Psychotherapy alone is recommended for mild to moderate depression. A combination of psychotherapy and an antidepressant is recommended for severe or psychotic depression, or depression that hasn’t improved despite psychotherapy. Antidepressants are not recommended for minors with a type of bipolar disorder called rapid-cycling (at least four episodes of depression or mania in one year).
After the depression has resolved, patients should remain in treatment for a minimum of 8-12 months to decrease the likelihood of a recurrence. If antidepressants were prescribed, they should be maintained at their current dose.
When should a child or teenager be hospitalized? When it is too dangerous for them to remain in their current environment. This generally means when young people are having serious thoughts of hurting themselves or others, but can also be appropriate when young people repeatedly run away, cut or otherwise mutilate themselves without intent of death, set fires, or need detoxification from alcohol or recreational drugs. Patients and families should know exactly how to contact their clinicians in an emergency. If they are not under the care of a clinician or can’t get in touch with him or her, they should call 911 or go to their nearest emergency room. It is always better to err on the side of caution. Psychiatric hospitalizations are usually very brief, sometimes 72 hours. The purpose is to provide a safe environment while helping the patient to become stable enough for outpatient treatment. There are day treatments or partial hospitalization programs for patients who don’t need to stay in a hospital overnight but need more than weekly or twice weekly psychotherapy. These meet for several hours a day several days per week.
Psychotherapy, or counseling, is an important treatment for depression. One example of a psychotherapy that has been shown to improve depression and anxiety in children through adults is Cognitive Behavioral Therapy (CBT).
How does Cognitive Behavioral Therapy work? The therapist helps the patient to become a detective and uncover underlying themes or schemas-ways of perceiving the world that lead to depression. Certain ways of thinking lead to depression. For example, a basic schema many depressed people have is “I’m a bad person.” “I’m unlikable.” This idea is usually buried in the back of the mind, out of conscious awareness, and becomes a self-fulfilling prophecy- it perpetuates itself. For example, people who think, “nothing will ever work out for me” avoid taking risks and trying new things since they are afraid of failure. Children might not try to make new friends or participate in a sport or the school play. They end up with few friends and few activities. They see other kids having fun and think, “See, everything works out for everybody else. Nothing works out for me.” It’s like going around and round on a merry-go-round (rather, a “sad-go-round”) when you’d rather be riding the go-carts.
These are called cognitive distortions– seeing the world in a distorted way that leads to depression. The treatment is to be a scientist, uncover the schemas, and find alternative beliefs.
Scientists have been unraveling schemas for thousands of years. For example, the belief that the sun revolved around the earth is an idea that existed for thousands of years. It seemed perfectly obvious- the sun can be seen rising above the earth in the morning and dipping below it in the evening. It took Copernicus to ponder, “wait a minute, is there another explanation of why the sun goes over the horizon at night? He did some research and deduced that the earth was not the center of the universe. This was a major shift in belief.
Similarly, therapists will help patients to uncover the schemas that are perpetuating their depressions. For example, “Noah” (fictional) was a 12-year-old boy with the schema, “nothing ever works out for me.” He used the “D” on his spelling test as proof of this. His therapist, Dr. Taylor, helped him with an alternative explanation. It turned out that Noah didn’t study for his spelling test, because he thought, “What’s the use, I’ll just fail anyway because I fail at everything I try.” Dr. Taylor helped him identify the sadness associated with this thought.
Together they came up with examples of things that had worked out for him – a successful social activity, an attractive art project, a good math grade. Hardest of all, he left his session with a homework assignment-to try something new to test the new belief that he could succeed.
The therapist helped him come up with a task he could probably succeed at with a little effort to build up his confidence. His goal was to study for his next spelling test to get a grade higher than a D. Noah studied for his spelling test, and got a B. His schema that nothing ever worked out for him was challenged, and he was developing a new belief, “things can work out for me.” Dr. Taylor also helped him to see that it was okay even if his tasks weren’t always successful.
The sky wouldn’t fall on his head and the world wouldn’t end if he got another D.
The human brain is “wired” to socialize. Humans have always relied on social networks for survival. Before modern technology, people needed to be allied in groups to protect themselves from intruders and divide the work. Modern technology has resulted in an improved quality of living, but also has allowed people to isolate themselves in ways that were not possible for thousands of years. Spending all of your free time with your TV, computer, or video games may be seem like fun, but can cause a lot of problems in the long run, since you’re not getting real human contact. Real human interaction will help depression.