problem solving skills for depression

13 Helpful Worksheets for Combating Depression

However, when a depressed mood or unbearable sadness is present for a long time – a couple of weeks or months – then it might meet the criteria for depression.

Depression affects over 264 million people worldwide. Between 76% and 85% of those experiencing depression do not seek or receive treatment for their disorder (World Health Organization, 2020a).

This article provides a starting point to understand depressive symptoms and also offers helping professionals resources to assist their patients with recovery.

Please note that the resources provided in this article are not a substitute for treatment from a medical professional. If you are suffering from depression or know someone who is, we recommend you seek help. Guidance is provided at the end of this article.

Before you continue, we thought you might like to download our three Stress & Burnout Prevention Exercises (PDF) for free . These science-based exercises will equip you and those you work with, with tools to manage stress better and find a healthier balance in your life.

This Article Contains:

2 worksheets to help combat depression, handouts for cbt sessions, 2 group therapy worksheets, depression worksheets for teens and youth, 4 worksheets on coping skills, positivepsychology.com’s toolkit resources, a take-home message.

Individuals who experience depression often deal with difficult emotions and engage in unhelpful thought patterns that worsen their depression. One of those responses that is widely recognized is excessive guilt .

Excessive guilt is one of the distinctive symptoms of depression, as it is often exaggerated and experienced out of context (Pulcu, Zahn, & Elliott, 2013).

Typically, individuals with major depressive disorder feel guilty for their emotions and are often upset at themselves for being affected by depression, as they feel they are worthless for being in a depressive state.

One of the most common types of guilt experienced by individuals who have depression is called omnipotent responsibility guilt , which is defined as “taking responsibility for events which may be out of one’s control and feeling guilty about their consequences” (Pulcu et al., 2013, p. 312).

Often, individuals with depression take responsibility for situations they have little or no control over, causing them to feel a sense of overwhelming guilt, even when they had nothing to do with the outcome.

Understanding what parts of a situation you can control or influence is an essential part of seeking treatment for depression. The Control–Influence–Accept Model (Thompson & Thompson, 2008) originated as a means to help people be more productive at work.

However, the basic principles of the model aim to identify pieces of a situation that you can control or influence, as well as aspects of a situation you may have to adapt to or accept.

If these sound like issues you are struggling with, feel free to consult the following worksheets:

1. Control–Influence–Accept Model

This is a good activity for individuals with depression to help break down situations. The model allows better visualization of different aspects of a situation and what specifically can be controlled, instead of worrying about all the possible outcomes.

2. Guilt and Shame: Emotions That Drive Depression

Guilt and shame are two emotions that drive your emotions when depression manifests. This exercise will help you identify guilt and shame that drives your depression and provides suggestions for channeling those emotions to facilitate more positive thinking  patterns.

CBT operates on the principle that emotional reactions and behaviors are influenced by cognitions (Westbrook, Kennerley, & Kirk, 2011).

Our behavior is governed by these cognitions, meaning that someone with anxiety might display more anxious behavior or engage in negative thinking patterns.

When an individual is affected by depression, they can experience cognitive distortions that are negatively biased errors in thinking. When individuals experience automatic thoughts, they are typically consistent with their core beliefs about aspects of themselves, others, and the world (Rnic, Dozois, & Martin, 2016).

Therefore, individuals who are experiencing depressive thoughts or symptomatology tend to have negatively charged core beliefs, which activate negative automatic thoughts. The cycle of negative thinking causes the symptoms of depression to continue and consolidate negative thoughts as part of an individual’s emotional response.

Our worksheet on Unhelpful Thinking Patterns categorizes the unhelpful thinking patterns that are present when someone is experiencing depression. It also provides strategies for individuals to reconstruct their thinking and identify the negative thinking patterns they might engage in.

Because of negative thinking patterns or cognitions, individuals often develop negative beliefs about everyday situations. This may cause them to change their behavior.

This worksheet on Behavioral Experiments to Test Beliefs encourages you to challenge your negative thoughts or beliefs. You are assisted to develop a hypothesis from your beliefs and test whether your negative core beliefs actually come true.

It is a useful worksheet if you are trying to confront negative beliefs about a specific situation, such as going out in social situations, or struggling to leave home. Having a concrete situation will allow you to better challenge the negative thinking patterns you might experience.

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Delivering CBT in a group therapy format is sometimes recommended for those who may benefit from a group to relate to when dealing with symptoms and situations specific to depression.

Individuals may also benefit from group cohesion and can potentially use the group as an arena for challenging their negative thoughts and behavior (Thimm & Antonsen, 2014).

1. Awareness of the mind

One of the most important goals in group therapy is for participants to get comfortable telling their story and learning about themselves. I Am is an introductory activity for people doing group therapy. Filling out the prompts helps them define themselves, specifically their boundaries and strengths.

The ultimate goal of the ‘I Am’ exercise is for the individual to gain an awareness of their own mind. They can then share this activity with other participants so they can all get to know each other better, form a trusting bond, and promote a safe space to discuss their depression.

2. Contributing events

Often, people with depression can identify a series of events that may have contributed to the development or worsening of their condition.

My Depression Story is designed for individuals taking part in group therapy. It encourages participants to make a timeline of their lives, highlighting key moments that have shaped their individual perceptions. It then asks them to do the same thing with their depression so they can better understand what the contributing factors may have been.

By sharing these events with the group, they can determine how depression has affected their perceptions and figure out a healthier way to map out their goals from now on.

According to the World Health Organization (2020b), one in six youths between the ages of 10 and 19 are affected by a mental illness. Moreover, depression is one of the leading causes of illness and disability among adolescents.

Therefore, it is essential to have resources and information for teens and their parents so they can identify the symptoms of depression. If you suspect your teen is experiencing depressive symptoms or you simply want to learn more, read on for resources you could use.

Recognizing the warning signs of depression is one of the most important preventative measures a parent or guardian can take to ensure that their teenager gets the help they need.

Our Depression Fact Sheet for Teenagers is designed to break down the symptoms and behaviors that characterize depression specific to teenagers. It also provides resources for teenagers to consult if they have a friend who is experiencing these symptoms and don’t know what to do.

Teenagers in particular may struggle to put their emotions into words, specifically when they are experiencing depression. This Letter to a Loved One About My Depression activity provides ideas for teenagers to help express their feelings. It even has a template that they can fill in and print if they are having trouble finding the right way to tell a parent or another loved one about their depression.

As discussed in the previous section, confronting negative thoughts is a central part of dealing with depression. The Depressive Thoughts for Teens worksheet acts as a companion to the Unhelpful Thinking Styles  worksheet.

It has specific activities for teenagers to break down their responses to various situations and an example to follow when confronting their negative thoughts. We encourage parents to complete this alongside their teenager to help them identify trigger situations and provide more productive problem-solving solutions.

An important part of facilitating long-term recovery from depression is to encourage coping skills that individuals can implement in their everyday lives when they feel overwhelmed or upset.

Coping strategies “consist of behaviors, primarily management and problem-solving techniques that are implemented to manage stressful situations” (Bautista & Erwin, 2013, p. 687).

Coping skills can either focus on targeting the problem (problem-based) or seek to make yourself feel better when the circumstances are out of your control (emotion-based).

The point of introducing these coping skills is not only to give individuals strategies to fight off depression, but also to discourage the use of unhealthy coping strategies (e.g., drugs, alcohol, avoidance, overeating, or overspending). These are strategies that provide instant gratification  but could have negative consequences if the unhealthy patterns continue.

1. Deep breathing

If you are looking for a technique that is easy to do and free of charge, consider exploring deep breathing. Three Steps to Deep Breathing gives you a quick overview of how to use deep breathing when you are feeling stressed, upset, or overwhelmed.

Our Power of Deep Breathing article also provides more details about how deep breathing can help you overcome stress and anxiety, and introduces practices where deep breathing is commonly used (e.g., yoga, meditation).

2. Coping style

Part of knowing how to implement coping skills into your daily routine is to understand what your coping style is and what strategies might work best for you. This Coping Styles Formulation activity helps individuals work with their therapist to identify the problem that is causing them distress.

By delving deeper into the events and actions that caused the problem, they may be able to better understand what coping style or skills they need to implement, especially if this is a recurring issue that causes distress.

3. Self-care

Another important part of coping is to implement self-care. Self-care is any activity that involves taking care of our mental, emotional, or physical health. Self-care not only leads to improved mood and reduced anxiety, but can also improve your self-esteem (Michael, 2016).

This Self-Care Checkup gives ideas for self-care and allows you to rate how often you engage in each activity. This worksheet also divides self-care into emotional, physical, social, professional, and spiritual self-care. It will reveal which area of your life needs the most attention and help you implement the strategies as needed.

4. Self-love

Additionally, this Self-Love Journal is helpful for daily self-care, as it gives you an opportunity to think about the moments and aspects of yourself that are positive, rather than focusing on more difficult things that are happening.

17 Exercises To Reduce Stress & Burnout

Help your clients prevent burnout, handle stressors, and achieve a healthy, sustainable work-life balance with these 17 Stress & Burnout Prevention Exercises [PDF].

Created by Experts. 100% Science-based.

We have an excellent selection of resources that can assist those battling depression. For therapists, the following masterclasses and worksheets will equip you to be better able to support your clients.

Self-Acceptance Masterclass

The Science of Self-Acceptance Masterclass© is an excellent tool for practitioners and individuals who are struggling with accepting themselves. Often, a strong driver of depression is an individual’s difficulty with loving and accepting themselves for who they are.

This course focuses on building a healthy relationship with yourself first by using science-based activities to help build your self-esteem. This is also an excellent resource for practitioners who have a client who is struggling with depression and low self-esteem.

Meaning & Valued Living Masterclass

This masterclass on Meaning and Valued Living aims to help individuals find meaning in everyday life. People with depression often struggle to find meaning or value in themselves or their everyday actions, as they are caught in a cycle of negative thought patterns and experiences.

This course aims to help them regain a sense of purpose and find value in the contributions they are making, no matter how small or insignificant they may seem.

17 Stress & Burnout Prevention Exercises

If you’re looking for more science-based ways to help others manage stress without spending hours on research and session prep, this collection contains 17 validated stress management tools for practitioners. Use them to help others identify signs of burnout and create more balance in their lives.

Depression can be a difficult condition to overcome, especially when you feel lonely or isolated. Changing your thinking and behavior can be a daunting task, as it is often less intimidating to stick with something you are familiar with, even if it has a negative impact on your daily living.

Reading this article is a great first step to understand depression and struggles with negative thoughts. Be kind to yourself, and remember that every small step you take along your self-improvement journey is an important one and should be celebrated.

Reach out to a professional, close friend, or family member to help you with the next steps. Getting out of the hole is a challenging journey, so asking for help and someone to be on your side is the best decision you can take. You don’t have to do this alone.

If you are struggling with severe symptoms of depression or suicidal thoughts, please call the following number in your respective country:

• USA: National Suicide Prevention Hotline at 988
• UK: Samaritans hotline at 116 123
• The Netherlands: Netherlands Suicide Hotline at 0900 0767
• France: Suicide écoute at 01 45 39 40 00
• Australia: Lifeline at 13 11 14
• Germany: Telefonseelsorge at 0800 111 0 111 or 0800 111 0 222

For a list of other suicide prevention websites, phone numbers, and resources, see this website or consult Open Counseling’s list of International Suicide and Emergency Hotlines . Resources are listed by country, and you can click on the ‘more hotlines’ and ‘in-person counseling’ tabs to get further help.

Please know that there are people who care and treatments that can help.

We hope you enjoyed reading this article. Don’t forget to download our three Stress & Burnout Prevention Exercises (PDF) for free .

• Bautista, R. E., & Erwin, P. A. (2013). Analyzing depression coping strategies of patients with epilepsy: A preliminary study. Seizure , 22 , 686–691.
• Michael, R. (2016, August 10). What self-care is and what it isn’t. Psych Central. Retrieved April 23, 2021, from https://psychcentral.com/blog/what-self-care-is-and-what-it-isnt-2#1
• Pulcu, E., Zahn, R., & Elliott, R. (2013). The role of self-blaming moral emotions in major depression and their impact on social decision making. Frontiers in Psychology , 4 , 310–319.
• Rnic, K., Dozois, D. J. A., & Martin, R. A. (2016). Cognitive distortions, humor styles and depression. Europe’s Journal of Psychology , 12 (3), 348–362.
• Thimm, J. C., & Antonsen, L. (2014). Effectiveness of cognitive behavior group therapy for depression in routine practice. BMC Psychiatry , 14 (292), 1–9.
• Thompson, N., & Thompson, S. (2008). The critically reflective practitioner . MacMillian International Higher Education.
• Westbrook, D., Kennerley, H., & Kirk, J. (2011). An introduction to cognitive behavior therapy: Skills and applications (2nd ed.). SAGE.
• World Health Organization. (2020a). Depression . Retrieved April 21, 2021, from https://www.who.int/news-room/fact-sheets/detail/depression
• World Health Organization. (2020b). Adolescent mental health . Retrieved April 22, 2021, from https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health

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What Is Problem-Solving Therapy?

Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

• Applying a positive problem-solving orientation to your life
• Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

• Knowing how to identify a problem
• Defining the problem in a helpful way
• Trying to understand the problem more deeply
• Setting goals related to the problem
• Generating alternative, creative solutions to the problem
• Choosing the best course of action
• Implementing the choice you have made
• Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

• Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
• Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
• Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
• Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

• Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
• Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
• Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

• Chronic stress due to accumulating minor issues
• Complications associated with traumatic brain injury (TBI)
• Emotional distress
• Post-traumatic stress disorder (PTSD)
• Problems associated with a chronic disease like cancer, heart disease, or diabetes
• Self-harm and feelings of hopelessness
• Substance use
• Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

• Death of a loved one
• Dissatisfaction at work
• Everyday life stressors
• Family problems
• Financial difficulties
• Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

• Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
• Confidence that you can handle problems that you face
• Having a systematic approach on how to deal with life's problems
• Having a toolbox of strategies to solve the issues you face
• Increased confidence to find creative solutions
• Knowing how to identify which barriers will impede your progress
• Knowing how to manage emotions when they arise
• Reduced avoidance and increased action-taking
• The ability to accept life problems that can't be solved
• The ability to make effective decisions
• The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

• Older adults
• People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

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What Types of Therapy Are Helpful for Depression?

