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46 PSYCHIATRIC TIMES DECEMBER 2008

www.psychiatrictimes.com CLINICAL

Cognitive-Behavioral Therapy
for Adolescent Depression
Processes of Cognitive Change

by Sara J. Becker, MA,
Christina C. Sanchez, MA,
John F. Curry, PhD, Susan Silva, PhD,
and Simon Tonev, PhD
he substantial and often recur-
change can serve as the engine of ther-
apeutic progress.
Despite different areas of empha-
sis, both of the major CBT approaches
posit that cognitive factors such as
cognitive distortions, negative auto-
across both conditions, then hopeless-
ness would be considered a predictor.
Moderators are pretreatment fac-
tors that interact with the treatment
conditions to predict treatment out-
come, and thereby represent factors
ficiently powered to test their main hy-
potheses, which pertain to outcome,
and to identify predictors. By contrast,
most trials are not sufficiently pow-
ered to test adequately for moderators
or mediators. Therefore, most analy-

T rent distress and impairment as-

sociated with major depressive
disorder (MDD) in youth has prompt-
matic thoughts, dysfunctional atti-
tudes, negative attributional style, and
hopelessness play a major role in the
that predict a differential response to
CBT. For example, if adolescents with
high levels of hopelessness had better
ses for moderators or mediators must
be considered exploratory.

