Wall Street Journal (5.25.04)

Emerging Teen-Depression Treatment Teaches Kids How to Handle Anxiety.

By MICHAEL WALDHOLZ

As the use of antidepressant drugs rises, and the debate over their safety and effectiveness for children heats up, psychologists and therapists who treat youngsters are beginning to embrace an innovative form of therapy.

"Cognitive behavioral therapy," once used mainly in adults to treat anxiety disorders, increasingly is being used to treat depression in kids. Several studies have shown that this short-term, systematic program can be as effective as other forms of therapy, as well as drugs. The technique requires a therapist with specialized training, and understanding the approach can help parents give their teens guidance.

About 10 million children and teenagers suffer from some form of psychiatric illness, according to a recent surgeon-general report. There has been significant growth since 1990 in both the number of youngsters diagnosed with depression and in the use of antidepressants to treat them, according to research presented at the American Psychological Association's meeting this month.

Some psychiatrists credit the drugs for the sharp decline in the suicide rate among young people since 1994. Suicide still is the third-leading cause of teenage death after accidents and homicides, however. Parents and mental-health experts have grown increasingly concerned about anecdotal evidence that the drugs can lead to suicidal tendencies in teens. In the search for alternative treatments, cognitive behavioral therapy is emerging as a viable choice.

CBT rests on an increasingly popular notion among child psychologists that teens can be taught, much like with math and reading skills, to recognize and react to stresses in a positive, appropriate manner. The aim is to teach adolescents in a four- to nine-month course of weekly discussion sessions how to alter their tendency to respond negatively to difficult experiences.

Proponents contend that certain emotionally vulnerable children develop a habit of viewing life through a dark filter. For reasons not clear -- in some cases due to genetics, trauma or a combination of the two -- these kids enter their teen years seeing themselves as helpless and inferior, and the world around them and their future as bleak, says Anne Marie Albano, a CBT researcher who recently moved to Columbia University from New York University's Child Study Center.

Unlike some forms of therapy, CBT isn't concerned with why this attitude has taken hold. More simply, the goal is to help the child accept that their situation is under their control.

The first step, Dr. Albano says, is to help teens understand that their mood comes from viewing the world as a "glass half-empty." For instance, a depressed or anxious teen may have a habit of automatically concluding the worst outcome of a situation is the one most likely to occur. Or, a teen may routinely discount his or her successes while focusing on mistakes. These responses, the child is told, can be altered with practice.

The teen then is asked to monitor mood changes each day so the earliest signs of anxiety can be identified. This helps the therapist and child zero in on specific problems at school or with friends that trigger negative feelings. The therapy may uncover, for instance, that a child gets especially anxious the night before a test and may have trouble falling asleep or going to school the next day.

Together, the teen and the therapist come up with different ideas for solving the problems. One approach might involve helping the child get a realistic idea of the worst-case consequences of not doing well. The child is asked to test out new ways of thinking or acting about the things that generate anxiety. The last weeks of therapy are spent fine-tuning new problem-solving strategies.

As with traditional psychotherapy, "some of the benefit comes simply by giving the feelings words, and by identifying what triggers them," Dr. Albano says.

CBT's effectiveness is increasingly bolstered by clinical data. In several studies in the 1990s, "CBT provided more rapid relief and proved more credible to parents" than other forms of psychotherapy, according to John March, a Duke University researcher. This fall, Dr. March and researchers elsewhere are expected to release the results of a government-funded six-year trial comparing the use of CBT alone, CBT with antidepressant drugs, and the use of drugs alone.

The technique also is gaining favor in graduate-training programs, says Laura Mufson, a research psychologist at Columbia University, as more psychology and social-work students are pursuing it as a field of study.

Even so, CBT's advocates say the short-term technique isn't a cure-all, noting that the studies show 40% of children treated failed to respond. That is about the same failure rate for drugs or other forms of psychotherapy. Specialists argue that it takes an experienced therapist to determine if it is an appropriate approach.

Some critics say it is best for alleviating sources of apprehension, such as social phobias or test-taking and other performance anxieties, but that it isn't as effective once a deep depression has set in.

"The truth is we don't really know what works best for depression in adolescents," says Rachel Klein, also a researcher at NYU. She points out that only since the early 1980s have professionals begun to accept that teenagers can suffer the same wide spectrum of emotional illnesses as adults, and that severe moodiness in teens isn't simply something kids will outgrow.