Mark A Reinecke John F Curry

Depression among children and adolescents is an important social and clinical concern. Epidemiological studies indicate that, at any given time, approximately 1-3% of children and 5-7% of adolescents meet criteria for major depressive disorder (MDD; Essau & Dobson, 1999). Depression during childhood and adolescence is associated with impaired social and academic performance, and places young people at risk for alcohol and substance abuse. Many youth who meet criteria for MDD also meet criteria for additional psychiatric disorders. In a national sample of adolescents with major depression (Treatment for Adolescents with Depression Study [TADS] Team, 2005), halfmet formal criteria for one or more comorbid disorders.

Of particular concern is the fact that depression places adolescents at increased risk for suicidal ideation, attempts, and completions (Brent, 1995; Shaffer et al., 1996). Depression also places youth at risk for adult depression and psychosocial impairment (Weissman et al., 1999).

Depression among youth is often chronic and persistent. Kovacs, Obrosky, Gatsonis, and Richards (1997), for example, reported that the median duration of a major depressive episode in a sample of 8- to 13-year-olds was 9 months, and that the median duration of dysthymic disorder was

3.9 years. The median duration of depressive episodes at baseline among youth enrolled in the TADS was 40 weeks and the mean was 71 weeks (TADS Team, 2005). At the same time, depression among children and adolescents tends to be recurrent. Rao and colleagues (1995) reported a 7-year recurrence rate (i.e., emergence of depressive symptoms after a period of sustained recovery from a depressive episode) of approximately 70% among depressed youth.

Taken together, these findings suggest that early-onset depression might be viewed as a chronic, recurring disorder. How, though, shall we define "chronic"? Several approaches have been proposed. One might note the duration of a depressive episode, with episodes exceeding a particular length being defined as "chronic" or "persistent." Alternatively, one could count the number of episodes an individual has experienced (an index of recurrence), or note whether an individual has failed to respond favorably to a trial of treatment. There is little consensus, however, as to the definition of chronic depression; how duration of episode, recurrence, and treatment response are related to one another; or how these guide treatment planning for youth.

How, then, are we to understand chronic depression among youth? In one sense, childhood depression might not be seen as a chronic disorder. Inasmuch as children are, most often, experiencing their first depressive episode, one correctly hesitates to presume that it will become a chronic condition. As we have seen, however, early-onset major depression can be a pernicious disorder, whether persistent or recurring. We propose, then, that early-onset depression may in certain cases be viewed as a particularly malignant subtype of MDD and may be conceptually similar to chronic depression among adults. Like early-onset diabetes or cystic fibrosis, it may follow a fluctuating course and may not spontaneously remit. Early-onset depression may usefully be conceptualized as a chronic disorder and treated accordingly. Childhood depression is an important concern in that evidence suggests that each subsequent episode of depression may increase the likelihood that an individual will experience additional episodes in the future. Studies with depressed adults suggest that the brain may become sensitized when exposed to repeated episodes of depression, reducing the threshold for activation of subsequent episodes (Kendler, Thornton, & Gardner, 2000).

Although important advances have been made during recent years in understanding and treating depression during childhood and adolescence, these disorders continue to present a challenge for clinicians. Over one-fourth of clinically depressed children and adolescents do not respond to treatment with either psychotherapy or medications, and many of those who do respond do not experience a full or complete amelioration of their symptoms. Moreover, relapse and recurrence rates after discontinuation of antidepressant medications are unacceptably high.

More effective strategies for managing treatment-resistant depression and chronic depression among youth, then, are needed. A number of factors appear to be associated with long-term outcomes. Among adults, chronicity and severity of previous episodes of depression are among the most consistent predictors of long-term outcome (Simon, 2000). Research is ongoing into predictors and moderators of adolescent treatment response. Little is known, however, about characteristics of recovered children or adolescents that may predict relapse or recurrence. Existing treatment strategies might be refined, so that they are more effective with these very challenging cases, and approaches based upon research in developmental psychopathology (Reinecke & Simons, 2005) should be developed.

In this chapter we discuss contemporary cognitive-behavioral therapy (CBT) approaches for conceptualizing and treating depression among adolescents, and briefly discuss evidence for the efficacy and effectiveness of these approaches. We conclude with a discussion of possible areas for research and clinical innovation.

Natural Depression Cures

Natural Depression Cures

Are You Depressed? Heard the horror stories about anti-depressants and how they can just make things worse? Are you sick of being over medicated, glazed over and too fat from taking too many happy pills? Do you hate the dry mouth, the mania and mood swings and sleep disturbances that can come with taking a prescribed mood elevator?

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