ed increased interest in the identifica-
tion and dissemination of effective
treatment models. Evidence supports
the use of several antidepressant med-
ications, specific psychotherapies,
and, in the largest treatment study of
depressed teenagers, the combination
of fluoxetine and cognitive-behavior-
al therapy (CBT) as effective treat-
ments.1-3 CBT is the most extensively
tested psychosocial treatment for
MDD in youth, with evidence from re-
views and meta-analyses that supports
its effectiveness in that population.3-5
CBT is a time-limited, problem-
focused intervention that seeks to re-
duce emotional distress through the
modification of maladaptive beliefs,
assumptions, attitudes, and behav-
iors.6 As outlined by Lewinsohn and
Clarke,7 different CBT interventions
emphasize different techniques to ef-
fect change, with some interventions
primarily targeting cognitive factors
and others primarily targeting be-
havioral factors. Reflecting this dis-
tinction, there have been 2 major
theoretical approaches to CBT with
adolescents.
The first approach, identified with
the cognitive therapy of Beck and his
colleagues,8 is based on a model in
which cognitive processes are seen as
the major maintaining variables asso-
ciated with MDD. In Beck’s model,
the task of the therapist is to enhance
the patient’s ability to monitor mood;
identify connections between mood
and cognition; and identify, challenge,
and modify automatic thoughts, as-
sumptions, and core beliefs that sus-
tain MDD. This model has been adapt-
ed by Brent and colleagues9 for
treating adolescents.
The second approach is more be-
havioral and multifactorial. Associat-
ed with Lewinsohn and colleagues,10
this approach has been used with
adults and adolescents and is based on
the assumptions that behavior and
thoughts sustain depressed mood, and
that either behavioral or cognitive
onset and maintenance of depressive outcomes with CBT than with an al- CBT emphasizing cognition
symptoms.6 However, the specific ternative psychotherapy, hopelessness The first major stream of CBT re-
cognitive processes through which would be a moderator. Mediators are search in adolescent MDD has been
CBT works to counter MDD in young factors that account for or explain the the work of Brent and colleagues,9
people are not well understood. Un- process of therapeutic change during who used Beck’s theoretical approach
derstanding treatment mechanisms is CBT. For example, if it were shown to cognitive therapy. They adapted the
of both theoretical and practical im- that CBT treatment outcomes were at- Beck model for adolescents by includ-
portance. A clear understanding of tributable to a reduction in hopeless- ing psychoeducation, problem solv-
therapeutic mechanisms would allow ness during treatment, then hopeless- ing, affect regulation, and social skills
psychosocial treatment developers to ness would be a mediator. training. Nevertheless, the primary
focus on the intervention components Mediational analyses are those that focus of treatment is on identification
that are most effective, thereby pro- are most valuable in highlighting pro- and modification of dysfunctional,
moting amplification of the more ac- cesses of change associated with ef- depressogenic thinking.
One randomized trial has evaluat-
ed the effectiveness of the Brent model
CHECK POINTS of individual CBT relative to 2 alter-
native psychotherapy conditions: Sys-
 Cognitive variables that have been found to predict favorable treatment temic Behavioral Family Therapy and
outcomes in adolescents with depression include higher levels of rational
Nondirective Supportive Therapy.9 In
thoughts, less hopelessness, fewer negative thoughts, and fewer cognitive
distortions at baseline.
the sample of adolescents with MDD,
CBT was found to be more effective in
 Cognitive-behavioral therapy (CBT) is a time-limited, problem-focused alleviating depression after 12 to 16
intervention that seeks to reduce emotional distress through the modifica-
weeks of treatment than either of the
tion of maladaptive beliefs, assumptions, attitudes, and behaviors.
2 comparison psychotherapy condi-
 In Beck’s theoretical approach to cognitive therapy, the primary focus tions. Cognitive variables measured in
of the treatment is on identification and modification of dysfunctional, this study, which were directly target-
depressogenic thinking. ed by the CBT intervention, included
 Lewinsohn’s multifactorial model identifies multiple behavioral, cognitive, cognitive distortions and hopeless-
and biological factors that contribute to major depressive disorder. ness. Cognitive distortions were mea-
sured using the overall score on the
Children’s Negative Cognitive Errors
tive components and reduction or re- fective treatment. The evaluation of Questionnaire,12 while hopelessness
moval of the less active elements. In mediators can help address the follow- was measured using the Beck Hope-
addition, a review by Kazdin and ing 3 questions, which have been ex- lessness Scale.13
Nock11 proposes that studying mecha- plored in the literature on adults with An investigation of predictors of
nisms of therapeutic change can assist MDD and are only beginning to be treatment effect revealed that higher
the adoption of effective treatments by studied in adolescents with MDD. levels of both of these cognitive vari-
practicing clinicians. First, does CBT lead to changes in ables at intake predicted continued
In this article we focus on cognitive cognition associated with MDD? Sec- depression and failure to attain remis-
factors that have been shown to influ- ond, if CBT leads to cognitive change, sion at termination.14 An additional
ence the effectiveness of CBT for ado- does the cognitive change lead to a re- predictor of negative treatment out-
lescent MDD. We identify factors that duction in symptoms of MDD? Third, come was entering the study as a clin-
affect CBT treatment outcomes by ex- is change in depressive cognitions ical referral, rather than in response to
amining 3 types of variables: predic- unique to CBT, or is it associated with an advertisement. The effect of clini-
tors, moderators, and mediators. Pre- other effective treatments for MDD? cal referral status on treatment out-
dictors are variables present before In this article, we explore the first 2 come was mediated by hopelessness,
treatment that influence treatment out- questions with reference to studies of which reflects that adolescents who
comes across all treatment conditions. CBT that emphasize cognition, stud- were referred to the study had higher
For example, if, in a comparison of ies of multifactorial CBT, and the levels of hopelessness than did adoles-
CBT and a different psychotherapy for largest treatment study of CBT for cents who answered an advertisement.
MDD, adolescents with high levels adolescent MDD to date. When controlling for adverse predic-
of hopelessness had worse outcomes Of note, most clinical trials are suf- tors including cognitive variables, the
PT_1212008_00047.ps 11/25/08 12:35 PM Page 47
DECEMBER 2008
efficacy of nondirective supportive
therapy declined significantly, but not
that of the other treatments. These
findings support the overall robustness
of CBT with patients who have dys-
functional cognitive processes.
More recent analyses of this trial
provided additional information about
the process of cognitive change during
CBT and the other 2 psychosocial
treatments.15 During treatment, CBT
had a significantly greater impact in
reducing cognitive distortions than did
either of the other psychotherapies.
Furthermore, when analyses included
data from a 2-year follow-up assess-
ment, CBT demonstrated significant-
ly greater and more consistent im-
provement for cognitive distortions in
children than did nondirective sup-
portive therapy. By contrast, there was
no difference among treatments in
their impact on hopelessness.
Despite evidence of treatment-
specific effects, cognitive distortion
failed to meet the criteria for media-
tion because of the absence of group
differences over time in the severity of
depressive symptoms. As noted by the
investigators, mediation in a treatment
arm may have been difficult to show
within the relatively brief time frame
of acute treatment, particularly when
considering the episodic nature of
MDD among adolescents. The lack of
significant mediators was congruent
with the results of the literature on
adults, which has generally been un-
successful in identifying mediators of
treatment effects for CBT interven-
tions among patients with a confirmed
diagnosis of MDD .16 It is of interest to
note that Ackerson and colleagues17
