DEPRESSION AND ANXIETY 26:98–103 (2009)

Clinical Case Study

CLINICAL CASE STUDY: CBT FOR DEPRESSION
IN A PUERTO RICAN ADOLESCENT: CHALLENGES
AND VARIABILITY IN TREATMENT RESPONSE
Marı́a I. Jiménez Chafey, Psy.D., Guillermo Bernal, Ph.D., and Jeannette Rosselló, Ph.D.

Background: There is ample evidence of the efficacy of cognitive-behavioral

therapy (CBT) for depression in adolescents, including Puerto Rican adolescents.
However, there is still a high percentage of adolescents who do not respond to a
standard ‘‘dose’’ of 12 sessions of CBT. This clinical case study explores the
characteristics associated with treatment response in a Puerto Rican adolescent
and illustrates the challenges and variability inherent in CBT treatment for
major depressive disorder (MDD) in youth. Methods: The patient is a 15-year-
old adolescent female who at pretreatment presented a diagnosis of MDD with
severe depressive symptoms, high suicidal ideation, low self-concept, and highly
dysfunctional attitudes. CBT treatment consisted of 12 standard individual
therapy sessions plus four additional sessions, and one family intervention. A case
study method was used. Both qualitative and quantitative data for the case are
presented using self-report instruments, clinical case notes and recordings of
therapy sessions. Results: Some of the characteristics she presented that have been
associated with partial or no response to therapy were: increased severity of
depressive symptoms, a prior MDD episode, co-morbidity with other mental
disorders, and significant parental conflict. At termination the patient presented
decreases in depressive symptoms, dysfunctional attitudes, and suicidal ideation, as
well as improvements in self-concept. These improvements were maintained up to
1 year posttreatment. Conclusions: Cultural issues are discussed in terms of the
potential for parental conflict to perpetuate the patient’s depressive symptoms.
Depression and Anxiety 26:98–103, 2009. & 2008 Wiley-Liss, Inc.

Key words: cognitive-behavioral therapy; depression; adolescent

population given that most samples in clinical trials do

INTRODUCTION
There is ample research documenting the efficacy of
cognitive-behavioral therapy (CBT) for depression in
adolescents[1–7] including research specifically con-
ducted with Puerto Rican adolescents.[8] Studies that
have compared CBT to anti-depressant medications
have found mixed results, with some citing superior
outcomes for anti-depressants alone and the combina-
tion of CBT with anti-depressants when compared to
CBT alone,[6] and others that have found superior
outcomes with CBT alone when compared to anti-
depressants alone or a combination of both.[5] How-
ever, there is much debate over the ability to generalize
the results of these efficacy studies to the general
not resemble ‘‘real world’’ community samples in which
Department of Psychology, University of Puerto Rico, Rı́o
Piedras
Correspondence to: Marı́a I. Jiménez Chafey, Psy.D., Depart-
ment of Psychology, University Center for Psychological Services
and Research, University of Puerto Rico, P. O. Box 23174, San
Juan, Puerto Rico 00931-3174. E-mail: mijimenez@uprrp.edu
Received for publication 26 April 2007; Revised 1 November 2007;
Accepted 2 November 2007
DOI 10.1002/da.20457
Published online 9 September 2008 in Wiley InterScience
(www.interscience.wiley.com).

r 2008 Wiley-Liss, Inc.

 Clinical Case: CBT for Adolescent Depression
co-morbidity, suicidal ideation, and depression severity
tend to be higher, which in turn may complicate
treatment and effect treatment response.[9]
Many efficacy studies still reflect a high percentage of
adolescents who either do not respond or present a
limited response to standard treatment for depression.