What is psychotherapy, psychotherapy for depression.

• Therapy Approaches
• How Long Does It Take to Work?
• Choosing a Therapist

Depression is more than feeling sad or unmotivated for a few days; it’s an ongoing and persistent feeling of extreme sadness or despair affecting every aspect of a person’s life. Data from 2020 shows 18.4% of U.S. adults have received a diagnosis of depression.

Fortunately, treatment options like psychotherapy can be effective. The key is finding out what type of psychotherapy is right for you, depending on the severity of your symptoms, personal preferences, and therapy goals. 

This article covers the most effective evidence-based psychotherapy treatments for depression.

The Good Brigade / Getty Images

Psychotherapy is talk therapy . It takes place in outpatient settings (i.e., therapy offices) and inpatient settings (i.e., hospitals). Its purpose is to help relieve symptoms and prevent them from returning.

Each form of psychotherapy is unique, but typical sessions help a person identify the thought patterns, learned behaviors, or personal circumstances that may be contributing to their depression. The focus then shifts to building healthy coping strategies for managing negative thoughts, unwanted behaviors, and difficult emotions or experiences.

The following are the most common types of psychotherapy for depression.

Cognitive Therapy

Cognitive therapy (also called cognitive processing therapy) is a type of cognitive behavioral therapy shown to be effective in helping people challenge and change unhelpful or unwanted beliefs or attitudes that result from traumatic experiences such as sexual assault or natural disaster.

Cognitive therapy involves learning about symptoms like intrusive thoughts resulting from traumatic experiences and working on processing the experience and questioning and reframing negative self-thinking.  

Behavioral Therapy

Behavioral therapy (also called behavioral activation) focuses on how certain behaviors influence or trigger symptoms of depression. It works by helping a person identify and understand specific behavioral triggers and then providing behavioral activation exercises that encourage behavioral modifications or changes where possible, resulting in more positive mood outcomes.

Cognitive Behavioral Therapy (CBT)

CBT is considered the best-researched technique and the "gold standard" of psychotherapy. It's been shown effective in reducing depression symptoms and helping patients build skills to change thought patterns and behaviors to break them out of depression. It also encourages greater adherence to medications and other treatments.

CBT when combined with medication for depression has been shown more effective in treating symptoms and preventing relapse than pharmacology alone.

Dialectical Behavior Therapy (DBT)

DBT is a skilled-focused technique centered on acceptance and change. It involves acceptance-oriented skills, such as mindfulness and increasing tolerance to distress. It also uses change-oriented skills, emotional regulation (keeping emotions in check), and interpersonal development (i.e., saying no, asking for what you want, and establishing interpersonal boundaries).

Research suggests DBT is particularly beneficial for people experiencing chronic suicidal thinking .

Suicide Prevention Hotline

If you or someone you know is having suicidal thoughts, dial  988  to contact the  988 Suicide & Crisis Lifeline  and connect with a trained counselor. For more mental health resources, see our  National Helpline Database.

Psychodynamic Therapy

Psychodynamic therapy is based on the theory that moods and behaviors are directly but unconsciously related to childhood and past experiences. It involves building self-awareness of these experiences and their influence on a person while empowering them to change unwanted patterns.

Treatment with psychodynamic therapy has been shown to be as effective as other treatments in reducing depressive symptoms in depressive disorders.

Interpersonal Therapy (IPT)

IPT focuses on how relationships impact mental health. It helps people manage and strengthen current relationships, as well as looking at how different environments influence thinking and behavior. Numerous studies support the effectiveness of ITP for depression treatment and symptom relapse prevention.

Problem-Solving Therapy (PST)

PST is about strengthening a person’s ability to cope with stressful events by enhancing problem-solving skills. Several studies support the effectiveness of problem-solving therapy for people with depression, depressive disorders, and other mental health conditions.

Approaches to Therapy for Depression

Therapy is not one-size-fits-all. The best approach will depend on severity of symptoms and overall therapy goals, and may include a combination of individual therapy, group therapy , family therapy , or couples therapy . Someone experiencing ongoing depression may benefit from the one-on-one support of individual therapy, but also from a family-based approach and peer support groups .

How Long Does Therapy for Depression Take?

The length of time therapy takes to experience results will vary depending on factors such as:

• Depression type: Acute depression (i.e. depression that does not persist over a long period of time) will typically take fewer sessions to show results than chronic depression.
• Symptom severity: More severe symptoms like suicidal thinking may require longer or more intensive treatment.
• Therapy goals: Focused goals are reached more quickly than broader-based goals.
• Session frequency: People are typically advised to attend as often as they feel comfortable, but more frequent sessions typically result in quicker results.
• Technique: Some types of therapy like cognitive behavioral therapy are more goal-focused and generally quicker than other types.
• Trust: Higher levels of trust between client and therapist often yield quicker results.
• Personal circumstances: A new or ongoing traumatic life experience or other health condition like substance use disorder may prolong how long treatment takes.

General Timeline

Psychotherapy can be short-term and last a few weeks to months (for situational acute depression) or long-term and last a few months to years (for persistent or chronic depression).

How to Choose a Technique and Therapist

Consider which types of therapy best align with your goals and seek a therapist who offers that type of therapy. Bear in mind that therapists may offer more than one technique and can help you determine which techniques may be most suitable.

When choosing a therapist, you may consider their credentials, such as if they have a medical degree and can prescribe medication for depression , as a psychiatrist can. It's crucial to choose a therapist whom you feel comfortable working with. It’s OK to attend a few sessions before deciding if they're the right therapist for you. 

A Word From Verywell

Making sure you feel comfortable and have rapport with your therapist is one of the most important determinants for effective therapy. Set up short introductions or consultations with a few therapists so you can pick one you feel you can build the most rapport with.

There are many types of evidence-based therapy that are suitable for treating depression. Some involve working one-on-one with a therapist, and others may include family members, spouses, or peer groups experiencing depression. Making the correct choice includes determining your therapy goals and finding a therapist you feel comfortable working with.

Centers for Disease Control and Prevention. National, state-level, and county-level prevalence estimates of adults aged ≥18 years self-reporting a lifetime diagnosis of depression — United States, 2020 .

Informed Health. Depression: How effective is psychological treatment?

American Psychological Association. Cognitive processing therapy (CPT) .

University of Michigan. Behavioral activation for depression .  

Gautam M, Tripathi A, Deshmukh D, Gaur M. Cognitive behavioral therapy for depression . Indian J Psychiatry . 2020;62( 2):S223-S229. doi:10.4103/psychiatry.IndianJPsychiatry_772_19

Wersen AD, Meiser-Stedman R, Laidlaw K. A meta-analysis of CBT efficacy for depression comparing adults and older adults . Journal of Affective Disorders . 2022;319:189-20. doi:10.1016/j.jad.2022.09.020

University of Washington. Dialectical behavioral therapy . 

American Psychiatric Association. What is psychotherapy?

Steinert C, Munder T, Rabung S, Hoyer J, Leichsenring F. Psychodynamic therapy: as efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes . AJP . 2017;174(10):943-953. doi:10.1176/appi.ajp.2017.17010057

American Psychological Association. APA dictionary of psychology: interpersonal psychotherapy (ITP) .

Cuijpers P, Donker T, Weissman MM, Ravitz P, Cristea IA. Interpersonal psychotherapy for mental health problems: A comprehensive meta-analysis. Am J Psychiatry . 2016;173(7):680-687. doi:10.1176/appi.ajp.2015.15091141 

Zhang A, Park S, Sullivan JE, Jing S. The effectiveness of problem-solving therapy for primary care patients' depressive and/or anxiety disorders: A systematic review and meta-analysis . J Am Board Fam Med . 2018;31(1):139-150. doi:10.3122/jabfm.2018.01.170270

American Psychological Association. How long will it take for treatment to work?

By Michelle Pugle Pulge is a freelance health writer focused on mental health content. She is certified in mental health first aid.

Therapy for Depression

Reviewed by Psychology Today Staff

Good therapy is like driver’s education for the mind. It enables people to understand what sets off their descent into depression and not only helps them develop suitable tools for finding their way out but teaches ways of regulating difficult emotions going forward. Clinicians and researchers have long known that a prime contributor to depression is the inability to process negative emotions in constructive or adaptive ways. Medication can relieve some of the psychic pain of depression, but it does not help people learn good ways of coping with distressing experiences and feelings—which make them feel overwhelmed—or learn how to manage the kinds of thoughts that can trigger such feelings. As a result, they are always at the mercy of circumstances, ever-susceptible to depression. The goal of psychotherapy is to build the pillars of mental health.

On This Page

• Why is therapy important for treating depression?
• Does therapy help in ways that medication does not?
• When is therapy used in conjunction with medication?
• How is therapy coordinated with medication use?
• What does therapy do?
• How effective is therapy?
• When is it best to seek therapy for depression?
• Why is it important to seek therapy promptly?
• How soon will I notice any effect?
• How will know that therapy is working?
• How long will therapy be needed?
• Can any type of therapy help?
• Are some types of therapy especially effective against depression?
• Is group therapy ever helpful?
• Can therapy help someone who is suicidal?
• How is progress evaluated in therapy?

From one perspective, depression can be seen as a state of depletion that occurs when problems overwhelm a person’s resources for solution. Therapy aims directly at the development of new solution patterns . It is at least as effective as medication during the period of treatment but its effects last longer and it is effective in preventing recurrence of depression. The coping techniques, problem-solving skills, and understanding of one’s own vulnerabilities gained during therapy are useful over the course of a lifetime.

Many studies have evaluate the effects of psychotherapy vs. medications . Medication for depression may relieve symptoms more quickly than therapy, but the symptom relief lasts only as long as medication is taken. Therapy has enduring effects; it not only relieves symptoms of a current episode of depression but reduces the risk of future episodes. Studies show that both types of treatment change the way the brain functions. Therapy gives people insight into how their own patterns of reactions to negative experience set off a downward spiral of thinking that lead to depression. It also fosters the development of coping skills that interrupt the chain of reactivity. Further, therapy restores a sense of control, something no medication can deliver. Perhaps most important, the bond that develops between patient and therapist becomes an instrument of support and recovery.

Because psychotherapy can take many weeks to months to have an effect, psychotherapy is frequently prescribed along with medication for people needing relief from severe depression, although less than a third of patients respond to the first drug they’re given. A new crop of medications for depression —all related to psychedelic drugs—appears to open new neural pathways to recovery and is proving especially powerful when used in conjunction with intensive psychotherapy. One such drug, ketamine, is fast-acting and has been shown to reduce suicidal ideation; administered intravenously, it is increasingly used for suicidal patients.

Combination psychotherapy and pharmacotherapy (medication) for major depression is very common, both for acute and chronic forms of the disorder. Treatment with both modalities may begin simultaneously or be sequenced. Sometimes reduction in agitation or cloudiness of thinking or the abatement of psychic pain by medication is necessary before patients can be responsive to psychotherapy. Other times, medication can boost the effects of psychotherapy.

Typically, a psychiatrist or other medical doctor prescribes medication, monitors the response, and makes adjustments to the dosage or changes the type of medication as needed, while the psychotherapy is carried out separately by a psychologist or other mental health professional. Because the interaction between therapist and patient provides a prime window into a patient’s thoughts and feelings, the psychotherapist is also ideally positioned to observe the response to antidepressant drugs and deliver invaluable feedback to the prescribing physician. Patients do best when the two professionals are in regular contact coordinating their respective treatments rather than delivering them independently..

Therapy is just as “real” a treatment for depression as medication. It produces long-lasting changes in brain function that show up in brain imaging studies. It changes patters of connectivity between brain regions, enabling patients to exert more cognitive control over emotional reactivity.

Because major depression is a recurrent disorder, psychotherapy has the dual value of relieving current suffering and preventing future episode of distress. It also reverses the social and occupational decline depressed patients typically experience. Through a strong alliance with a therapist , in meetings, or sessions, typically held weekly for a limited period of time, patients learn to identify the kinds of inner and outer experiences that overwhelm them emotionally and set off the downward spiral of negative thinking and feeling that incapacitates them. Patients also learn to identify the distorted thinking patterns that contribute to hopelessness and despair. By discovering their own resources for problem solving, patients are equipped to regain control of their life.

Therapy is highly effective provided patients complete a prescribed course of therapy. Recent data show that only 10.6 percent of depressed patients haver ever received weekly therapy during their treatment period, which is typically 12 to 16 weeks. But when they do, therapy is more effective than medication over the long term and the effects are more enduring. Patients are less likely to need a second course of treatment and less likely to relapse . In fact, studies show that a single course of psychotherapy works at least as well as keeping patients on medication.

After two weeks of persistent sadness or loss of capacity for pleasure, along with a sense of hopelessness or guilt and such physical changes as appetite shifts and early-morning awakening, it is wise to consider the possibility of major depression. Depression is diagnosed after a thorough health examination rules out treatable physical conditions, such as thyroid disorder, that can create many of the same symptoms. Therapy should be started as soon as a diagnosis of depression is rendered. The longer an episode of depression goes untreated, the more difficult it becomes to treat, the greater the possibility of future episodes, and the greater the possibility of inflammatory changes to the brain itself. Further, depression undermines functioning in every domain of life, including work and family; starting therapy soon minimizes the disruptive impact of the disorder.

Early treatment of depression is essential because depression itself changes the brain . Research shows that depression is linked to inflammatory changes in the brain. As a result of such changes, the longer an episode of depression lasts, the greater the likelihood of a recurrence of depression. Untreated, depression can become a progressive disease leading to neurodegeneration. Untreated depression especially compromises the prefrontal cortex, the area of the brain essential for reasoning and decision-making and enabling control of emotional reactivity. Therapy helps patients develop the skills not just to beat back a current episode of depression but to prevent future ones as well.

