Treatment for Depression
What parents need to know about therapy, medication and finding a good clinician
Getting treatment for depression can feel daunting. Often the depression itself gets in the way. A child who is depressed might be feeling overwhelmed, tired and hopeless. She might also be unfairly blaming herself or her circumstances for the way she feels. These are some of the characteristic symptoms and thoughts that accompany depression, and they can make it hard for someone who’s depressed to speak up and ask for help, or believe concerned parents when they say treatment for depression can help them.
But treatment can really help children and adolescents struggling with depression, including several different kinds of therapy and medication that have all been proven to be effective. The kind of treatment recommended for your child will depend on her symptoms and preferences, and the expertise of her clinician. Many clinicians recommend that if a child is taking antidepressant medication then she should also be participating in therapy.
Wendy Nash, MD, a psychiatrist at the Child Mind Institute, says she considers therapy “nearly a requirement” when she is prescribing medication for depression, explaining that “people have to learn the skills taught in therapy.” Part of the advantage with therapy is that the skills children learn will always stay with them.
What to expect from a clinician
Having a good relationship with your clinician is essential, because the more engaged and committed a person is in treatment, the more likely it is to be successful. A good clinician should make sure you understand the goals of treatment and make you feel like your questions are being taken seriously. You should also feel like you can be honest about how you are doing.
Jill Emanuele, PhD, senior director of the Mood Disorders Center at the Child Mind Institute, says one of the first things she does with a new patient is try to establish a good rapport. “You get to know the person, you make them comfortable. You establish a safe space where you show them that you’re listening and you care. Often enough we’re the first person that’s actually listening to them in a way they haven’t experienced before, or have not experienced often.”
If a person is resistant to treatment, Dr. Emanuele says she tries to address that. “Maybe they’ve had a difficult experience with therapy before, or they don’t really trust adults, or perhaps they are shamed by their behavior or what they’re feeling, and they don’t want to show it to another person.” Dr. Emanuele says these are some common reasons why someone might be reluctant to start treatment. Good clinicians will try to address this resistance, explain how treatment works (and why it might be different from a previous experience), and gain the trust of their patient.
If your child hasn’t received a formal diagnosis yet, his clinician should also perform an evaluation. This is to confirm that your child actually does have depression, and also to determine if he may have another mental health or learning disorder as well. It isn’t that uncommon for kids with undiagnosed anxiety, ADHD, learning disorders and other issues to develop depression. If your child has multiple disorders, then his treatment plan should include getting help for all of them.
Therapy for depression
There are different kinds of therapy that are considered “evidence-based” for treating depression, which means that they have been studied and clinically proven to be effective. Here is a breakdown of some of them:
Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy is the gold standard therapy for treating children and adolescents with depression. CBT works by giving people skills to cope with symptoms like depressed mood and unhelpful thoughts (like “no one likes me” or “things will always be like this”). In CBT children and therapists actively collaborate to meet set goals, like catching those unhelpful thought patterns and improving problem-solving ability.
Central to the treatment is teaching people that their thoughts, feelings and behaviors are all interconnected, so changing one of these points can change all three. For example, one technique called “behavioral activation” encourages people to participate in activities and then observe the effect it has on their mood. In Dr. Emanuele’s words, “We set up a hierarchy of activities they can start to engage in. The idea is to get moving and active, so you not only get that physical momentum, but you also start to experience more positive thoughts from having success and interacting more with others.”
Behavioral activation helps counter the isolation that people with depression often experience, which can reinforce their depressed mood.
Dialectical behavior therapy (DBT)
For people with more severe depression, dialectical behavior therapy can be helpful. DBT is a form of CBT that was adapted for people who have trouble managing very painful emotions, and may engage in risky behavior, self-harm like cutting, and suicidal thoughts or attempts.
To manage intense emotions, people participating in DBT learn to practice mindfulness (being fully present in the moment and focusing on one thing at a time, without judgment) and develop problem solving skills like tolerating distress, handling difficult situations in a healthy way and interacting more effectively with friends and family. DBT is a highly structured treatment that includes individual therapy and skills groups. DBT for adolescents includes sessions with parents and their child learning skills together.
Interpersonal psychotherapy (IPT)
Social relationships can sometimes influence and even maintain depression. When a person is depressed her relationships can also suffer. Interpersonal therapy works by addressing a child’s relationships to make them more healthy and supportive. In this therapy children learn skills for better communicating their feelings and expectations, they build problem-solving skills for handling conflicts, and they learn to observe when their relationships might be impacting their mood.
IPT has been adapted for adolescents with depression to address common teen relationship concerns including romantic relationships and problems communicating with parents or peers. Called IPT-A, this specialized form of interpersonal therapy is typically a 12- to 16-week treatment. Parents will be asked to participate in some of the sessions.