Clinical trials using CBT and interpersonal therapy
(IPT) with Puerto Rican adolescents have found a 12-
session treatment using CBTor IPT to be efficacious in
59– 82% of adolescents treated for depression.[8, 10, 11]
In these studies efficacy was defined as a clinically
significant change in depressive symptoms where the
depressive symptomatology of posttreatment adoles-
cents was reduced to the normal or average range of a
community sample of adolescents. This suggests that
between 18 and 41% of Puerto Rican adolescents in
clinical trials continue to present symptoms of depres-
sion after 12 sessions of psychotherapy. Although it has
been demonstrated that a standard 12-session ‘‘dose’’ of
CBT is efficacious for over half of depressed Puerto
Rican adolescents participating in clinical trials, less
attention has been given to what the optimal dose or
number of sessions of CBT is for complete remission of
depression in adolescents. In particular, more attention
needs to be directed towards studying adolescents with
partial or limited treatment response, as well as
examining the variables associated with treatment
response.
In children and adolescents, studies have cited the
following factors as predictors of poor response to
CBT treatment for depression: severe depression,
anxiety, cognitive distortions, age of onset of the
disorder, co-morbid mental disorders, poor coping
skills, parent–child discord, parental divorce, and
parental depression.[12–14] In Puerto Rican youth,
nonresponse to psychotherapy for depression has been
associated with lower self-concept and more internaliz-
ing behavior[15] in press. This case study aims to
explore variables associated with a partial or limited
treatment response to CBTand illustrate the challenges
and variability in CBT treatment for major depressive
disorder (MDD) in adolescence.
CASE HISTORY AND
SYMPTOMATOLOGY
The patient was a 15-year-old Puerto Rican adoles-
cent female living with both her parents and a younger
sibling. Her parents presented with significant marital
problems had been separated several times and were
discussing divorce. Her mother reported having a
history of psychiatric treatment for depression and
anxiety and indicated that the patient’s father suffered
from bipolar disorder and had been receiving psychia-
tric treatment. He was hospitalized on multiple
occasions during previous years for serious psychiatric
symptoms.
99
The patient was failing several classes in school, and
her family was in the process of looking for a new
school due to her failing grades and difficulties getting
along with her classmates. She presented the following
symptoms: frequent sadness and crying, increased
appetite and overeating, guilt, low self-concept, anxi-
ety, irritability, insomnia, hopelessness, and difficulty
concentrating. In addition, she presented difficulties in
her interpersonal relationships, persistent negative
thoughts about her appearance and scholastic abilities,
as well as guilt regarding her parents’ marital problems.
The patient’s medical history revealed that she
suffered from asthma, used eyeglasses, and was over-
weight. Her mother reported that she had been
previously diagnosed with MDD 3 years ago and was
treated intermittently for 2 years with supportive
psychotherapy and anti-depressants (fluoxetine and
sertraline; no dosage information available). This first
episode was triggered by rejection by a boy for whom
she had romantic feelings. Her most recent episode
appeared to be related to her parents’ marital problems
and to academic and social difficulties at school.
DIAGNOSIS
A diagnosis of MDD was established using the
Diagnostic Interview Schedule for Children (DISC-
IV).[16] In addition, according to the DISC-IV, she also
met criteria for generalized anxiety disorder, separation
anxiety disorder, and attention deficit disorder. Symp-
toms of depression were assessed every 2–4 weeks
throughout therapy using the Children’s Depression
Inventory—CDI[17] (Fig. 1). The Children’s Depres-
sion Rating Scale—CDRS-R[18] was also used to assess
depressive symptoms at baseline, termination, and
follow-up (Table 1). In addition, other variables related
to depression were assessed at pre, mid, post and
follow-up treatment using the Piers Harris Children’s
Self-concept Scale—PHCSC,[19] the Hopelessness
Scale for Children—HSC,[20] the Dysfunctional Atti-
tude Scale—DAS,[21] and the Suicide Ideation Ques-
tionnaire—SIQ-Jr[22] (Table 1). At pretreatment
evaluation the patient presented depressive symptoms
Figure 1. Depressive symptoms at different phases of treatment
with CBT. CDI, Children’s Depressive Inventory.
Depression and Anxiety
100 Jime´nez Chafey et al.
TABLE 1. Measures of depression, suicidal ideation, dysfunctional attitudes, and self-esteem at pretreatment and
follow-up
Measure Pretreatment
Depression (CDRS-R) 60
Suicide ideation (SIQ-Jr) 52
Dysfunctional attitudes (DAS) 63
Self-concept (PHSCS) 8 14
CDRS-R, Children’s Depression Rating Scale-Revised; SIQ-Jr, Suicide Ideation Questionnaire; DAS, Dysfunctional Attitudes Scale; PHSCS,
Piers Harris Children’s Self-concept Scale.
in the severe range and high suicidal ideation, as well as
highly dysfunctional attitudes and low self-concept.