Research indicates that 50 percent of patients recover within 15 to 20 sessions, and many patients experience some improvement within a few sessions. Patients differ in the nature and severity of their problem and in their progress, but most patients experience a gradual return of ability to function. They also notice a lessening of hopelessness. The first sign that depression is improving may be a reduction in sadness or reduced pessimism about the future. There may be a lessening of irritability or a renewed interest in something once enjoyed. Feelings of guilt may also begin to abate.

Feeling better is a good yardstick, but it is by no means the only measure of therapeutic effectiveness. Mental health professionals regularly assess the progress of therapy and rely on two important tools to monitor patient gains. One is their own experienced judgment of the patient’s ability to engage in the therapeutic process. The other is a standardized symptom rating scale that assesses patient standing on each of the constellation of symptoms of depression, from personal outlook to physical slowness. Has the veil on thinking or sluggishness of thought or speech persisted, lifted slightly, lifted significantly, or completely disappeared? Does the patient weep frequently, occasionally, or not at all? The most widely used symptom checklist is the Hamilton Rating Scale for Depression, often called the Ham-D.

Research indicates that 50 percent of patients recover within 15 to 20 sessions. As with drug therapy, patients fare better when therapy is continued for a period beyond symptom remission. There are three goals of psychotherapy . The first is response—an improvement in symptoms. Patients may begin to experience improvement within a few sessions. The second is remission—disappearance of all symptoms and a return to healthy functioning in all domains of life. There may be a temptation to stop therapy at this point, but the consensus of experts is that treatment should continue at least four months after disappearance of symptoms to ensure recovery (the third goal of treatment) and to maintain the ability to handle the stresses of daily life that challenge coping skills. Completing a full course of therapy is critical for full recovery.

For patients, recovery from depression requires understanding the kinds of events that precipitate a depressive response, awareness of their own psychological vulnerabilities, identifying distorted thinking patterns that lead to feelings of hopelessness, recognizing behavior patterns that exacerbate problems, developing problem-solving skills, and taking action even when they may not feel like it. An experienced therapist will gauge t he best way to treat depression based on individual patient needs but incorporate all such goals into their treatment plan. However, there are several types of psychotherapy that specifically target one or more of these needs through treatment protocols that have been well-validated by extensive field-testing.

Depression is a multifaceted disorder, and it responds to therapies that specifically target one or another area of dysfunction. Four types of therapy have proved effective in patients with depression extensively studied during treatment and followed up for significant periods of time afterwards. They are: Cognitive and Behavioral Therapy (CBT), Interpersonal Therapy (IPT), Psychodynamic Therapy, and Behavioral Activation (BA).

CBT takes straight aim at the distorted ways of thinking—often acquired early in life—that are typical of depressed people, and study upon study has proved its effectiveness. It is based on the evidence that negatively-biased thinking and beliefs give rise to the feelings of hopelessness and despair that are typical of depression, and changing thoughts changes emotions . Studies show that in depression, dysfunction in neural circuitry inclines patients to a negative view of themselves, the world, and their future, and therapy effectively alters patterns of neural transmission. CBT involves an active collaboration between patient and therapist that guides patients to challenge and test their own thoughts and beliefs, try out new behavioral strategies, and to curb reactivity to distressing situations.  

Like CBT, IPT is a short-term, present-oriented therapy. It’s primary target, however, is the difficultiy in interpersonal (social) functioning that both gives rise to and results from depression. Many studies support the value of ameliorating interpersonal distress as a route to relieving depression. IPT focuses on four major interpersonal problem areas—unresolved or complicated grief, struggles with a significant other (role disputes), role transitions such as the end of a marriage or becoming physically ill, and frank deficits in interpersonal skills. Patients learn to understand which problem area is linked to onset of their episode of depression and to directly redress those difficulties, often by learning how to better express their emotions. With supportive guidance from the therapist, they learn new communication strategies and may even rehearse through role play new solutions to longstanding social difficulties.

Behavioral Activation is a short-term, evidence-based therapy that directly counters the avoidance patterns—loss of interest in and withdrawal from once-enjoyed activities—that are hallmarks of depression. BA fosters engagement in rewarding activity as a lever to change the negative feelings and disturbed mood that make depression so oppressive. Perhaps best regarded as a small slice of CBT applied intensively, Behavioral Activation assigns to patients activities of their own choosing—exercising, going out to dinner, getting together with friends, tackling a chore—known to bring them some measure of pleasure or sense of achievement. With active guidance from a therapist, patients come to understand the vicious cycle of depression  and the role of activity itself to spark motivation and energy.

Psychodynamic therapy is a modern evolution of psychoanalysis, and it is similarly aimed at the development of insight into oneself, specifically understanding of the problem situations and personal vulnerabilities that set the stage for depression. The therapist takes an active role in guiding therapy, and the relationship between therapist and patient is a major conduit of recovery. While CBT and IPT are staunchly present-focused, psychodynamic therapy may examine current difficulties in the context of earlier life experiences and relationships.

Although depression is a very individualized disorder, with each patient exhibiting a distinctive patterns of symptoms, group therapy can sometimes be helpful. One area of special value may be group education in coping skills, problem-solving skills, and techniques for managing difficult emotions, as deficits in those areas are known to underlie most expressions of depression. Such treatment is often labeled psychoeducation and it may be especially appealing to people who cannot afford an individual course of therapy or who feel stigmatized by it. Whatever the format of depression group therapy , it can offer some advantages over individual therapy. Most obviously, it counters the social isolation that is a major precipitant of depression. Groups also allow for working though the dysfunctional relationship patterns that contribute to depression. Further, group interaction provides a forum for credible challenges to the negative evaluations depressed people make about themselves.

Studies show that about 5 percent of depressed patient have thoughts about suicide—suicidal ideation. Suicide is seen as a way of escaping the mental pain of depression , which distorts patterns of thinking and feeling so that sufferers cannot see a way out their current state of mind or envision a future possibility of feeling better.

Good therapy includes a specific assessment of suicide risk separate from the depression evaluation. It also includes specific measures to manage the risk of suicide in the present and the future. Many therapists draw up anti-suicide pacts with their patients. A contract may be written or verbal but, either way, patients at risk agree to commit no self-harm and to call the therapist if they ever have thoughts of ending their life, or to call an emergency number such as 911. In addition, studies show that such widely used treatments for depression as cognitive behavioral therapy (CBT) can be very helpful when adapted to specifically target the ways distorted thinking leads to depressive despair and thoughts of suicide.

While unstructured interactions with patients under their care can provide a window into patient functioning, therapists providing good care make regular assessments of a patient’s clinical status using criteria that have been validated in many studies. To know whether and how much depression is improving , they regularly monitor treatment progress by measuring the severity of multiple symptoms of depression on standardized scales. The most widely used assessment instrument is the Hamilton Rating Scale for Depression, or Ham-D, which gauges progress in 21 constellations of symptoms, from level of sadness to degree of guilty feelings to lack of energy to sleep problems. Severity is rated for each cluster of symptoms. Comparison of results over several sessions provides an accurate picture of treatment effectiveness and indicates areas where more intensive work may be needed.

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Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis

• Karolin R. Krause   ORCID: orcid.org/0000-0003-3914-7272 1 , 2 ,
• Darren B. Courtney   ORCID: orcid.org/0000-0003-1491-0972 1 , 3 ,
• Benjamin W. C. Chan 4 ,
• Sarah Bonato   ORCID: orcid.org/0000-0002-5174-0047 1 ,
• Madison Aitken   ORCID: orcid.org/0000-0002-4921-5462 1 , 3 ,
• Jacqueline Relihan 1 ,
• Matthew Prebeg 1 ,
• Karleigh Darnay   ORCID: orcid.org/0000-0002-0395-8674 1 ,
• Lisa D. Hawke   ORCID: orcid.org/0000-0003-1108-9453 1 , 3 ,
• Priya Watson   ORCID: orcid.org/0000-0001-9753-6490 1 , 3 &
• Peter Szatmari   ORCID: orcid.org/0000-0002-4535-115X 1 , 3 , 5  

BMC Psychiatry volume  21 , Article number:  397 ( 2021 ) Cite this article

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Problem-solving training is a common ingredient of evidence-based therapies for youth depression and has shown effectiveness as a versatile stand-alone intervention in adults. This scoping review provided a first overview of the evidence supporting problem solving as a mechanism for treating depression in youth aged 14 to 24 years.

Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for controlled trials of stand-alone problem-solving therapy; secondary analyses of trial data exploring problem-solving-related concepts as predictors, moderators, or mediators of treatment response within broader therapies; and clinical practice guidelines for youth depression. Following the scoping review, an exploratory meta-analysis examined the overall effectiveness of stand-alone problem-solving therapy.

Inclusion criteria were met by four randomized trials of problem-solving therapy (524 participants); four secondary analyses of problem-solving-related concepts as predictors, moderators, or mediators; and 23 practice guidelines. The only clinical trial rated as having a low risk of bias found problem-solving training helped youth solve personal problems but was not significantly more effective than the control at reducing emotional symptoms. An exploratory meta-analysis showed a small and non-significant effect on self-reported depression or emotional symptoms (Hedges’ g = − 0.34; 95% CI: − 0.92 to 0.23) with high heterogeneity. Removing one study at high risk of bias led to a decrease in effect size and heterogeneity (g = − 0.08; 95% CI: − 0.26 to 0.10). A GRADE appraisal suggested a low overall quality of the evidence. Tentative evidence from secondary analyses suggested problem-solving training might enhance outcomes in cognitive-behavioural therapy and family therapy, but dedicated dismantling studies are needed to corroborate these findings. Clinical practice guidelines did not recommend problem-solving training as a stand-alone treatment for youth depression, but five mentioned it as a treatment ingredient.

Conclusions

On its own, problem-solving training may be beneficial for helping youth solve personal challenges, but it may not measurably reduce depressive symptoms. Youth experiencing elevated depressive symptoms may require more comprehensive psychotherapeutic support alongside problem-solving training. High-quality studies are needed to examine the effectiveness of problem-solving training as a stand-alone approach and as a treatment ingredient.

Peer Review reports

Depressive disorders are a common mental health concern in adolescence [ 1 , 2 , 3 ] and associated with functional impairment [ 4 ] and an increased risk of adverse mental health, physical health, and socio-economic outcomes in adulthood [ 5 , 6 , 7 , 8 ]. Early and effective intervention is needed to reduce the burden arising from early-onset depression. Several psychotherapies have proven modestly effective at reducing youth depression, including cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) [ 9 , 10 ]. Room for improvement remains; around half of youth do not show measurable symptom reduction after an average of 30 weeks of routine clinical care for depression or anxiety [ 11 ]. One barrier to greater impact is a lack of understanding of which treatment ingredients are most critical [ 12 , 13 ]. Identifying the “active ingredients” that underpin effective approaches, and understanding when and for whom they are most effective is an important avenue for enhancing impact [ 13 ]. Distilling interventions to their most effective ingredients while removing redundant content may also help reduce treatment length and cost, freeing up resources to expand service provision. Given that youth frequently drop out of treatment early [ 14 ], introducing the most effective ingredients at the start may also help improve outcomes.

One common ingredient in the treatment of youth depression is problem-solving (PS) training [ 15 ]. Problem solving in real-life contexts (also called social problem solving) describes “the self-directed process by which individuals attempt to identify [ …] adaptive coping solutions for problems, both acute and chronic, that they encounter in everyday living” (p.8) [ 16 ]. Within a relational/problem-solving model of stress and well-being, mental health difficulties are viewed as the result of maladaptive coping behaviours that cannot adequately safeguard an individual’s well-being against chronic or acute stressors [ 17 ]. According to a conceptual model developed by D’Zurilla and colleagues ([ 16 , 17 , 18 , 19 ]; see Fig.  1 ), effective PS requires a constructive and confident attitude towards problems (i.e., a positive problem orientation ), and the ability to approach problems rationally and systematically (i.e., rational PS style ). Defeatist or catastrophizing attitudes (i.e., a negative problem orientation ), passively waiting for problems to resolve (i.e., avoidant style ), or acting impulsively without thinking through possible consequences and alternative solutions (i.e., impulsive/careless style ) are considered maladaptive [ 16 , 18 , 20 ]. Empirical studies suggest maladaptive PS is associated with depressive symptoms in adolescents and young adults [ 21 , 22 , 23 , 24 , 25 ].

Dimensions of Problem-Solving (PS) Ability

Problem-Solving Therapy (PST) is a therapeutic approach developed by D’Zurilla and Goldfried [ 26 ] in the 1970s, to alleviate mental health difficulties by improving PS ability. Conceptually rooted in Social Learning Theory [ 27 ], PST aims to promote adaptive PS by helping clients foster an optimistic and self-confident attitude towards problems (i.e., a positive problem orientation), and by helping them develop and internalize four core PS skills: (a) defining the problem; (b) brainstorming possible solutions; (c) appraising solutions and selecting the most promising one; (d) implementing the preferred solution and reflecting on the outcome ([ 16 , 17 , 18 , 19 ]; see Fig. 1 ). PST is distinct from Solution-Focused Brief Therapy (SFBT), which has different conceptual roots and emphasizes the construction of solutions over the in-depth formulation of problems [ 28 ].

PS training is also a common ingredient of other psychosocial depression treatments [ 15 , 20 ], such as CBT and Dialectical Behaviour Therapy (DBT) [ 15 , 29 , 30 , 31 , 32 ] that typically focus on strengthening PS skills rather than problem orientation [ 20 ]. In IPT, PS training focuses on helping youth understand and resolve relationship problems [ 29 , 30 , 33 , 34 ]. PS training is also a common component of family therapy [ 35 ], cognitive reminiscence therapy [ 36 ], and adventure therapy [ 37 ]. The extent to which PS training in these contexts follows the conceptual model by D’Zurilla and colleagues varies. Hereafter, we will use the term PST (“Problem-Solving Therapy”) where problem-solving training constitutes a stand-alone intervention; and we will use the term “PS training” where it is mentioned as a part of other therapies or discussed more broadly as an active ingredient of treatment for youth depression.