Mindfulness-based cognitive therapy (MBCT)
While its efficacy is still being measured in adolescents, mindfulness-based cognitive therapy is another treatment that has been shown to work for young adults and adults with depression.
MBCT works by combining cognitive behavioral therapy (CBT) methods with mindfulness. Mindfulness teaches people to be fully present in the moment and observe their thoughts and feelings without judgment. This can help them interrupt undesirable thought patterns that can maintain or lead to a depressive episode, like being self-critical or fixating on negative things in ways that are not constructive.
MBCT was originally developed to help people with recurring episodes of depression, but it can also be used for treating a first episode of depression.
Children and adolescents with depression can also benefit from medication, and clinicians often prescribe medication for more severe depression or when therapy alone isn’t providing effective treatment.
Medications most often prescribed to treat depression are selective serotonin reuptake inhibitors (SSRIs) like Zoloft, Prozac and Lexapro, and serotonin-norepinephrine reuptake inhibitors (SNRIs) like Strattera and Cymbalta. These medications are also known as antidepressants. Your child’s clinician may also prescribe an atypical antidepressant like Wellbutrin.
Dr. Nash says that sometimes young people (and their families) are worried about taking medication for depression. People often worry that medication will change their personality, or they will feel “drugged.” They also worry that they might become addicted to the medication.
She takes these concerns seriously, and talks to patients and their families about what to expect. The right medication at the right dose won’t make a child feel drugged and it won’t change who he is, but it should help his symptoms of depression. She also explains that antidepressants are not addictive. “You don’t have an urge to take them, or seek them out to the detriment of your relationships,” she says. When it is time to stop taking antidepressants, it is uncommon for people to have ongoing symptoms of withdrawal if they taper off the medication carefully, and under the supervision of their doctor.
Dosage and side effects
It is rare for a person to stay on the same dose she is initially prescribed. Instead, doctors adjust dosage once every week or every two weeks in the beginning, as the medication builds up in the brain to reach an effective level. During this time your child’s clinician will ask questions about how she is tolerating the medication, including side effects she might be experiencing.
“Most uncomfortable side effects will present early,” says Dr. Nash. “I tell patients you might experience side effects before the desired effects.” Clinicians should stay in touch with families during these first several weeks, monitoring how children are feeling and providing guidance because, as Dr. Nash says, “It can be a hard time for patients, who might feel headaches or insomnia, but not feel better yet.” She says the side effects can go away after one to two weeks.
It can take a while for a patient to start feeling the full effect of an antidepressant medication. “The medication might start to work at two to four weeks, but you can still be feeling more benefit at six weeks further out,” says Dr. Nash.
Monitoring for suicidal thinking
The Food and Drug Administration has issued a warning that children and adolescents taking some antidepressant medications may experience an increased risk of suicidal thoughts. Many studies have shown that the benefits of antidepressant medications outweigh the risks of going without treatment, so they are still prescribed to young people. To keep patients safe, a protocol has been developed for prescribing clinicians to help them closely monitor patients for any worsening in depression or emergence of suicidal thinking as they are adjusting to a new medication.
Going off medication
To avoid a recurrence of depression, Dr. Nash says it is a good idea to stay on medication for at least a year after a child has stopped feeling any symptoms of depression. She also warns that it is important to think about the “optimal” time to stop taking medication. For example, it isn’t a good idea to stop taking his medication right before the SATs or when he’s going off to college.
To avoid unpleasant side effects, your child shouldn’t stop taking medication cold turkey. Tapering off antidepressants gradually, with the guidance of a clinician who is monitoring him to make sure he is healthy, is important.
Both Dr. Nash and Dr. Emanuele emphasize that families should always be involved in the treatment of a child’s depression. “Part of treatment, especially in the beginning, is to teach parents about depression and how therapy works, says Dr. Emanuele. “It’s really important that parents understand the concepts behind the treatments so that they can coach their child, day-to-day, to use the skills that they’re learning.” Dr. Emanuele adds that parents often find that they benefit from learning the skills as well.
Clinicians can also be helpful in giving parents tips on interacting with a child with depression, which can sometimes be difficult. Children with depression might try to isolate themselves from family, or interpret even well-meaning parental concern as critical rather than loving. Knowing how to be supportive is important. Dr. Emanuele says that she helps parents develop a situation-specific plan to help them know when to lean in and when to back off. Clinicians can also give advice about fostering more positive interactions.
For parents who are struggling because of their child’s illness, getting this support can be a big relief. And, of course, as soon as a child starts feeling better, her parents will start feeling better, too.