TREATMENT
The patient was treated using a manual-based CBT,
which has demonstrated success in treating depression
in Puerto Rican adolescents.[8][11] She participated in a
research project on therapy for depression in adoles-
cents, which compared a standard 12-session ‘‘dose’’ of
CBT only, with CBT enhanced with a group psycho-
educational 8-session parent intervention. She was
randomized into the CBT only condition of the study.
As part of a supplemental research project, additional
sessions (up to a maximum of 12) were offered to
adolescents whose depression did not remit at post-
treatment to examine the optimal dose needed for
complete remission as well as characteristics associated
with treatment response. Five adolescents agreed to
participate in this study and received an average of
seven additional sessions. The adolescent chosen for
the case study had a therapist who was a doctoral level
graduate student in clinical psychology trained in CBT
who received weekly supervision from a licensed
clinical psychologist with a Ph.D. Qualitative data for
this case study were analyzed by reviewing progress
notes and video recordings of therapy sessions.
SESSIONS 1–4
The first four sessions focused on teaching the
patient about the influence of thoughts on mood and
strategies to debate dysfunctional thought patterns and
increase positive thoughts. During the week, the
patient was asked to complete a daily mood thermo-
meter, which was discussed at the beginning of every
session. Homework assignments such as keeping a daily
log of positive and negative thoughts and identifying
and challenging dysfunctional thoughts were some of
the homework assignments that the patient completed
between sessions.
The patient’s mood fluctuated widely during these
first sessions. She cried several times and verbalized
feelings of sadness, guilt, and low self-concept. The
main dysfunctional thoughts identified and challenged
during these sessions were mostly about herself (I’m
Depression and Anxiety
Follow-up Follow-up Follow-up
Posttreatment (3 months) (6 months) (12 months)
38 37 30 30
14 — 6 3
49 — 43 36
31 33 32
ugly and stupid; People look at me because I’m fat), anxiety
over not being able to fit in at a new school (I won’t
know anyone; I’ll be far away from my friends; It’ll be too
hard), and guilt about her parents’ marital problems
(My parents fight because of me; If I had better grades they
wouldn’t fight). By the fourth session, she succeeded in
rationally challenging several of these negative
thoughts (I can make new friends; I have a chance to start
over at a new school; I am good at drawing and I have a good
sense of humor). Nonetheless, many negative thoughts
persisted, mostly surrounding her parents’ relationship.
By the end of this therapy module, the patient began to
share some of her artistic talents with the therapist and
her self-concept appeared to be improving.
SESSIONS 5–8
The following four sessions worked with increasing
pleasant activities, time management, and goal setting
to improve mood. Homework assignments in this
module involved keeping a daily log of pleasant
activities, completing a weekly planner, and establish-
ing specific goals and steps to complete them.
By the 5th session, the patient’s mood improved
significantly, most likely due to having a positive
experience at her new school; she had made new
friends, her grades had improved, and she was getting
along well with her teachers. She also reported a
decrease in depressive symptoms (Fig. 1). This positive
experience at school was used in therapy to help the
patient challenge negative thoughts and expectations
by providing evidence that disqualified them (i.e. she is
likeable, she can cope in a new school). Consequently,
the number of negative thoughts she had decreased
markedly, and this reduction was reinforced verbally by
the therapist.
The patient recognized that one of the barriers to
enjoying pleasant activities, particularly social activ-
ities, was her negative thoughts (I’ll make a fool of myself;
I won’t do it right; I’ll be rejected by others) and her parents
(obtaining permission for certain activities). The
patient kept track of her pleasant activities and began
to organize her time better to accommodate her
homework and chores by using a weekly planner. This
allowed the patient and therapist to evaluate whether
she had an adequate balance of pleasant activities in her
 Clinical Case: CBT for Adolescent Depression
schedule that helped improve her mood and make
adjustments accordingly. Role-playing exercises were
used to help the patient learn to negotiate permission
from her parents to participate in social activities. Her
self-concept continued to improve as evidenced by her
verbalizations (Sometimes I feel pretty) and her physical
appearance (increased confidence, better posture, and
grooming). The therapist reflected these observations
back to the patient. She was also handling stressful
situations better as evidenced by her reaction to being
teased at school; she simply ignored it instead of feeling
sad and having persistent negative thoughts about
herself, which would have typically been her response.