Meta-analyses considering over 30 randomized control trials (RCTs) of stand-alone PST for adult depression suggest it is as effective as CBT and IPT, and more effective than waitlist or attention controls [ 38 , 39 , 40 ]. PST has been applied with children, adolescents, and young adults [ 41 , 42 , 43 , 44 , 45 , 46 ], but dedicated manuals for different developmental stages are not readily available. In an assessment of fit between evidence-based therapy components and everyday coping skills used by school children, PS skills were the third most frequently endorsed skill set in terms of frequency of habitual use and perceived effectiveness, suggesting these skills are highly transferable and relevant to youth [ 47 ]. PS training can be brief (i.e., involve fewer than 10 sessions) [ 38 ], and has been delivered to youth by trained clinicians [ 45 ], lay counsellors [ 46 ], and via online platforms [ 44 ]. It can also be adapted for primary care [ 40 ]. In light of its versatility and of its effectiveness in adults, PS training is a prime candidate for a treatment ingredient that deserves greater scrutiny in the context of youth depression. However, no systematic evidence synthesis has yet examined its efficacy and effectiveness in this population.

This study had two sequential parts. First, we conducted a mixed-methods scoping review to map the available evidence relating to PS training as an active ingredient for treating youth depression. Youth were defined as aged 14 to 24 years, broadly aligning with United Nations definitions [ 48 ]. In a subsequent step, we conducted an exploratory meta-analysis to examine the overall efficacy of free-standing PST, based on clinical trials identified in the scoping review.

Scoping review

Scoping review methodology was used to provide an initial overview of the available evidence [ 49 ]. The review was pre-registered on the Open Science Framework [ 50 ] and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews checklist [ 51 ] (Additional File  1 ). The review was designed to integrate four types of literature: (a) qualitative studies reporting on young people’s experiences with PS training; (b) controlled clinical trials testing the efficacy of stand-alone PST; (c) studies examining PS-related concepts as predictors, moderators, or mediators of treatment response within broader therapeutic interventions (e.g., CBT); and (d) clinical practice guidelines (CPGs) for youth depression. In addition, the search strategy included terms designed to identify relevant conceptual articles that are discussed here as part of the introduction [ 52 ].

Search strategy

Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for (a) empirical studies published from database inception through June 2020, and (b) CPGs published between 2005 and July 2020. Reference lists of key studies were searched manually, and records citing key studies were searched using Google Scholar’s “search within citing articles” function [ 52 ]. The search strategy was designed in collaboration with a research librarian (SB) and combined topic-specific terms defining the target population (e.g., “depression”; “adolescent?”) and intervention (e.g., “problem-solving”) with methodological search filters combining database-specific subject headings (e.g., “randomized controlled trial”) and recommended search terms. The search for CPGs built upon a previous systematic search [ 53 , 54 ], which was updated and expanded to cover additional languages and databases. A multi-pronged grey literature search retrieved records from common grey literature databases and CPG repositories, websites of relevant associations, charities, and government agencies. The search strategy is provided in Additional File  2 .

Inclusion and exclusion criteria

Empirical studies were included if the mean participant age fell within the eligible range of 14 to 24 years, and at least 50% of participants showed above-threshold depressive or emotional symptoms on a validated screening tool. Controlled clinical trials had to compare the efficacy or effectiveness of PST as a free-standing intervention with a control group or waitlist condition. Secondary analyses were considered for their assessment of PS ability as a predictor, moderator, or mediator of treatment response if they reported on data from controlled clinical trials of broader therapy packages. Records were included as CPGs if labelled as practice guidelines, practice parameters, or consensus or expert committee recommendations, or explicitly aimed to develop original clinical guidance [ 53 , 54 ]; and if focused on indicated psychosocial treatments for youth depression (rather than prevention, screening, or pharmacological treatment). Doctoral dissertations were included. Conference abstracts, non-controlled trials, and prevention studies were excluded. Language of publication was restricted to English, French, German, and Spanish.

All records identified were imported into the EPPI-Reviewer 4.0 review software [ 55 ], and underwent a two-stage screening process (Fig.  2 ). Title and abstract screening was conducted in duplicate for 10% of the identified records, yielding substantial inter-rater agreement ( kappa  = .75 and .86, for empirical studies and CPGs, respectively). Of studies retained for full text screening, 20% were screened in duplicate, yielding substantial agreement ( kappa  = .68 and .71, for empirical studies and CPGs, respectively). Disagreements were resolved through discussion.

PRISMA Flow Chart of the Study Selection Process

Data extraction and synthesis

Data were extracted using templates tailored to each literature type (e.g., the Cochrane data collection form for RCTs). Information extracted included: citation details; study design; participant characteristics; and relevant qualitative or quantitative results. Additional information extracted from CPGs included the issuing authority, the target population, the treatment settings to which the guideline applied, and any recommendations in relation to PS training. Data from clinical trials and secondary analyses were extracted in duplicate, and any discrepancies were discussed and resolved. Data synthesis followed a five-step process of data reduction, display, comparison, conclusion drawing, and verification [ 56 ]. Scoping review findings were summarized in narrative format. In addition, effect sizes reported in PST trials for depression severity were entered into an exploratory meta-analysis (see below).

The Centre for Addiction and Mental Health (CAMH) implements a Youth Engagement Initiative that brings the voices of youth with lived experience of mental health difficulties into research and service design [ 57 , 58 , 59 ]. Two youth partners were co-investigators in this review and consulted with a panel of twelve CAMH youth advisors to inform the review process and help contextualize findings. Formal approval by a Research Ethics Board (REB) was not required, as youth were research partners rather than participants.

To incorporate a variety of perspectives, the review team convened for an inference workshop where emerging review findings and feedback from youth advisors were discussed and interpreted. The multidisciplinary team involved a methodologist; two child and adolescent psychiatrists with expertise in CBT, DBT, and IPT; a psychologist with expertise in parent-adolescent therapy; a research librarian; a family doctor; a biostatistician; a clinical epidemiologist; two youth research partners; and a youth engagement coordinator.

Exploratory Meta-analysis

Although meta-analyses are not typical components of scoping reviews [ 60 ], an exploratory meta-analysis was conducted following completion of the scoping review and narrative synthesis, to obtain an initial indication of the efficacy of stand-alone PST based on the clinical trials identified in the review. The PICO statement that guided the meta-analysis is shown in Table  1 .

Quality assessment

Risk of bias for included PST trials was appraised using the Cochrane Collaborations Risk of Bias (ROB) 2 tool [ 61 ]. Ratings were performed independently by two reviewers (KRK and MA), and consensus was formed through discussion. In addition, a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) appraisal was conducted (using the GRADEpro software; [ 62 ] to characterize the quality of the overall evidence. The evidence was graded for risk of bias, imprecision, indirectness, inconsistency, and publication bias [ 63 ]. A GRADE of “high quality” indicates a high level of confidence that the true effect lies close to the estimate; “moderate quality” indicates moderate confidence; “low quality” indicates limited confidence; and “very low quality” indicates very little confidence in the estimate. ROB ratings and GRADE appraisal results are provided in Additional File  6 .

Statistical analysis

The meta-analysis was conducted using the meta suite of commands in Stata 16.1. Effect sizes (Hedges’ g) and their confidence intervals were calculated based on the mean difference in depression severity scores between the PST and control conditions at the first post-treatment assessment [ 64 ]. Hedges’ g is calculated by subtracting the post-treatment mean score of the intervention group from the score of the control group, and by dividing the mean difference by the pooled standard deviation. Effect sizes between g = 0.2 and 0.5 indicate a small effect; g = 0.5 to 0.8 indicates a moderate effect; and g ≥ 0.8 indicates a large effect. Effect sizes were adjusted using the Hedges and Olkin small sample correction [ 64 ]. Pooled effect sizes were computed using a random effects model to account for heterogeneity in intervention settings, modes of delivery, and participant age and depression severity. The I 2 statistic was computed as an indicator of effect size heterogeneity. Higgins et al. [ 65 ] suggest that an I 2 below 30% represents low heterogeneity while an I 2 above 75% represents substantial heterogeneity. Investigations of heterogeneity are unlikely to generate valuable insights in small study samples, with at least ten studies recommended for meta-regression [ 65 ]. We conducted limited exploratory subgroup analysis by computing a separate effect size after excluding studies with high risk of bias. We inspected the funnel plot and considered conducting Egger’s test to examine the likelihood and extent of publication bias [ 66 ].

Selection and inclusion of studies

The search for empirical studies identified 563 unique records (Fig. 2 ), of which 148 were screened in full. Inclusion criteria were met by four RCTs of free-standing PST and four secondary analyses of clinical trials investigating PS-related concepts as predictors, mediators, or moderators of treatment response. No eligible qualitative studies that explicitly examined youth experiences of PS training were identified. The search for CPGs identified 9691 unique records, of which 41 were subject to full text screening, and 23 were included in the review. Below we present scoping review findings for all literature types, followed by the results from the meta-analysis for stand-alone PST trials.

Clinical trials of PST

Characteristics of the included PST trials are shown in Table  2 . Studies were published between 2008 and 2020 and included 524 participants (range: 45 to 251), with a mean age of 16.7 years (range: 12–25; 48% female). Participants had a diagnosis of major depressive disorder (MDD; k  = 1), elevated anxiety or depressive symptoms ( k  = 1), or various mild presenting problems including depression ( k  = 2). Treatment covered PS skills but not problem orientation (i.e., youth’s problem appraisals) and was delivered face to face ( k =  3) or online ( k  = 1) in five to six sessions. PST was compared with waitlist controls ( k  = 2), PS booklets ( k =  1), and supportive counselling ( k  = 1). Risk of bias was rated as medium for two [ 44 , 45 ], and high for one study [ 43 ] due to concerns about missing outcome data and the absence of a study protocol.

Eskin and colleagues [ 43 ] randomized 53 Turkish high school and university students with MDD to six sessions of PST or a waitlist. The study reports a significant treatment effect on self-reported depressive symptoms (d = − 1.20; F [1, 42] = 10.3, p  < .01.), clinician-reported depressive symptoms (d = − 2.12; F [1, 42] = 37.7, p  < .001), and recovery rates, but not on self-reported PS ability (d = − 0.46; F [1, 42] = 2.2, p  > .05). Risk of bias was rated as high due to 37% of missing outcome data in the control group and the absence of a published trial protocol.

Michelson and colleagues [ 46 ] compared PST delivered by lay counsellors in combination with booklets, to PS booklets alone in 251 high-school students with mild mental health difficulties (53% emotional problems) in low-income communities in New Delhi, India. At six weeks, the intervention group showed significantly greater progress towards overcoming idiographic priority problems identified at baseline (d = 0.36, p  = .002), but no significant difference in self-reported mental health difficulties (d = 0.16, p  = .18). Results were similar at 12 weeks, including no significant difference in self-reported emotional symptoms (d = 0.18, p  = .089). As there was no long-term follow-up, it is unknown whether reduced personal problems translated into reduced emotional symptoms in the longer term. Perceived stress at six weeks was found to mediate treatment effect on idiographic problems, accounting for 15% of the overall effect at 12 weeks.

Two trials found no significant effect of PST on primary or secondary outcomes: Hoek and colleagues [ 44 ] randomized 45 youth with elevated depression or anxiety symptoms to five sessions of online PST or a waitlist control; Parker and colleagues [ 45 ] randomized 176 youth with mixed presenting problems (54% depression) to either PST with physical activity or PST with psychoeducation, compared with supportive counselling with physical activity or psychoeducation [ 45 ]. Drop-out from PST was high in both studies, ranging from 41.4% [ 45 ] to 72.7% [ 44 ].

PS-related concepts as predictors, moderators, or mediators of treatment response

The review identified four secondary analyses of RCT data that examined PS-related concepts as predictors, moderators, or mediators of treatment response (see Table  3 , below). Studies were published between 2005 and 2014 and included data from 761 participants with MDD diagnoses, and a mean age of 15.2 years (range: 12–18; 61.2% female).

A secondary analysis of data from the Treatment for Adolescents with Depression Study (TADS, n  = 439) [ 79 ] explored whether baseline problem orientation and PS styles were significant predictors or moderators of treatment response to Fluoxetine, CBT, or a combination treatment at 12 weeks [ 70 ]. Negative problem orientation and avoidant PS style each predicted less improvement in depression symptom severity ( p  = .001 and p  = .003, respectively), while positive problem orientation predicted greater improvement ( p  = .002). There was no significant moderation effect. Neither rational PS style nor impulsive-careless PS style predicted or moderated change in depressive symptoms.

A secondary analysis of data from the Treatment of Resistant Depression in Adolescents (TORDIA) study [ 80 ] examined the impact of specific CBT components on treatment response at 12 weeks in youth treated with a selective serotonin reuptake inhibitor (SSRI) in combination with CBT ( n  = 166) [ 71 ]. Youth who received PS training were 2.3 times ( p  = .03) more likely to have a positive treatment response than those not receiving this component. A significant effect was also observed for social skills training (Odds Ratio [OR] = 2.6, p  = .04) but not for seven other CBT components. PS and social skills training had the most equal allocation ratios between youth who received them (52 and 54%, respectively) and youth who did not. Balanced allocation provides maximum power for a given sample size [ 81 ]. With allocation ratios between 1:3 and 1:5, analysis of the remaining seven components may have been underpowered. Of further note, CBT components were not randomly assigned but selected based on individual clinical needs. The authors did not correct for multiple comparisons as part of this exploratory analysis.

Dietz and colleagues [ 73 ] explored the impact of social problem solving on treatment outcome based on data from a trial comparing CBT and Systemic Behaviour Family Therapy (SBFT) with elements of PS training on the one hand, with Non-Directive Supportive Therapy on the other hand ( n  = 63). Both CBT and SBFT were associated with significant improvements in young people’s interpersonal PS behaviour (measured by coding videotaped interactions between youth and their mothers) over the course of treatment (CBT: b* = 0.41, p  = .006; SBFT: b* = 0.30, p  = .04), which in turn were associated with higher rates of remission (Wald z = 6.11, p  = .01). However, there was no significant indirect effect of treatment condition via youth PS behaviour, and hence, no definitive evidence of a formal mediation effect [ 82 ].