found evidence that dysfunctional at-
titudes mediated response to a form of
cognitive bibliotherapy based on the
Beck cognitive model in a sample of
22 adolescents with depressive symp-
toms (not diagnoses). However, sup-
port for mediation was found only
when symptoms and cognitions were
both measured by self-report.
Multifactorial CBT
A second stream of research has been
built on Lewinsohn’s multifactorial
model of MDD, which identifies mul-
tiple behavioral, cognitive, and bio-
logical factors that contribute to
MDD.10 To simultaneously address
these factors, Clarke and colleagues18
designed the Adolescent Coping With
Depression Course (CWD-A), a
course of CBT that is group-adminis-
tered, psychoeducational, and skills-
oriented in nature.
Two randomized trials have as-
sessed the effectiveness of the CWD-
A group CBT intervention compared
with CWD-A plus a weekly parent
psychoeducation group and a wait-list
CLINICAL
control.10,19 The first study involved 59
adolescents who met diagnostic crite-
ria for MDD or intermittent depres-
sion, whereas the second study in-
volved 96 adolescents who met
diagnostic criteria for MDD or dys-
thymia. Both of these trials found that
rates of recovery, as defined by no
longer meeting criteria for initial diag-
nosis, were greater in the 2 CBT con-
ditions than in the wait-list group.
Across both studies, higher levels of
rational (nondepressive) thinking at
baseline, as measured by the Subjec-
tive Probability Questionnaire (R.
Munoz and P. Lewinsohn, unpub-
lished data, 1976), were a predictor of
better treatment outcomes. No analy-
ses of moderators or mediators were
reported in these trials.
A recent application of the CWD-A
compared it with a life skills condition
for adolescents with comorbid MDD
and conduct disorder.20 Adolescents
treated with CWD-A had higher re-
covery rates than those treated with the
life skills condition (39% vs 19%). In
the context of this controlled trial, the
cognitive variables of hopelessness,
negative automatic thoughts, and dys-
functional attitudes were assessed.
Over the 1-year follow-up, lower lev-
els of hopelessness and negative
thoughts, but not dysfunctional atti-
tudes, were found to predict faster
recovery.21
In analyses of this trial, potential
mediators of treatment outcome were
explored in adolescents who received
CBT intervention.22 One of the cogni-
tive factors, automatic negative cogni-
tions, which was measured with the
Automatic Thoughts Questionnaire
developed by Hollon and Kendall,23
mediated the effects of CBT on de-
pression outcomes. None of the other
variables that were tested (dysfunc-
tional attitudes, relaxation, social
skills, pleasant activities, or problem-
solving) fulfilled the criteria for medi-
ation of treatment effects. This finding
suggests that reducing negative think-
ing may be the primary mechanism
through which this form of CBT re-
duces depression among youths with
conduct disorder and depression.
Another notable finding was that
reducing negative thinking signifi-
cantly reduced symptoms of depres-
sion, even though CBT did not appear
to have an impact on underlying dys-
functional attitudes, as measured by
the Dysfunctional Attitude Scale.24
Counter to the findings of the cogni-
tive bibliotherapy trial, these findings
suggest that it may not be necessary
for the clinician to engage in depth-
oriented cognitive techniques for this
form of CBT to be effective.17
Taken together, results of the sec-
ond stream of research provide evi-
dence that CBT is associated with
change in a specific cognitive factor
(automatic negative thoughts) and that
this change accounts for the effect of
CBT on adolescent outcomes. Results
of this stream of research are consis-
tent with the results of 2 prevention
studies for adult depression that found
that measures of negative thoughts
were the strongest mediators of reduc-
tions in depressive symptoms follow-
ing treatment with CBT.
In the first study, Munoz and col-
leagues25 randomly assigned 150 pre-
dominantly minority, low-income pri-
mary care patients to an experimental
CBT condition or 1 of 2 control condi-
tions: information only or no treat-
ment. At posttreatment and 6-month
follow-up, reduction in depressive
symptoms was significantly mediated
by a reduction in negative thoughts,
while at the 12-month follow-up, re-
duction was mediated by reduced neg-
ative thoughts and increased optimism.
In the second study, Allart-van
Dam and colleagues26 randomized
adults at risk for developing MDD
to the Coping With Depression CBT
course or an assessment and ad-
vice only condition. One month after
acute treatment, negative automatic
thoughts and self-esteem were found
to mediate a reduction in symptoms of
MDD. By contrast, measures of the
frequency of interpersonal behavior
and pleasant events were not found to
mediate the results of CBT, which pro-
vided further indication that change in
cognition may be the most important
mechanism of change.
A large adolescent
treatment study
The Treatment of Adolescents With
Depression Study (TADS)2 represents
the largest treatment study of adoles-
cents with MDD to date. Before
TADS, a critical limitation of CBT re-
search was its isolation from develop-
ments in pharmacotherapy research.1
TADS was therefore designed to com-
pare CBT, fluoxetine, and their com-
bination as treatments for moderate to
severe MDD in adolescents.2 Re-
sponse rates for CBT and medication
in earlier studies were about 50% to
60%, indicating considerable room for
improvement in treatment outcomes.
A primary hypothesis of TADS was
that the combination of CBT and flu-
oxetine would be more effective than
either therapy alone.
In TADS, 439 adolescents with
moderate to severe MDD were ran-
domly assigned to receive CBT, flu-
oxetine, a CBT and fluoxetine combi-
nation, or clinical management with a
pill placebo for 12 weeks. The CBT
used in TADS combined the 2 streams
of American CBT for adolescents:
PSYCHIATRIC TIMES 47
www.psychiatrictimes.com
skills training from the Lewinsohn
model was embedded in individual
psychotherapy sessions that followed
a structure from the Beck model. (The
TADS CBT model has been described
by Rohde and colleagues.27)
Acute treatment results supported
combination treatment as the most ef-
fective intervention, as measured by
rate of change of scores on the Chil-
dren’s Depression Rating Scale–
Revised assessed by an independent
evaluator uninformed of treatment as-
signment.28,29 Fluoxetine, but not CBT,
was also superior to placebo at the end
of 12 weeks of treatment. A secondary
analysis indicated superiority of com-
bination treatment on speed of re-
sponse rated by treating clinicians.30
The TADS team explored possible
predictors or moderators of acute
treatment outcome, based on a litera-
ture review of previous studies of psy-
chotherapy or pharmacotherapy for
childhood or adolescent internalizing
disorders (anxiety or depression).31
Two of these were cognitive variables.
One of these, hopelessness, proved to
be a predictor of acute outcome.
Lower levels of hopelessness at base-
line predicted more favorable re-
sponse to treatment than did higher
levels of hopelessness, regardless of
treatment arm.
A second cognitive variable was a
moderator of acute outcome: cogni-
tive distortion. Among adolescents
with higher levels of cognitive distor-
tion, the addition of CBT to fluoxetine
led to improved results. By contrast,
the addition of CBT to fluoxetine did
not improve treatment outcome in
those with lower levels of distortion.
As noted by Curry and colleagues,31
one potential interpretation of these
results is that CBT addresses a vulner-
ability to depressogenic thinking, but
that its benefits for moderately to se-
verely depressed adolescents are only
evident in the short term when com-
bined with fluoxetine.
A recent secondary analysis of the
TADS trial compared the rate of cog-
nitive change across the 12 weeks of
treatment for each of the following
conditions: combination, fluoxetine,
CBT, and placebo.32 Cognitive change
was measured using factor analytical-
ly derived scores representing cogni-
tive distortions, cognitive avoidance,
and solution-focused thinking, based
on a previous analysis by Ginsburg
and colleagues.33 Combination treat-
ment led to a significantly greater rate
of reduction in cognitive distortions
and avoidance than did other condi-
tions. Thus, when analyzing data with
factor-derived scores, the pattern of
cognitive change paralleled that for
change in depression.
(Please see Cognitive Change, page 48)
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48 PSYCHIATRIC TIMES DECEMBER 2008