This suggests that the patient was internalizing skills
learned in the first few sessions, such as thought-
stopping techniques to decrease negative rumination.
SESSIONS 9–12
The last four sessions worked on the ways in which
interpersonal relationships affect mood and focused on
increasing and maintaining social support, as well as
improving assertive communication skills. The patient
reported having a good social support system, but
complained about one of her close friends who would
often put her down; this would activate negative
thoughts about her abilities and attractiveness. This
relationship was examined in the context of adequate
expectations for friendships. The patient presented a
passive communication style, which was contributing
to feeling hurt frequently and having her emotional
needs unmet. Thus, the focus of two sessions was to
work on developing assertiveness through role-playing
exercises. She reported some upsetting incidents at
school between her new and old friends but appeared
to be handling them well using cognitive strategies
learned in the first module.
However, during the last few sessions of this module
the patient was still experiencing feelings of guilt, anger,
and sadness about her parents’ marital problems.
Notably, she was disturbed by significant communica-
tion problems between her parents who often spoke
negatively about one another in her presence and used
her as a messenger to communicate with each other.
She confided in the therapist about having witnessed
physical and emotional abuse between her parents, as
well as living through several separations over the
previous 10 years. The therapist explored the possibility
of having a session with her parents to discuss how their
problems affected the patient, and she agreed. During
this session the therapist discussed with the parents how
their behavior was contributing to the patient’s depres-
sive symptoms and recommended marital therapy. The
parents admitted to having significant problems and
agreed to seek couples therapy.
ADDITIONAL SESSIONS (13–16)
On completion of the standard 12-session ‘‘dose’’ of
CBT, the patient was still presenting symptoms of
101
depression in the severe range (Fig. 1) and continued to
meet criteria for MDD; hence, she received additional
sessions of CBT until her symptoms decreased and
she no longer met MDD criteria according to the
DISC-IV, as established by the study’s protocol for
additional sessions. These four sessions worked mostly
with the patient’s feelings and thoughts surrounding
the possibility of her parents’ divorce or separation.
The focus was on how to manage these feelings
in order to decrease their impact on her mood and
daily functioning.
The patient’s main negative thoughts were mostly
related to fear that her father would leave and never
contact her, and that he would remarry and have
another family with whom she might not get along.
These were challenged in therapy by asking the patient
to find evidence that these thoughts would actually
come true. The patient realized that most of her friends
whose parents had divorced had good relationships
with them and their new families, and acknowledged
that although her father had often threatened to leave,
he had also told her that he would always be there for
her. She also realized that it was possible that things
would be better if they separated and that their fights
might even decrease. In addition, role-playing exercises
were used to practice talking to her father about her
fears and worries regarding the possibility of his leaving
and how it would affect their relationship.
On termination, the patient’s depressive symptoms
were in the moderate range and she no longer met
criteria for MDD according to the DISC-IV, which was
one of the study’s criteria for ending therapy. In
addition, her self-concept had improved, and the
therapist observed decreased dysfunctional attitudes
and suicidal ideation (Table 1). These improvements
were maintained at 6 and 12-month follow-up assess-
ments, and her depressive symptoms decreased to mild
by the last three follow-up assessments.
During the last session, the therapist worked on
closure with the patient, reinforced improvements in
the patient’s mood and coping skills, and counseled the
patient on relapse prevention strategies. Relapse
prevention strategies include monitoring depressive
symptoms and recognizing the need for treatment if
they worsen or recur, and using cognitive-behavioral
strategies to manage her mood (i.e. debating dysfunc-
tional thoughts, planning pleasant activities). The
therapist also counseled the patient’s mother on how
to monitor her daughter’s residual symptoms and the
importance of seeking treatment if symptoms wor-
sened. She also reiterated her previous recommenda-
tion that the parents seek couples counseling, which
they had yet to do.