Kaufman and colleagues [ 72 ] examined data from a trial comparing an Adolescent Coping with Depression (CWD-A) group-based intervention with a life-skills control condition in 93 youth with comorbid depression and conduct disorder. The secondary analysis explored whether change in six CBT-specific factors, including the use of PS and conflict resolution skills, mediated the effectiveness of CWD-A. There was no significant improvement in PS ability in CWD-A, compared with the control, and hence no further mediation analysis was conducted.

PS training in clinical practice guidelines

We identified 23 CPGs from twelve countries relevant to youth depression (see Additional File  4 ), issued by governments ( k  = 6), specialty societies ( k  = 3), health care providers ( k  = 4), independent expert groups ( k  = 2), and others, or a combination of these. Of these 23 CPGs, 15 mentioned PS training in relation to depression treatment for youth, as a component of CBT ( k  = 7), IPT ( k  = 4), supportive therapy or counselling ( k  = 3), family therapy ( k  = 1), DBT ( k  = 1), and psychoeducation ( k  = 1).

None of the reviewed CPGs recommended free-standing PST as a first-line treatment for youth depression. However, five CPGs mentioned PS training as a treatment ingredient or adjunct component in the context of recommending broader therapeutic approaches. The World Health Organization’s updated Mental Health Gap Action Programme guidelines recommended PS training as an adjunct treatment (e.g., in combination with antidepressant medication) for older adolescents [ 83 ]. A guideline by Orygen (Australia) suggested that for “persistent sub-threshold depressive symptoms (including dysthymia) or mild to moderate depression”, options should include “6–8 sessions of individual guided self-help based on the principles of CBT, including behavioural activation and problem-solving techniques” [ 84 ]. The Chilean Ministry of Health recommended supportive clinical care with adjunctive psychoeducation and PS tools, or supportive counselling for individuals aged 15 and older with mild depression (p. 52) [ 85 ]. The Cincinnati Children’s Hospital Medical Centre recommended four to eight sessions of supportive therapy for mild or uncomplicated depression, highlighting “problem solving coping skills” as one element of supportive therapy (p. 1) [ 86 ]. Fifth, the American Academy of Child and Adolescent Psychiatry’s 2007 practice parameter suggested each phase of treatment for youth depression should include psychoeducation and supportive management, which might include PS training (p. 1510) [ 87 ]. CPGs did not specify whether PS training should incorporate specific modules, or whether the term was used loosely to describe unstructured PS support.

Meta-analysis

Each of the four RCTs of free-standing PST identified by the scoping review contributed one comparison to the exploratory meta-analysis of overall PST efficacy (see Fig.  3 ). Self-rated depression or emotional symptom severity scores were reported by all four studies and constituted the primary outcome for the meta-analysis. We conducted additional exploratory analysis for clinician-rated depression severity as reported in two studies [ 43 , 45 ]. The pooled effect size for self-reported depression severity was g = − 0.34 (95% CI: − 0.92 to 0.23). Heterogeneity was high ( I 2  = 88.37%; p  < .001). Due to the small number of studies included, analysis of publication bias via an examination of the funnel plot and tests of funnel plot asymmetry could not be meaningfully conducted [ 88 , 89 ]. The funnel plot is provided in Additional File  5 for reference (Fig. S3).

Forest Plot: Random Effects Model with Self-Reported Depression or Emotional Symptoms as Primary Outcome (Continuous)

To achieve the best possible estimate of the true effect size and reduce heterogeneity we computed a second model excluding the one study with high risk of bias (i.e., [ 43 ]). The resulting effect size was g = − 0.08 (95% CI: − 0.26 to 0.10), with no significant heterogeneity ( I 2  = 0.00%; p  = 0.72; see Fig. S1 in Additional File 5 ). The pooled effect size for clinician-rated depression severity was g = − 1.39 with a wide confidence interval (95% CI: − 4.03 to 1.42) and very high heterogeneity ( I 2  = 97.41%, p  < 0.001; see Fig. S2 in Additional File 5 ).

Overall quality of the evidence

According to the GRADE assessment, the overall quality of the evidence was very low, with concerns related to risk of bias, the inconsistency of results across studies, the indirectness of the evidence with regards to the population of interest (i.e., only one trial focused exclusively on youth with depression), and imprecision in the effect estimate (Table S4 in Additional File 6 ).

This scoping review aimed to provide a first comprehensive overview of the evidence relating to PS training as an active ingredient for treating youth depression. The evidence base relating to the efficacy of PST as a stand-alone intervention was scarce and of low quality. Overall, data from four trials suggested no significant effect on depression symptoms. The scoping review identified some evidence suggesting PS training may enhance treatment response in CBT. However, this conclusion was drawn from secondary analyses where youth were not randomized to treatment with and without PS training, and where primary studies were not powered to test these differences. Disproportionate exposure to comparator CBT components also limits these findings. PST was not recommended as a stand-alone treatment for youth depression in any of the 23 reviewed CPGs; however, one guideline suggested it could be provided alongside other treatments for older adolescents, and four suggested PS training as a component of low-intensity psychosocial interventions for youth with mild to moderate depression.

Given the limited evidence base, only tentative suggestions can be made as to when and for whom PS training is effective. The one PST trial with a low risk of bias enrolled high-school students from low-income communities in New Delhi, and found that PST delivered by lay counselors in combination with PST booklets was more effective at reducing idiographic priority problems than booklets alone, but not at reducing mental health symptoms [ 46 ]. Within a needs-based framework of service delivery (e.g., [ 90 ]), PST may be offered as a low-intensity intervention to youth who experience challenges and struggle with PS—including in low-resource contexts. Future research could explore whether PS training might be particularly helpful for youth facing socioeconomic hardship and related chronic stressors by attenuating potentially harmful impacts on well-being [ 91 ]. If findings are promising, PS training may be considered for targeted prevention (e.g., [ 42 ]). However, at this time there is insufficient evidence to support PS training on its own as an intervention aimed at providing symptom relief for youth experiencing depression.

The PST manual suggests cognitive overload, emotional dysregulation, negative thinking and hopelessness can interfere with PS [ 16 ]. Youth whose depression hinders their ability to engage in PST may require additional support through more comprehensive therapy packages such as CBT or IPT with PS training. In the TORDIA study [ 80 ], where PS training was found to be one of the most effective components, it was generally taught alongside cognitive restructuring, behavioural activation, and emotion regulation, which may have facilitated youths’ ability to absorb PS training [ 71 ]. The focus of these other CBT components on changing negative cognitions and attributions may fulfil a similar function as problem orientation modules in stand-alone PST. Research that is powered to explore such mechanisms is needed. Future research should also apply methodologies designed to identify the most critical elements in a larger treatment package (e.g., dismantling studies; or sequential, multiple assignment, randomized trials) to examine the role of PS training when delivered alongside other components. While one trial focusing on CBT components is currently underway [ 92 ], similar research is needed for other therapies (e.g., IPT, DBT, family therapy).

The included PST trials provided between five and six sessions and covered PS skills but not problem orientation. Meta-analyses of PST for adult depression suggest treatment effectiveness may be enhanced by longer treatment duration (≥ 10 sessions) [ 38 ], and coverage of problem orientation alongside PS skills [ 39 ]. As per the PST treatment manual, strengthening problem orientation fosters motivation and self-efficacy and is an important precondition for enhancing skills [ 93 , 94 ]. In addition, only one youth PST trial assessed PS ability at baseline [ 43 ]. A meta-analysis of PST for adult depression [ 39 ] suggests that studies including such assessments show larger effect sizes, with therapists better able to tailor PST to individual needs. Future research should seek to replicate these findings specifically for youth depression.

Drop out from stand-alone PST was high in two out of four studies, ranging from 41.4% [ 45 ] to 72.7% [ 44 ]. Since its development in the 1970s, PST has undergone several revisions [ 16 , 93 , 95 , 96 , 97 ] but tailoring to youth has been limited. To contextualize the review findings, the review team consulted a panel of twelve youth advisors at the Centre for Addiction and Mental Health (without sharing emerging findings so as not to steer the conversation). Most had participated in PS training as part of other therapies, but none had received formal PST. A key challenge identified by youth advisors was how to provide PS training that is universally applicable and relevant to different youth without being too generic, rigid or schematic; and how to accommodate youth perspectives, complex problems, and individual situations and dispositions. Youth advisors suggested reviewing and reworking PS training with youth in mind, to ensure it is youth-driven, strengths-based, comprehensive, and personalized (see Fig. S4 in Additional File  7 for more detail). Youth advisors emphasized that PS training should identify the root causes underpinning superficial problems and address these through suitable complementary intervention approaches, if needed.

Solution-focused brief therapy (SFBT) has emerged as an antithesis to PST where more emphasis is given to envisaging and constructing solutions rather than analysing problems [ 28 ]. This may be more consistent with youth preferences for strengths-based approaches but may provide insufficiently comprehensive problem appraisals. Future research should compare the effectiveness and acceptability of PST and SFBT and consider possible benefits of combining the advantages of both approaches, to provide support that is strengths-based and targets root problems. More generally, given the effectiveness of PST in adults, future studies could examine whether there are developmental factors that might contribute to reduced effectiveness in youth and should be considered when adapting PST to this age group.

Strengths and limitations

This scoping review applied a broad and systematic approach to study identification and selection. We searched five bibliographic databases, and conducted an extensive grey literature search, considering records published in four languages. Nevertheless, our search may have missed relevant studies published in other languages. We found only a small number of eligible empirical studies, several of which were likely underpowered. As stated above, studies analysing PS-related concepts as predictors, moderators, or mediators of treatment response within broader therapies were heterogenous and limited by design and sample size constraints.

Similarly, there was heterogeneity in recruitment and intervention settings, age groups, and delivery formats across the four RCTs of stand-alone PST, and the overall quality of the evidence was very low. As reflected in our GRADE appraisal, one important limitation was the indirectness of the available evidence: Only one PST trial focused specifically on youth with an MDD diagnosis, while the remaining three included youth with a mix of mental health problems. Although outcomes were reported in terms of depression or emotional symptom severity, this was not based on a subgroup analysis focused specifically on youth with depression. Impact on this group may therefore have been underestimated. In addition, the only PST trial with a low risk of bias did not administer a dedicated depression symptom scale. Instead, our exploratory meta-analysis included scores from the 5-item SDQ emotional problems subscale, which assesses unhappiness, worries, clinginess, fears, and somatic symptoms—and may not have captured nuanced change in depression severity [ 98 , 99 ]. Other concerns that led us to downgrade the quality of the evidence related to considerable risk of bias, with only one out of four studies rated as having a low risk; and imprecision with several studies involving very small samples. Due to the small number of eligible studies, it was not possible to identify the factors driving treatment efficacy via meta-regression. The long-term effectiveness of PS training, or the conditions under which long-term benefits are likely to be realized also could not be examined [ 38 ].

PS training is a core component of several evidence-based therapies for youth depression. However, the evidence base supporting its efficacy as a stand-alone treatment is limited and of low quality. There is tentative evidence suggesting PS-training may drive positive outcomes when provided alongside other treatment components. On its own, PS training may be beneficial for youth who are not acutely distressed or impaired but require support with tackling personal problems. Youth experiencing moderate or severe depressive symptoms may require more comprehensive psychotherapeutic support alongside PS training, as there is currently no robust evidence for the ability of free-standing PST to effectively reduce depression symptoms.

High-quality trials are needed that assess PST efficacy in youth with mild, moderate, and severe depression, in relation to both symptom severity and idiographic treatment goals or priority problems. These studies should examine the influence of treatment length and module content on treatment impact. Dedicated studies are also needed to shed light on the role of PS training as an active ingredient of more comprehensive therapies such as CBT, DBT, IPT, and family therapy. Future studies should include assessments of adverse events and of cost effectiveness. Given high drop-out rates in several youth PST trials, it is important to adapt PS training approaches and therapy manuals as needed, following a youth-engaged research and service development approach [ 57 ], to ensure their relevance and acceptability to this age group.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

Avoidance style

Beck Depression Inventory

Centre for Addiction and Mental Health

Cognitive behavioural therapy

Children’s Depression Rating Scale—Revised

Center for Epidemiologic Studies Depression Scale

Clinical Global Impression Scale—Improvement

Cumulative Index to Nursing and Allied Health Literature

Clinical practice guideline

Adolescent Coping with Depression [intervention name]

Dialectical behaviour therapy

Grading of Recommendations Assessment, Development, and Evaluation

Impulsivity/Carelessness Style

Interpersonal psychotherapy

The Kiddie Schedule for Affective Disorders and Schizophrenia

Lifeskills training

Major depressive disorder

Medical Literature Analysis and Retrieval System Online

Negative problem orientation

Nondirective supportive therapy

Positive problem orientation

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

• Problem solving

Problem-solving training

Problem-Solving Therapy

Randomized controlled trial

Research ethics board

Risk of bias

Rational problem-solving style

Systemic Behaviour Family Therapy

Strengths and Difficulties Questionnaire

Solution-Focused Brief Therapy

Social Problem-Solving Inventory Revised

Selective serotonin reuptake inhibitors

Treatment for Adolescents with Depression Study

Treatment of Resistant Depression in Adolescents

Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015;56(3):345–65. https://doi.org/10.1111/jcpp.12381 .

Article   PubMed   Google Scholar  

Avenevoli S, Swendsen J, He J-P, Burstein M, Merikangas KR. Major Depression in the National Comorbidity Survey–Adolescent Supplement: Prevalence, Correlates, and Treatment. J Am Acad Child Adolesc Psychiatry. 2015;54(1):37–44 e2.

Article   Google Scholar  

Gore FM, Bloem PJN, Patton GC, Ferguson J, Joseph V, Coffey C, et al. Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet. 2011;377(9783):2093–102. https://doi.org/10.1016/S0140-6736(11)60512-6 .