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Cognitive Change
Continued from page 47
Analysis of treatment mediators in
TADS is currently under way. In addi-
tion, more detailed analyses of specif-
ic cognitive variables including nega-
tive automatic thoughts, dysfunctional
attitudes, and attributional style will
track changes in these processes
across the different treatments.
Summary
CLINICAL
Acad Child Adolesc Psychiatry. 2003;42:531-542.
3. Weisz JR, McCarty CA, Valeri SM. Effects of psy-
chotherapy for depression in children and adoles-
cents: a meta-analysis. Psychol Bull. 2006;132:132-
149.
4. Curry JF. Specific psychotherapies for childhood
and adolescent depression. Biol Psychiatry. 2001;49:
1091-1100.
5. Reinecke M, Ryan N, DuBois D. Cognitive-behav-
ioral therapy of depression and depressive symptoms
during adolescence: a review and meta-analysis.
J Am Acad Child Adolesc Psychiatry. 1998;37:26-34.
6. Freeman A, Reinecke M. Cognitive therapy. In: Gur-
man AS, Messer SB, eds. Essential Psychotherapies:
Theory and Practice. New York: Guilford Press; 1995:
182-225.
7. Lewinsohn PM, Clarke GN. Psychosocial treatments
for adolescent depression. Clin Psychol Review. 1999;
pression Rating Scale–Revised. Psychopharmacol
Bull. 1985;21:979-989.
30. Kratochil C, Emslie G, Silva S, et al. Acute time to
response in the Treatment for Adolescents With De-
pression Study (TADS). J Am Acad Child Adolesc Psy-
chiatry. 2006;45:1412-1418.
31. Curry JF, Rohde P, Silva S, et al. Predictors and
moderators of acute outcome in the Treatment for
Adolescents With Depression Study (TADS). J Am
Acad Child Adolesc Psychiatry. 2006;45:1427-1439.
32. Curry JF, Becker SB, Sanchez CS, et al. Process-
es of cognitive change in adolescents receiving treat-
ment for depression. Poster presented at: the 53rd
Annual Meeting of American Academy of Child and
Adolescent Psychiatry; 2006; San Diego.
33. Ginsburg GS, Silva SG, Tonev S, et al. Cognitive
measures of adolescent depression: unique or unitary
constructs? Manuscript under review.
Evidence-Based References
Kaufman N,Rohde P,Seeley J,et al.Potential mediators
of cognitive-behavioral therapy for adolescents with
comorbid depression and conduct disorder. J Consult
Clin Psychol.2005;73:38-46.
March J, Silva S, Petrycki S, et al; Treatment for Ado-
lescents With Depression Study (TADS) Team. Fluoxe-
tine,cognitive-behavioral therapy,and their combina-
tion for adolescents with depression: Treatment for
Adolescents With Depression Study (TADS) random-
ized controlled trial. JAMA. 2004;292:807-820. ❒