DISCUSSION
In this case, CBT appeared to reduce depressive
symptoms as well as dysfunctional attitudes and
suicidal ideation. The number of CBT sessions needed
Depression and Anxiety
102 Jime´nez Chafey et al.
to achieve partial remission in this case was 16; four
additional sessions to the standard 12 in most CBT
studies. In addition, the patient continued to show
improvements several months posttreatment in depres-
sive symptoms and other related areas of outcome such
as low self-concept and dysfunctional attitudes. None-
theless, a possible limitation in the interpretation of
these results is that improvements in depressive
symptoms might be attributed to common factors
(e.g. talking about one’s problems with an attentive
professional, receiving a credible treatment rationale,
etc.) that reduce feelings of hopelessness in the
patient.[23] In addition, simply the passing of time
could account for the changes, since studies have found
that some patients with depression recover without
treatment.
This patient presented several of the characteristics
that have been found to be related in the literature to
partial or limited response to treatment: greater initial
severity of depressive symptoms, earlier depressive
episodes, co-morbidity with other mental disorders,
and parental conflict. Although she met diagnostic
criteria for generalized anxiety disorder, separation
anxiety disorder, and attention deficit disorder at
pretreatment, these diagnoses were not evident in
therapy sessions; hence, they were not specifically
addressed in treatment. Also, she was participating in a
research trial that tested a manual-based CBT depres-
sion intervention, which was not designed to address
symptoms of other disorders although many cognitive
and behavioral strategies used in the manual could
generalize to symptoms of anxiety.[7] The CBT research
literature is beginning to recognize that treatments for
specific disorders evaluated in clinical trials may not
always generalize to ‘‘real world’’ settings. Youth treated
in community mental health clinics tend to have higher
rates of co-morbidity, and depression tends to be more
chronic and severe, often resulting in lower treatment
effects.[9] As a result, some investigators are recommend-
ing that CBT manual-based treatments be tested in
effectiveness trials and become more flexible in content,
structure, and format, in addition to involving other
family members in therapy.[24]
The most significant stressor contributing to the
maintenance of this patient’s symptoms was parental
conflict. This was evidenced by her fluctuating mood
throughout therapy, which appeared to be contingent
upon thoughts relating to her parents’ relationship.
Familismo is an important value in Puerto Rican and
other Latino cultures, and there is a strong correlation
between parental and family variables to adolescent
depression.[25, 26] Forty percent (40%) of Puerto Rican
adolescents in a clinical trial of treatment for depres-
sion considered their most frequent problem to be a
family problem[27] and 70% considered their most
frequent interpersonal problem to involve one or both
parents.[28] Familismo is a cultural value that refers to a
traditional modality in Latino cultures that reflects the
importance of family integrity, both nuclear and
Depression and Anxiety
extended.[29] It shapes members’ conduct by expecting
them to protect the safety and interests of other
members and thus avoid bringing negative public
attention to the family’s honor. This might explain
why family factors had a significant role in maintaining
the patient’s depressive symptoms despite the presence
of other protective factors such as positive friendships
and academic experiences. She required four additional
CBT sessions and a session with her parents to address
parental conflict. It is not clear whether this emphasis
on the family context and its acceptance by this Latino
adolescent would be the same for a non-Latino girl.
While CBT and anti-depressants alone appear to
have been partially effective in this case, a combination
of the two might have proven to be a better alternative
for complete recovery and prevention of relapse. In
addition, booster sessions have been found to accel-
erate the recovery of nonresponders to CBT[1] and
might have helped improve response in this case after
therapy termination. Other alternative or complemen-
tary treatment modalities such as family therapy should
also be considered for depression in adolescence that
presents limited response to treatment, particularly
with Latino populations in which the family can play a
significant role in the perpetuation of depressive
symptoms. Family therapy has been found to be
efficacious with Latino youth presenting externalizing
disorders[30] however, no studies using family therapy
for depression in Latino youth have been identified.