Fergusson DM, Woodward LJ. Mental health, educational, and social role outcomes of adolescents with depression. Arch Gen Psychiatry. 2002;59(3):225–31. https://doi.org/10.1001/archpsyc.59.3.225 .

Jonsson U, Bohman H, von Knorring L, Olsson G, Paaren A, von Knorring A-L. Mental health outcome of long-term and episodic adolescent depression: 15-year follow-up of a community sample. J Affect Disord. 2011;130(3):395–404. https://doi.org/10.1016/j.jad.2010.10.046 .

Article   CAS   PubMed   Google Scholar  

Clayborne ZM, Varin M, Colman I. Systematic review and Meta-analysis: adolescent depression and long-term psychosocial outcomes. J Am Acad Child Adolesc Psychiatry. 2019;58(1):72–9. https://doi.org/10.1016/j.jaac.2018.07.896 .

Fletcher JM. Adolescent depression: diagnosis, treatment, and educational attainment. Health Econ. 2008;17(11):1215–35. https://doi.org/10.1002/hec.1319 .

Article   PubMed   PubMed Central   Google Scholar  

Fletcher JM. Adolescent depression and adult labor market outcomes. South Econ J. 2013;80(1):26–49. https://doi.org/10.4284/0038-4038-2011.193 .

Zhou X, Hetrick SE, Cuijpers P, Qin B, Barth J, Whittington CJ, et al. Comparative efficacy and acceptability of psychotherapies for depression in children and adolescents: a systematic review and network meta-analysis. World Psychiatry. 2015;14(2):207–22. https://doi.org/10.1002/wps.20217 .

Zhou X, Teng T, Zhang Y, Del Giovane C, Furukawa TA, Weisz JR, et al. Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis. Lancet Psychiatry. 2020;7(7):581–601. https://doi.org/10.1016/S2215-0366(20)30137-1 .

Bear HA, Edbrooke-Childs J, Norton S, Krause KR, Wolpert M. Systematic review and Meta-analysis: outcomes of routine specialist mental health Care for Young People with Depression and/or anxiety. J Am Acad Child Adolesc Psychiatry. 2020;59(7):810–41. https://doi.org/10.1016/j.jaac.2019.12.002 .

Cuijpers P, Stringaris A, Wolpert M. Treatment outcomes for depression: challenges and opportunities. Lancet Psychiatry. 2020;7(11):925–7. https://doi.org/10.1016/S2215-0366(20)30036-5 .

Kazdin AE. Understanding how and why psychotherapy leads to change. Psychother Res. 2009;19(4–5):418–28. https://doi.org/10.1080/10503300802448899 .

de Haan AM, Boon AE, de Jong JTVM, Hoeve M, Vermeiren RRJM. A meta-analytic review on treatment dropout in child and adolescent outpatient mental health care. Clin Psychol Rev. 2013;33(5):698–711. https://doi.org/10.1016/j.cpr.2013.04.005 .

Chorpita BF, Daleiden EL. Mapping evidence-based treatments for children and adolescents: application of the distillation and matching model to 615 treatments from 322 randomized trials. J Consult Clin Psychol. 2009;77(3):566–79. https://doi.org/10.1037/a0014565 .

Nezu AM, Nezu CM, D’Zurilla TJ. Problem-solving therapy: A treatment manual. Problem-solving therapy: A treatment manual: Springer Publishing Company; 2013. x, 323–x, 323

D’Zurilla TJ, Nezu AM. Problem-solving therapy. In: Handbook of Cognitive-Behavioral Therapies. Third. New York, NY: Guilford Press; 2010. p. 197–225.

Google Scholar  

Nezu AM. Problem solving and behavior therapy revisited. Behav Ther. 2004;35(1):1–33. https://doi.org/10.1016/S0005-7894(04)80002-9 .

D’Zurilla TJ, Nezu AM, Maydeu-Olivares A. Social Problem Solving: Theory and Assessment. In: Chang EC, D’Zurilla TJ, Sanna LJ, editors. Social problem solving: Theory, research, and training: American Psychological Association; 2004. p. 11–27.

Ugueto AM, Santucci LC, Krumholz LS, Weisz JR. Problem-Solving Skills Training. In: Sburlati ES, Lyneham HJ, Schniering CA, Rapee RM, editors. Evidence-based CBT for anxiety and depression in children and adolescents: a competencies-based approach. Chichester, UK: John Wiley & Sons; 2014. p. 247–59. https://doi.org/10.1002/9781118500576.ch17 .

Chapter   Google Scholar  

D’Zurilla TJ, Chang EC, Nottingham EJ IV, Faccini L. Social problem-solving deficits and hopelessness, depression, and suicidal risk in college students and psychiatric inpatients. J Clin Psychol. 1998;54(8):1091–107. https://doi.org/10.1002/(SICI)1097-4679(199812)54:8<1091::AID-JCLP9>3.0.CO;2-J .

Haugh JA. Specificity and social problem-solving: relation to depressive and anxious symptomology. J Soc Clin Psychol. 2006;25(4):392–403. https://doi.org/10.1521/jscp.2006.25.4.392 .

Nezu AM. Cognitive appraisal of problem solving effectiveness: relation to depression and depressive symptoms. J Clin Psychol. 1986;42(1):42–8. https://doi.org/10.1002/1097-4679(198601)42:1<42::AID-JCLP2270420106>3.0.CO;2-2 .

Reinecke MA, Dubois DL, Schultz TM. Social problem solving, mood, and suicidality among inpatient adolescents. Cognit Ther Res. 2001;25(6):743–56. https://doi.org/10.1023/A:1012971423547 .

Siu AMH, Shek DTL. Social problem solving as a predictor of well-being in adolescents and young adults. Soc Indic Res. 2010;95(3):393–406. https://doi.org/10.1007/s11205-009-9527-5 .

D’Zurilla TJ, Goldfried MR. Problem solving and behavior modification. J Abnorm Psychol. 1971;78(1):107–26. https://doi.org/10.1037/h0031360 .

Bandura A. Social learning theory. Englewood Cliffs, NJ: Prentice Hall; 1977.

Gingerich WJ, Eisengart S. Solution-focused brief therapy: a review of the outcome research. Fam Process. 2000;39(4):477–98. https://doi.org/10.1111/j.1545-5300.2000.39408.x .

Boyd RC, Lewis J, Borreggine K, Benton TD. Adolescent depression: identification and treatment. Curr Treat Options Pediatr. 2018;4(3):350–62. https://doi.org/10.1007/s40746-018-0135-y .

Hamrin V, Pachler MC. Child & adolescent depression: review of the latest evidence-based treatments. J Psychosoc Nurs Ment Health Serv. 2005;43(1):54–63. https://doi.org/10.3928/02793695-20050101-08 .

McCarty CA, Weisz JR. Effects of psychotherapy for depression in children and adolescents: what we can (and can’t) learn from meta-analysis and component profiling. J Am Acad Child Adolesc Psychiatry. 2007;46(7):879–86. https://doi.org/10.1097/chi.0b013e31805467b3 .

Fréchette-Simard C, Plante I, Bluteau J. Strategies included in cognitive behavioral therapy programs to treat internalized disorders: a systematic review. Cogn Behav Ther. 2018;47(4):263–85. https://doi.org/10.1080/16506073.2017.1388275 .

Verdeli H, Mufson L, Lee L, Keith J. Review of evidence-based psychotherapies for pediatric mood and anxiety disorders. Curr Psychiatr Rev. 2006;2(3):395–421. https://doi.org/10.2174/157340006778018102 .

Mufson L, Weissman MM, Moreau D, Garfinkel R. Efficacy of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 1999;56(6):573–9. https://doi.org/10.1001/archpsyc.56.6.573 .

Diamond G, Siqueland L. Family therapy for the treatment of depressed adolescents. Psychotherapy. 1995;32(1):77–90. https://doi.org/10.1037/0033-3204.32.1.77 .

Hallford DJ, Mellor D. Cognitive-reminiscence therapy and usual care for depression in young adults: study protocol for a randomized controlled trial. Trials. 2013;14(1):1–8.

Richardson ED. Adventure-based therapy and self-efficacy theory: Test of a treatment model for late adolescents with depressive symptomatology. Blacksburg, VA: Virginia Polytechnic Institute and State University; 1998.

Cuijpers P, de Wit L, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: an updated meta-analysis. Eur Psychiatry. 2018;48(1):27–37. https://doi.org/10.1016/j.eurpsy.2017.11.006 .

Bell AC, D’Zurilla TJ. Problem-solving therapy for depression: a meta-analysis. Clin Psychol Rev. 2009;29(4):348–53. https://doi.org/10.1016/j.cpr.2009.02.003 .

Zhang A, Park S, Sullivan JE, Jing S. The effectiveness of problem-solving therapy for primary care patients’ depressive and/or anxiety disorders: a systematic review and meta-analysis. J Am Board Fam Med. 2018;31(1):139–50. https://doi.org/10.3122/jabfm.2018.01.170270 .

Stark KD, Reynolds WM, Kaslow NJ. A comparison of the relative efficacy of self-control therapy and a behavioral problem-solving therapy for depression in children. J Abnorm Child Psychol. 1987;15(1):91–113. https://doi.org/10.1007/BF00916468 .

Spence SH, Sheffield JK, Donovan CL. Preventing adolescent depression: an evaluation of the problem solving for life program. J Consult Clin Psychol. 2003;71(1):3–13. https://doi.org/10.1037/0022-006X.71.1.3 .

Eskin M, Ertekin K, Demir H. Efficacy of a problem-solving therapy for depression and suicide potential in adolescents and young adults. Cognit Ther Res. 2008;32(2):227–45. https://doi.org/10.1007/s10608-007-9172-8 .

Hoek W, Schuurmans J, Koot HM, Cuijpers P. Effects of internet-based guided self-help problem-solving therapy for adolescents with depression and anxiety: a randomized controlled trial. PLoS One. 2012;7(8):1–7.

Parker AG, Hetrick SE, Jorm AF, Mackinnon AJ, McGorry PD, Yung AR, et al. The effectiveness of simple psychological and physical activity interventions for high prevalence mental health problems in young people: a factorial randomised controlled trial. J Affect Disord. 2016;196:200–9. https://doi.org/10.1016/j.jad.2016.02.043 .

Michelson D, Malik K, Parikh R, Weiss HA, Doyle AM, Bhat B, et al. Effectiveness of a brief lay counsellor-delivered, problem-solving intervention for adolescent mental health problems in urban, low-income schools in India: a randomised controlled trial. Lancet Child Adolesc Heal. 2020;4(8):571–82. https://doi.org/10.1016/S2352-4642(20)30173-5 .

Ng MY, Eckshtain D, Weisz JR. Assessing fit between evidence-based psychotherapies for youth depression and real-life coping in early adolescence. J Clin Child Adolesc Psychol. 2016;45(6):732–48. https://doi.org/10.1080/15374416.2015.1041591 .

United Nations. Youth [Internet]. 2020 [cited 2020 Nov 4]. Available from: https://www.un.org/esa/socdev/documents/youth/fact-sheets/youth-definition.pdf .

Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):1–7.

Krause KR, Courtney DB, Bonato S, Aitken M, Hawke LD, Szatmari P. Problem Solving as an Active Ingredient of Treatment for Youth Depression: A Scoping Review [Protocol] [Internet]. [cited 2021 Jan 13]. Available from: osf.io/ydxge

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73. https://doi.org/10.7326/M18-0850 .

Booth A, Carroll C. Systematic searching for theory to inform systematic reviews: is it feasible? Is it desirable? Health Inf Libr J. 2015;32(3):220–35. https://doi.org/10.1111/hir.12108 .

Courtney DB, Duda S, Szatmari P, Henderson J, Bennett K. Systematic review and quality appraisal of practice guidelines for self-harm in children and adolescents. Suicide Life-Threatening Behav. 2019;49(3):707–23. https://doi.org/10.1111/sltb.12466 .

Bennett K, Duda S, Brouwers M, et al Towards high-quality, useful practice guidelines for child and youth mental health disorders: protocol for a systematic review and consensus exercise BMJ Open. 2018;8:e018053. https://doi.org/10.1136/bmjopen-2017-018053 .

Thomas J, Brunton J, Graziosi S. EPPI-Reviewer 4.0: software for research synthesis; 2010.

Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546–53. https://doi.org/10.1111/j.1365-2648.2005.03621.x .

Heffernan OS, Herzog TM, Schiralli JE, Hawke LD, Chaim G, Henderson JL. Implementation of a youth-adult partnership model in youth mental health systems research: challenges and successes. Health Expect. 2017;20(6):1183–8. https://doi.org/10.1111/hex.12554 .

Hawke LD, Darnay K, Relihan J, Khaleghi-Moghaddam M, Barbic S, Lachance L, et al. Enhancing researcher capacity to engage youth in research: researchers’ engagement experiences, barriers and capacity development priorities. Health Expect. 2020;23(3):584–92. https://doi.org/10.1111/hex.13032 .

Hawke LD, Relihan J, Miller J, McCann E, Rong J, Darnay K, et al. Engaging youth in research planning, design and execution: practical recommendations for researchers. Health Expect. 2018;21(6):944–9. https://doi.org/10.1111/hex.12795 .

Peters M, Godfrey C, McInerney P, Munn Z, Trico A, Khalil H. Chapter 11: Scoping Reviews. In: JBI Manual for Evidence Synthesis [Internet]. JBI; 2020. Available from: https://wiki.jbi.global/display/MANUAL/Chapter+11%3A+Scoping+reviews . Accessed 20 Dec 2020.

Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:1–8.

GRADEpro GDT. GRADEpro Guideline Development Tool [Software] [Internet]. McMaster University (developed by Evidence Prime, Inc.); 2020. Available from: gradepro.org . Accessed 20 Dec 2020.

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–6. https://doi.org/10.1136/bmj.39489.470347.AD .

Hedges LV. A random effects model for effect sizes. Psychol Bull. 1983;93(2):388–95. https://doi.org/10.1037/0033-2909.93.2.388 .

Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. Cochrane handbook for systematic reviews of interventions. Cochrane Handbook for Systematic Reviews of Interventions: John Wiley & Sons; 2019. https://doi.org/10.1002/9781119536604 .

Book   Google Scholar  

Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34. https://doi.org/10.1136/bmj.315.7109.629 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Beck AT, Steer RA. Internal consistencies of the original and revised beck depression inventory. J Clin Psychol. 1984;40(6):1365–7. https://doi.org/10.1002/1097-4679(198411)40:6<1365::AID-JCLP2270400615>3.0.CO;2-D .

Radloff LS. The CES-D scale. Appl Psychol Meas. 1977;1(3):385–401. https://doi.org/10.1177/014662167700100306 .

Goodman R. Psychometric properties of the strengths and difficulties questionnaire (SDQ). J Am Acad Child Adolesc Psychiatry. 2001;40(11):1337–45. https://doi.org/10.1097/00004583-200111000-00015 .

Becker-Weidman EG, Jacobs RH, Reinecke MA, Silva SG, March JS. Social problem-solving among adolescents treated for depression. Behav Res Ther. 2010;48(1):11–8. https://doi.org/10.1016/j.brat.2009.08.006 .

Kennard BD, Clarke GN, Weersing VR, Asarnow JR, Shamseddeen W, Porta G, et al. Effective components of TORDIA cognitive–behavioral therapy for adolescent depression: preliminary findings. J Consult Clin Psychol. 2009;77(6):1033–41. https://doi.org/10.1037/a0017411 .

Kaufman NK, Rohde P, Seeley JR, Clarke GN, Stice E. Potential mediators of cognitive-behavioral therapy for adolescents with comorbid major depression and conduct disorder. J Consult Clin Psychol. 2005;73(1):38–46. https://doi.org/10.1037/0022-006X.73.1.38 .

Dietz LJ, Marshal MP, Burton CM, Bridge JA, Birmaher B, Kolko D, et al. Social problem solving among depressed adolescents is enhanced by structured psychotherapies. J Consult Clin Psychol. 2014;82(2):202–11. https://doi.org/10.1037/a0035718 .

Beck AT, Steer RA, Brown GK. Beck depression inventory-ii. San Antonio, TX: Psychological Corporation; 1996.

Poznanski E, Mokros H. Children’s depression rating scale–revised (CDRS-R). Los Angeles, CA: Western Psychological Services; 1996.

Busner J, Targum SD. The clinical global impressions scale: applying a research tool in clinical practice. Psychiatry (Edgmont). 2007;4(7):28–37.

Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, et al. Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry. 1997;36(7):980–8. https://doi.org/10.1097/00004583-199707000-00021 .

D’Zurilla TJ, Nezu AM. Maydeu- Olivares a. social problem-solving inventory - revised: technical manual. North Tonawanda, NY: Multi-Health Systems; 2002.

March JS, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, et al. The treatment for adolescents with depression study (TADS). Arch Gen Psychiatry. 2007;64(10):1132–43. https://doi.org/10.1001/archpsyc.64.10.1132 .

Brent D, Emslie G, Clarke G, Wagner KD, Asarnow JR, Keller M, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression. JAMA. 2008;299(8):901–13. https://doi.org/10.1001/jama.299.8.901 .

Brysbaert M. How many participants do we have to include in properly powered experiments? A tutorial of power analysis with some simple guidelines. J Cogn. 2019;2(1):1–38.

MacKinnon DP, Warsi G, Dwyer JH. A simulation study of mediated effect measures. Multivariate Behav Res. 1995;30(1):41–62. https://doi.org/10.1207/s15327906mbr3001_3 .

World Health Organization. Update of the Mental Health Gap Action Programme (mhGAP) guidelines for mental, neurological and substance use disorders [Internet]. 2015. Available from: https://www.who.int/maternal_child_adolescent/documents/health-promotion-interventions/en/ . Accessed 20 Dec 2020.

Orygen. Treating depression in young people: Guidance, resources and tools for assessment and management [Internet]. Orygen. 2017. Available from: https://www.orygen.org.au/Training/Resources/Depression/Clinical-practice-points/Treating-depression-in-yp . Accessed 20 Dec 2020.

Ministerio de Salud. Guía Clínica Depresión en personas de 15 años y más [Internet]. Santiago, Chile; 2013. Available from: https://www.minsal.cl/portal/url/item/7222754637c08646e04001011f014e64.pdf . Accessed 20 Dec 2020.f

Cincinnati Children's Hospital Medical Center. Best Evidence Statement (BESt): Treatment of Children and Adolescents With Major Depressive Disorder (MDD) During the Acute Phase. Cincinnati: Cincinnati Children's Hospital Medical Center; 2010.

Birmaher B. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1503–26. https://doi.org/10.1097/chi.0b013e318145ae1c .

Lau J, Ioannidis JPA, Terrin N, Schmid CH, Olkin I. The case of the misleading funnel plot. Br Med J. 2006;333(7568):597–600. https://doi.org/10.1136/bmj.333.7568.597 .

Sterne JAC, Sutton AJ, Ioannidis JPA, Terrin N, Jones DR, Lau J, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ. 2011;343(7818):1–8.

Wolpert M, Harris R, Hodges S, Fuggle P, James R, Wiener A, et al. THRIVE framework for system change. London: United Kingdom; 2019.

Hostinar CE, Miller GE. Protective factors for youth confronting economic hardship: current challenges and future avenues in resilience research. Am Psychol. 2019;74(6):641–52. https://doi.org/10.1037/amp0000520 .

Van Den Heuvel MWH, Bodden DHM, Moerbeek M, Smit F, Engels RCME. Dismantling the relative effectiveness of core components of cognitive behavioural therapy in preventing depression in adolescents: protocol of a cluster randomized microtrial. BMC Psychiatry. 2019;19(1):1–13.

Nezu AM, Perri MG. Social problem-solving therapy for unipolar depression: an initial dismantling investigation. J Consult Clin Psychol. 1989;57(3):408–13. https://doi.org/10.1037/0022-006X.57.3.408 .

D’Zurilla TJ, Nezu AM. Problem-solving therapy: a positive approach to clinical intervention. 3rd ed. New York, NY: Spring Publishing Company; 2007. 261 p.

Chang EC, D’Zurilla TJ, Sanna LJ. Social problem solving: theory, research, and training: American Psychological Association; 2004. https://doi.org/10.1037/10805-000 .

Nezu AM, Nezu CM, Perri MG. Problem-solving therapy for depression: theory, research, and clinical guidelines. New York, NY: Wiley; 1989.

Nezu AM. A problem-solving formulation of depression: a literature review and proposal of a pluralistic model. Clin Psychol Rev. 1987;7(2):121–44. https://doi.org/10.1016/0272-7358(87)90030-4 .

Goodman R, Meltzer H, Bailey V. The strengths and difficulties questionnaire: a pilot study on the validity of the self-report version. Eur Child Adolesc Psychiatry. 1998;7(3):125–30. https://doi.org/10.1007/s007870050057 .

Goodman R. The strengths and difficulties questionnaire: a research note. J Child Psychol Psychiat. 1997;38(5):581–6. https://doi.org/10.1111/j.1469-7610.1997.tb01545.x .

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Acknowledgments

We would like to thank the members of the Centre for Addiction and Mental Health (CAMH) youth advisory group for their valuable insights and suggestions. The systematic search for clinical practice guidelines presented in this review was based on a search strategy developed by Dr. Kathryn Bennett. We would like to thank Dr. Bennett for agreeing to the reuse of the strategy as part of this review. We would also like to thank the Cundill Centre for Child and Youth Depression for providing institutional support to this project.

This work was funded by a Wellcome Trust Mental Health Priority Area “Active Ingredients” commission awarded to KRK, DBC and PS, and the Centre for Addiction and Mental Health, Toronto, Canada.

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Darren B. Courtney, Madison Aitken, Lisa D. Hawke, Priya Watson & Peter Szatmari

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Contributions

KRK, DBC and PS formulated the research questions and designed the study. SB conducted the systematic search for clinical practice guidelines and the grey literature search, and advised on the search for retrieving empirical studies, which was led by KRK. KRK, DBC and BWCC performed the screening of records for inclusion criteria. Data extraction was performed by KRK and BWCC. The risk of bias assessment for included randomized control trials was conducted by KRK and MA. The youth consultation was led by JR, MP and KD with input from LDH and KRK. Data analysis was led by KRK. All authors contributed to the interpretation of emerging findings through an internal findings workshop and through several rounds of feedback on the draft manuscript, which was drafted by KRK. All authors have reviewed and approved the final manuscript.

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Supplementary Information

Additional file 1..

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

Additional file 2.

Search Strategy.

Additional file 3.

List of Studies Included in the Scoping Review.

Additional file 4.

Characteristics of Included Clinical Practice Guidelines.

Additional file 5.

Additional Data and Outputs from the Meta-Analysis.

Additional file 6.

Risk of Bias Assessment and GRADE Appraisal.

Additional file 7.

Illustration of Insights from the Consultation of Youth Advisors.

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Krause, K.R., Courtney, D.B., Chan, B.W.C. et al. Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis. BMC Psychiatry 21 , 397 (2021). https://doi.org/10.1186/s12888-021-03260-9

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Article contents

Cognitive behavioral therapy for depression.

• Stirling Moorey Stirling Moorey South London and Maudsley NHS Foundation Trust, Centre for Anxiety Disorders and Trauma
•  and  Steven D. Hollon Steven D. Hollon Department of Psychology, Vanderbilt University
• https://doi.org/10.1093/acrefore/9780190236557.013.837
• Published online: 23 February 2021

Cognitive behavioral therapy (CBT) has the strongest evidence base of all the psychological treatments for depression. It has been shown to be effective in reducing symptoms of depression and preventing relapse. All models of CBT share in common an assumption that emotional states are created and maintained through learned patterns of thoughts and behaviors and that new and more helpful patterns can be learned through psychological interventions. They also share a commitment to empirical testing of the theory and clinical practice. Beck’s Cognitive Therapy sees negative distorted thinking as central to depression and is the most established form of CBT for depression. Behavioral approaches, such as Behavioral Activation, which emphasize behavioral rather than cognitive change, also has a growing evidence base. Promising results are emerging from therapies such as Mindfulness Based Cognitive Therapy (MBCT) and rumination-focused therapy that focus on the process of managing thoughts rather than their content. Its efficacy-established CBT now faces the challenge of cost-effective dissemination to depressed people in the community.

• cognitive behavior therapy
• cognitive therapy
• behavior therapy
• evidence-based therapy

Origins and Development of Behavioral and Cognitive Models of Depression

Behavioral models of depression have been largely based on Skinnerian or operant conditioning theory. Ferster ( 1973 ) proposed a model that saw depression as characterized by a decrease in the frequency of positively reinforced activities. Factors such as decreased environmental reward (e.g., resulting from a significant loss), avoidance or escape from aversive stimuli, schedules of reinforcement, and suppressed anger contribute to a reduction in the depressed person’s behavioral repertoire which in turn leads to less rewarding experiences. Lewinsohn ( 1974 ) developed this model further, as did Staats and Helby ( 1985 ) (see Dimidjian, Barrera, Martell, Muñoz, & Lewinsohn, 2011 ). However, this did not lead to significant developments in treatment or in outcome research, partly due to the surge in interest in Beck’s cognitive approach to depression that resulted from publication of the first randomized controlled trial to show that a psychological treatment could be as effective as antidepressants in depression (Rush, Beck, Kovacs, & Hollon, 1977 ). Beck first identified the importance of thoughts in depression in the early 1960s (Beck, 1963 , 1964 ). In contrast to behavioral approach that saw “internal” self-talk as a covert behavior, Beck suggested that cognition was central to depression. Beck noted that the dreams and self-reports of depressed patients were pervasively negative: They experienced a stream of negative automatic thoughts in response to events. In depression, he hypothesized, there was a shift in information processing such that stimuli which might usually be perceived as neutral or positive are seen as negative: a systematic cognitive bias. Underlying this bias are cognitive structures or schemas, often expressed as dysfunctional attitudes which, when activated by an event or accumulation of events, skew the interpretations and evaluations the person makes about the world. Examples of these include beliefs such as, “If I fail at something it means I’m a complete failure” or “If I don’t have someone to love and accept me it means I’m unlovable.” This results in an increasingly negative view of the self (“I am a failure; I am unlovable”), the world (“the world is unrewarding; others will reject me”), and the future (“I will never achieve my goals”) during the course of a depressive episode. Reduced expectations of being valued or succeeding at what the depressed person undertakes lead to avoidance and passivity that further reinforces the depressed mood and negative beliefs (Beck, 1967 , 1987 ).

Adverse life events and experiences in childhood lead to underlying assumptions, often expressed in conditional form: “If . . . then . . . .” For instance, the belief “If I fail at something, I’m a complete failure” may be laid down over years of being on the receiving end of demanding parental expectations. A significant failure experience in adult life, such as not passing an exam, will lead to activation of this schema and consequent depression (see Figure 1 ). Evidence for the cognitive model has accumulated since its original presentation (Beck & Alford, 2009 ; Clark & Beck, 1999 ). The association between negative thoughts and depression is particularly robust and seems to apply across cultures (Beshai, Dobson, Adel, & Hanna, 2016 ). Beck has modified the model to take account of research findings to include the concept of cognitive reactivity. People who are prone to depression will have a greater activation of negative beliefs than those who are not when they experience mood shifts in response to the vicissitudes of life (Scher, Ingram, & Segal, 2005 ). While major life events may be needed to trigger first-onset depression, repeated episodes make it easier for mild events to produce depression: the so-called kindling effect (Kendler, Thornton, & Gardner, 2000 ).

Figure 1. Developmental formulation.