Cognitive variables that predict favor-

able treatment outcomes in adoles-
cents with depression include higher
levels of rational thoughts, less hope-
lessness, fewer negative thoughts, and
fewer cognitive distortions at base-
line.10,14,22 In an analysis of TADS data,
cognitive distortions at baseline were
also shown to moderate the effects of
combined CBT and fluoxetine, such
that adolescents with high levels of
cognitive distortion were more likely
to experience incremental benefits
from CBT as part of combination
treatment.31 In an analysis of the Brent
study, hopelessness was found to me-
diate the predictive effects of referral
source on outcome across 3 types of
psychotherapy.14
The only variables that have been
found to mediate the results of CBT
specifically are negative automatic
thoughts, and in a small subclinical
sample, dysfunctional attitudes,
which suggests that a reduction in
these variables may be important
mechanisms of change in CBT.17,23
Mediational analyses have not yet
been conducted on the TADS data,
which precludes conclusions about
the mechanisms of change in pharma-
cological and combination treatments.
Further research is needed to uncover
the specific strategies used in therapy
that reframe negative cognition, mod-
ify dysfunctional beliefs, and improve
depressive symptoms.
Ms Becker and Ms Sanchez are doctoral can-
didates and Dr Curry is professor in the de-
partment of psychology and neuroscience at
Duke University in Durham, NC. Dr Silva is re-
search associate professor in the department
of psychiatry and behavioral sciences at Duke
University Medical Center, and Dr Tonev is a
statistician at the Duke Clinical Research
Institute . The authors report no conflicts of in-
terest concerning the subject matter of this
article.
Drug Mentioned in This Article
Fluoxetine (Prozac, Sarafem)
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