzine and tranylcypromine), the tricyclic antidepressants (including lofepramine, imipramine, and nortriptyline) and the recently developed selective serotonin and serotonin-noradrenergic re-uptake inhibitors (including fluoxetine, paroxetine and venlafaxine) (Schulz and Remschmidt 2001). Although virtually all medications found to be effective for adult depression have been tested with children, systematic studies with clear results are rare, and superiority of antidepressant medication over placebos for children and adolescents has not been reliably demonstrated (Kovacs and Sherrill 2001; Schulz and Remschmidt 2001). Therefore, antidepressant medications should only be prescribed for children and adolescents when: symptoms are so severe that they prevent effective psychotherapy; symptoms fail to respond to psychotherapy; and the depression is either chronic/recurrent, nonrapid bipolar, or psychotic (Schulz and Remschmidt 2001). Selective re-uptake inhibitors are the initial antidepressant of choice, although the presence of other symptoms such as impulsivity, suicide, or attention deficit hyperactivity disorder (ADHD) may require alternative medications (Schulz and Remschmidt 2001).

Psychotherapy. Studies of psychosocial interventions for depression among youngsters have traditionally included clinically diagnosed children, children classified as having a depressive syndrome, or youngsters deemed at risk for depression based on elevated scores on depressive symptom checklists. Controlled psychotherapy trials on clinically depressed youth typically include short-term cognitive behavioral therapy (CBT) delivered in individual or group format (Kovacs and Sherrill 2001). Cognitive behavioral therapy is based on the premise that depressed individuals have distortions in thinking concerning themselves, the world, and their future. Thus, therapy focuses on changing or preventing these distortions (cognitive restructuring), and also includes training in social skills, assertiveness, relaxation, and coping skills. Of the seven clinical studies reported to date, 35 to 90 percent of the youths recovered, with higher rates of success for experimental therapies than the control conditions (Kovacs and Sherrill 2001). Although only two studies included a parent component as part of the treatment condition, including the parent component did not improve outcomes. Interventions targeted at nonclinical but at-risk youth identified in school settings have had even more favorable results. Seven of eight studies reported decreases in depressed mood and syndromes. One demonstrated long-term effects of the intervention in reducing the likelihood for developing clinical levels of depression. These promising results highlight the beneficial effects of early identification and prevention efforts. Additional studies are needed to clarify how parents and other family members may be included in treatment programs.

According to Maria Kovacs and Joel Sherrill (2001), clinically referred depressed youth usually experience a disruption to the parent-child relationship. Because depressed children and adolescents are either unwilling or unable to verbalize their affective experience, parents, in turn, may withhold emotional support, guidance, and expressions of affection. Based on their work and that of others, Kovacs and Sherrill suggest that the most appropriate treatment of depressed juveniles should include structured, goal-directed, or problem-solving oriented interventions that focus on symptom reduction, enhancement of self-esteem, and social/interpersonal skill development. In addition, involvement of the parents or primary caretakers is essential and should occur at two levels. First, parents should be assessed to determine if they themselves suffer from a form of emotional or mental disorder. Those who are positively identified should receive treatment. Second, parents should be engaged as agents of change in treatment of their own children, including some sessions explicitly focused on the depressed child's needs and concerns.