Family therapy has recently begun to be studied as an
intervention for depressed youth demonstrating pre-
liminary positive results.[31, 32]
This case study illustrates some of the challenges of
using manual-based CBT and the variability in
response to depression treatment. Cases such as this
one, with partial response and significant family
stressors, will often require additional sessions as well
as modifications in the treatment manual to specifically
address these issues in order to achieve complete
remission. Some alternatives can be dismantling treat-
ment to address the patients’ particular needs and
strengths by increasing the emphasis on certain
treatment components (i.e. interpersonal skills, beha-
vioral activation), and adding specific family and/or
parent–child modules to address conflict and commu-
nication. This case study provides further support to
the recommendations mentioned above that investiga-
tors have offered along this line in the treatment of
youth depression.[2, 7, 9, 32, 33] Also, identifying the
characteristics associated with treatment response in
the initial stages of treatment can help inform
treatment planning in terms of selection of treatment
format, components, and number of sessions (‘‘do-
sage’’) to maximize positive outcomes.
REFERENCES
1. Clarke GN, Rohde P, Lewinsohn PM, Hops H, Seeley JR.
Cognitive-behavioral treatment of adolescent depression: efficacy
 Clinical Case: CBT for Adolescent Depression
of acute group treatment and booster sessions. J Am Acad Child
Adolesc Psychiatry 1999;38:272–279.
2. Compton SN, March JS, Brent D, Albano A, Weersing VR,
Curry J. Cognitive-behavioral psychotherapy for anxiety and
depressive disorders in children and adolescents: evidence-based
medicine review. J Am Acad Child Adolesc Psychiatry 2004;43:
930–959.
3. Kaslow NJ, Thompson MP. Applying the criteria for empirically
supported treatments to studies of psychosocial interventions for
child and adolescent depression. J Clin Child Psychol 1998;
27:146–155.
4. Lewinsohn PM, Rohde P, Seeley JR. Major depressive disorder in
older adolescents: prevalence, risk factors and clinical implica-
tions. Clin Psychol Rev 1998;18:765–794.
5. Melvin GA, Tonge BJ, King NJ, Heyne D, Gordon MS, Klimkeit
E. A comparison of cognitive-behavioral therapy, sertraline and
their combination for adolescent depression. J Am Acad Child
Adolesc Psychiatry 2006;45:1151–1161.
6. TADS. Fluoxetine, cognitive-behavioral therapy, and their
combination for adolescents with depression: Treatment for
Adolescents with Depression Study (TADS) randomized control
trial. JAMA 2004;292:807–820.
7. Weisz JR, McCarty CA, Valeri SM. Effects of psychotherapy for
depression in children and adolescents: a meta-analysis. Psychol
Bull 2004;132:132–149.
8. Rosselló J, Bernal G. The efficacy of cognitive-behavioral and
interpersonal treatments for depression in Puerto Rican adoles-
cents. J Consult Clin Psychol 1999;67:734–745.
9. Weersing VR, Weisz JR. Community clinic treatment of
depressed youth: benchmarking usual care against CBT clinical
trials. J Consult Clin Psychol 2002;70:299–310.
10. Rosselló J, Bernal G. Cognitive-behavioral and interpersonal
treatments for depressed Puerto Rican adolescents. In: Hibbs E,
Jensen P, eds. Psychosocial treatments for children and adoles-
cent disorders: empirically based approaches. Washington, DC:
American Psychological Association Press; 1996.
11. Rosselló J, Bernal G. New developments in cognitive-behavioral
and interpersonal treatments for depressed Puerto Rican
adolescents. In: Hibbs ED, Jensen PS, eds. Psychosocial
treatments for child and adolescent disorders: empirically based
strategies for clinical practice (2nd ed.). Washington, DC, US:
American Psychological Association; 2005:187–217.
12. Brent D, Kolko DJ, Birmaher B, et al. Predictors of treatment
efficacy in a clinical trial of three psychosocial treatments for
adolescent depression. J Am Acad Child Adolesc Psychiatry
1998;37:906–914.
13. Jayson D, Wood A, Kroll L, Fraser J, Harrington R. Which
depressed patients respond to cognitive-behavior treatment?
J Am Acad Child Adolesc Psychiatry 1998;37:35–39.
14. Rhode P, Seeley JR, Kaufman NK, Clarke GN, Stice E.
Predicting time to recovery among depressed adolescents treated
in two psychosocial group interventions. J Consult Clin Psychol
2006;74:80–88.
15. Rosselló J, Rivera-Dueño MT, Jiménez-Chafey MI. Character-
istics of responders and non-responders to psychotherapy for
depression in Puerto Rican adolescents. Ciencias de la Conducta
2007;1:1–27.
16. Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME.
NIMH Diagnostic Interview Schedule for Children Version IV:
103
description, differences from previous version, and reliability
of some common diagnoses. J Am Acad Child Adolesc 2000;
39:28–29.
17. Kovacs M. Children’s depression inventory (CDI) manual. New
York: Multi-Health Systems; 1992.
18. Poznanski EO, Mokros HB. Children’s Depression Rating
Scale Revised. Los Angeles, CA: Western Psychological Services;
1996.
19. Piers E, Harris D. The Piers–Harris Children’s Self-Concept
Scale. Los Angeles: Western Psychological Services; 1984.
20. Kazdin AE, French NH, Unis AS, Esveldt-Dawson K, Sherick
RB. Hopelessness, depression, and suicidal intent among
psychiatrically disturbed children. J Consult Clin Psychol 1983;
51:504–510.
21. Weissman A. The Dysfunctional Attitude Scale. A validation
study. Abstracts International [University Microfilm]; University
of Pennsylvania, 1979.
22. Reynolds WM. Suicide ideation questionnaire professional manual.
Odessa, FL: Psychological Assessment Resources, Inc.; 1998.
23. Iliardi SS, Craighead WE. The role of nonspecific factors in
cognitive-behavior therapy for depression. Clin Psychol: Sci
Pract 1994;1:138–156.
24. Curry JF, Wells KC. Striving for effectiveness in the treatment
of adolescent depression: cognitive behavior therapy for
multisite community intervention. Cogn Behav Pract 2005;12:
177–185.
25. Sáez-Santiago E, Rosselló J. Percepción sobre los conflictos
maritales de los padres, ajuste familiar y sintomatologı́a depresiva
en adolescentes puertorriqueños. [Perception of parental marital
conflicts, family adjustment and depressive symptoms in Puerto
Rican adolescents]. Interam J Psychol 1997;31:279–291.
26. Sáez-Santiago E, Rosselló J. Relación entre el ambiente familiar,
los sı́ntomas depresivos y los problemas de conducta en
adolescentes puertorriqueños. [Relationship between family
environment, depressive symptoms and behavior problems in
Puerto Rican adolescents]. Interam J Psychol 2001;35:113–125.
27. Padilla L, Dávila E, Rosselló J. Problems presented by a group of
Puerto Rican adolescents with depression [in Spanish]. Pedago-
gı́a 2002;36:80–91.
28. Rosselló J, Rivera Z. Problemas interpersonales presentados por
adolescentes puertorriqueños/as con depresión [Interpersonal
problems presented by Puerto Rican adolescents with depres-
sion]. Rev Puertorriqueña de Psicologı́a 1999;12:55–76.
29. Zayas LH, Palleja J. Puerto Rican familism: considerations for
family therapy. Fam Relat 1988;37:260–264.
30. Muir JA, Schwartz SJ, Szapocznik J. A program of research with
Hispanic and African American families: three decades of
intervention development and testing influenced by the
changing cultural context of Miami. J Marital Fam Ther 2004;30:
285–303.
31. Diamond GS, Lebow JL. Attachment-based family therapy for
depressed and anxious adolescents. Handbook of clinical family
therapy. Hoboken, NJ, US: John Wiley & Sons; 2005:17–41.
32. Sander JB, McCarty CA. Youth depression in the family context:
familial risk factors and models of treatment. Clin Child Fam
Psychol Rev 2005;8:203–219.
33. Simons AD, Rohde P, Kennard BD, Robins M. Relapse and
recurrence prevention in the Treatments for Adolescents with
Depression Study. Cogn Behav Pract 2005;12:240–251.
Depression and Anxiety