Cognitive approaches such as Beck’s and Alloy and Abramson’s hopelessness model of depression (Abramson et al., 1989 ) generated the most research in the last decades of the 20th century , but in the first decades of the 21st century , behavioral models of depression experienced a resurgence, initially stimulated by the finding in a dismantling trial that the behavioral component of cognitive therapy was as effective as the full package (Jacobson et al., 1996 ). Contemporary behavioral activation models, based on Lewinsohn’s more integrative model (Lewinsohn, Hoberman, Teri, & Hautzinger, 1985 ), have a more sophisticated account of positive reinforcement, pay more attention to cognition by targeting ruminations, and emphasize the importance of avoidance of interpersonal situations in maintaining depression. There has also been a shift away from cognitive content (i.e., negative thoughts) to an interest in cognitive processes such as ruminations. Post-Beckian cognitive models emphasize the importance of how one relates to one’s thoughts as a factor in maintaining depression. Trying to analyze why one is depressed or fix one’s perceived inadequacies leads to cycles of rumination that dig one deeper into depression. Metacognitive therapy, rumination-focused cognitive behavioral therapy (CBT), and mindfulness-based cognitive therapy are examples of these more process-oriented forms of CBT (Segal, Williams, & Teasdale, 2013 ; Watkins, 2018 ; Wells, 2011 ). Table 1 summarizes the CBT models for depression in chronological order.

Table 1. Current Cognitive Behavior Therapies for Depression

Beck’s cognitive therapy, outline of treatment.

This form of cognitive behavioral therapy (CBT) is the best known and most researched, so it is described here in some detail. Cognitive therapy for depression (CT) is a relatively brief (20 sessions), structured, problem-focused treatment, firmly based on the cognitive model of depression. It can be understood to have a hierarchy of aims:

to reduce hopelessness and suicidality

to resolve target problems related to depression by teaching strategies to manage mood

to reduce vulnerability to future depression by modifying underlying beliefs and developing a relapse prevention plan

Target problems and goals are established at the beginning of therapy and each session is structured to use time as effectively as possible; an agenda is set which generally follows the plan:

bridge to last session with review of risk and current mood

review of homework

two to three agreed topics to address

setting homework

summary and feedback

Treatment is based on an individualized formulation which is developed in partnership with the patient. This initially focuses on the way in which thoughts, feelings, and behaviors interact to maintain the depression. The patient learns to identify situations that trigger a lowering of mood and the link between their negative thoughts and the mood shift. Similarly, the resulting patterns of behavior, such as withdrawal, are recognized. As therapy progresses, this conceptualization is deepened: Repeating sets of negative automatic thoughts reveal themes of underlying beliefs. The developmental conceptualization (Figure 1 ) links past learning experiences to these underlying beliefs or schemas and helps the patient see how these have made them vulnerable to depression. Because patients will be asked to examine deeply held beliefs, therapy tries to be as collaborative as possible. Rather than telling the patient their beliefs are maladaptive, the therapist encourages the patient to enter into a partnership to explore the validity and usefulness of them. Beliefs are turned into hypotheses that can then be tested through verbal discussion (Socratic questioning) or direct action (behavioral experiments). Depressed patients discover that their thoughts may be biased by their mood and learn to identify cognitive distortions or thinking errors. This process of putting beliefs to the test is referred to as “collaborative empiricism.” Therapy consists of a variety of cognitive and behavioral techniques. At the beginning of therapy, particularly if the patient is more deeply depressed, techniques will be more behavioral. These often begin with monitoring activities and rating them for the degree to which they are pleasurable or give a sense of achievement (mastery). Patients are then encouraged to engage in activities that promote pleasure or mastery and to note the effect on their mood. In contrast to Behavioral Activation that seeks behavioral change for its own sake, the activity work in cognitive therapy is always used in the service of cognitive change and, wherever possible, framed as an experiment to test negative thoughts. For instance, someone may predict that if they call a friend, they won’t be interested in them. The therapist can help them devise an experiment in which they take the risk of telephoning and evaluate the result: They may find that it took them half an hour to end the call because the friend was so pleased to hear from them! The next phase of therapy is for the patient to learn to recognize and evaluate their thoughts. This begins with monitoring of negative automatic thoughts as they arise in everyday situations. Patients learn to recognize how the depression biases their thinking in a negative direction. The therapist then uses Socratic questioning to evaluate the thoughts with the patient in the session, asking questions to help them examine their view of the situation. The touchstone for evaluating the thoughts is their logical consistency and the evidence available. Patients then practice identifying thoughts, asking questions such as: “What’s the evidence for and against this thought?”; “What’s the effect of thinking in this way? Is it helpful to me?”; and “Could there be an alternative explanation or way of testing my thoughts?” as homework between sessions. In the third phase of therapy, beliefs are elicited and tested that underlie the distorted thinking and make the patient vulnerable to future depression. So, for instance, a belief that “I must always succeed” or “I’m a failure” may be associated with perfectionistic behavior. The person may stay late at work, spend twice as long as their colleagues writing reports, and check them several times. The belief that “If I don’t do things perfectly, I’ll be found out and seen as a failure” can be tested through experiments where the patient spends less time preparing and checking reports and discovers that the result is just as good. They can then move on to deliberately making small mistakes and may discover that no one notices. In this final phase of therapy, the patient is encouraged to develop a blueprint or relapse prevention plan that summarizes as follows:

what she has learned from therapy

what techniques she needs to continue practicing (e.g., “make sure I structure my week so I don’t have long periods where I can ruminate”)

what risk factors and early warning signs to look out for

what she can do if her mood starts to drop

Efficacy of Cognitive Therapy for Depression

The first randomized controlled trial of CT (Rush et al., 1977 ) demonstrated a slight superiority of psychological treatment over tricyclic antidepressants with respect to acute response, but largely because the medications were tapered too soon such that early relapse was confounded with a lack of response. In the succeeding 40 years, numerous studies have compared Beck’s therapy with tricyclics and with specific serotonin reuptake inhibitors (SSRIs) and consistently found the two approaches to be equally effective (see reviews by Butler, Chapman, Forman, & Beck, 2006 ; Cuijpers et al., 2013a ; Cuijpers, Cristea, Karyotaki, Reijnders, & Huibers, 2016 ), though an individual patient data meta-analysis suggests there may be a slight advantage of medication over CBT (Weitz et al., 2015 ). There is evidence that combining CBT and medication adds to the effects of both (Cuijpers et al., 2014 ), although that effect appears to be heavily moderated (Hollon et al., 2014 ) and may come at the expense of undercutting CBT’s enduring effect (DeRubeis et al., 2020 ). CBT is significantly more effective than waiting list controls, treatment as usual, or placebo (effect size 0.71; Cuipers et al., 2013a ), while head to head comparisons of CBT with other evidence-based therapies, such as interpersonal therapy, tend to show both therapies to be equally effective (e.g., Luty et al., 2007 ). CBT is not only effective with mild-moderate levels of depression but also for the moderate-severe range when delivered by well-trained therapists (DeRubeis et al., 2005 ). Despite these encouraging findings that place CBT as the psychological treatment with the most robust empirical support, only 60% of patients achieve remission. When publication bias and use of waiting list controls are accounted for, the effect size of studies reduces considerably (Cuijpers, Cristea, Karyotaki, Reijnders, & Huibers, 2016 ; Driessen, Hollon, Bockting, Cuijpers, & Turner, 2015 ), as for antidepressant medications (Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008 ). Table 2 summarizes comparisons between CBT (not exclusively Beck’s cognitive therapy), antidepressant medication, waiting list control, treatment as usual, and other psychotherapies.

Table 2. Efficacy of CBT for Depression

Notes : WL = waiting list; TAU = treatment as usual; ADM = antidepressant medication; NNT = number needed to treat.

Source : Data adapted from Cuijpers et al. ( 2013a ).

Relapse Prevention

Early randomized controlled trials comparing CBT with antidepressant medication that was withdrawn at the end of the trial reported relapse rates of 15–28% for CBT compared to 50–60% with a tricyclic (Evans et al., 1992 ; Simons, Murphy, Levine, & Wetzel, 1986 ). Biological psychiatrists argued that the antidepressant may have been withdrawn too soon for a fair comparison, since the recommendation is that medication be continued for 6–9 months after symptoms remit, but the differential relapse does indicate that CBT has an enduring effect. Later studies then compared CBT with maintenance medication. The relapse rates for patients receiving continuation medication were equivalent at 30% to patients receiving CBT alone (Cuijpers et al., 2013b ). In effect, CBT cuts risk of relapse among remitted patients by more than half relative to prior medications, and the two studies that compared prior CBT found that the enduring effect extended to the prevention of recurrence relative to recovered patients withdrawn after a year of continuation medication (Dobson et al., 2008 ; Hollon et al., 2005 ). In partially recovered depressed outpatients, adding CT to maintenance medication reduces relapse rates more than maintenance medication alone, and the beneficial effects of CBT persist for up to 3½ years (Paykel et al., 1999 , 2005 ). There is strong support in these studies for an enduring relapse prevention effect from CBT (Clarke, Mayo-Wilson, Kenny, & Pilling, 2015 ). However, it has been argued that rather than CBT preventing relapse, it is antidepressant discontinuation that promotes it (Andrews, Kornstein, Halberstadt, Gardner, & Neale, 2011 ). SSRIs increase serotonin available in the synapse by blocking reuptake but over time the system responds by reducing serotonin synthesis in the presynaptic neurone and reducing postsynaptic receptor sensitivity. This would explain why it seems to be so difficult to take patients off SSRIs without triggering a relapse (Hollon et al., 2019 ). Further research will hopefully answer this question.

Mediating Factors

Research into the factors that mediate outcome of CBT for depression fall into two categories: dismantling studies that attempt to identify active elements of treatment, and correlational studies that assess the relationship between treatment variables and reduction in depressive symptoms. Cuijpers, Cristea, Karyotaki, Reijnders, and Hollon ( 2019a ) recently carried out a meta-analysis of component studies to date and concluded that few had sufficient power to detect differences. Hundt, Mignogna, Underhill, and Cully ( 2013 ) reviewed the evidence for the impact of CBT skills on outcome and found that the small number of studies to date provided evidence that the frequency and quality of skill use influenced outcome. Click or tap here to enter text.Segal et al. ( 2019 ) found that the use of CBT skills post therapy was linked to reduced relapse and that this was mediated by the extent to which patients “decentered” from their negative thinking. Strunk and colleagues found that those patients who best mastered the skills taught in CBT were those least likely to relapse following treatment termination (Strunk, DeRubeis, Chiu, & Alvarez, 2007 ). The inclusion of homework has a significant effect on therapy outcome (Kazantzis, Whittington, & Dattilio, 2010 ). The therapeutic alliance is associated with therapy outcome across a range of different therapies (see Moorey & Lavender [ 2018 ] for a discussion of the importance of the therapeutic relationship in CBT). In CBT for depression, it may be the agreement on tasks and goals of therapy that is the most important aspect of this. Patients who accept the cognitive model and experience early symptom gains are likely to report a better therapeutic alliance and to make greater gains in therapy (Webb et al., 2011 ).

Behavioral Treatments for Depression

In 1996 , Neil Jacobson and colleagues reported the results of a three-way dismantling study that compared the behavioral activation (BA) component of Beck’s cognitive therapy (CT) for depression with BA plus thought challenging (AT), and with the full CT package. Each proved equally effective and the results held up at follow-up (Jacobson et al., 1996 ; Gortner et al., 1998 ). This revitalized the interest in behavioral models of treatment for depression and led to the development of a new therapy: BA. Like earlier behavioral approaches, BA sees depression as a result of a reduction in positive reinforcement which leads to a reduction in behavior and further low mood. In contrast to earlier models, this approach emphasizes the role of negative reinforcement of avoidance behavior: Social withdrawal and avoidance of responsibility and rumination bring temporary relief from painful affect but lead to more passivity and inactivity. BA uses activity monitoring and scheduling to encourage healthy behaviors and teaches patients to do their own functional analysis. Patients identify triggers for avoidance (Triggers, Reactions, and Avoidance Patterns—TRAPs) and replace them with coping responses (Triggers, Reactions, and Coping response—TRACs). A range of other techniques, including graded task assignment, mental rehearsal, problem-solving, and skills training, may all be employed (Martell, Addis, & Jacobson, 2001 ; Martell, Dimidjian, & Herman-Dunn, 2010 ). Behavioral activation is simpler and easier to teach than cognitive therapy (Ekers, Dawson, & Bailey, 2013 ) and there is a growing body of evidence for its effectiveness. Meta-analysis has found that there is a large effect size in comparison with controls (standardized mean difference [ SMD ] of −0.74) and a moderate superiority of BA over medication ( SMD −0.42) (Ekers et al., 2014 ).

Behavioral couple therapy (BCT) is a brief (12–20 sessions) intervention that can be applied when there is relationship distress and at least one partner is depressed. There is an interaction between the couple’s behavior and the depression such that intimacy and support is reduced and conflict increased. BCT seeks to improve the relationship through communication training, fostering positive exchanges between partners and teaching joint problem-solving skills. The approach is based on the groundbreaking work of Neil Jacobson (Jacobson et al., 1991 , 1993 ) but has developed over the subsequent 20 years. BCT improves both depression and the quality of the relationship (Christensen, Atkins, Yi, Baucom, & George, 2006 ) and is recommended in a number of guidelines such as the NICE guidelines for depression. A recent Cochrane review advised caution since the quality of randomized controlled trials (RCTs) of couples therapies and sample sizes are relatively low (Barbato, D’Avanzo, & Parabiaghi, 2018 ).

Process-Oriented Cognitive Behavioral Therapies

In contrast to cognitive behavioral therapy (CBT) for anxiety disorders, which has progressed through delineating specific models for the subgroups of anxiety diagnoses (panic, social phobia, etc.), depression has resisted this type of subcategorization beyond perhaps the distinction between acute and chronic depression. The research has therefore focused on refining the methodology of trials using Beck’s manualized cognitive therapy and more latterly behavioral activation (BA). Alternative cognitive approaches that have developed over the past 20 years have moved the focus from cognitive content (i.e., distorted negative thinking) to cognitive processes (e.g., rumination): the “third wave” behavior therapies. Well’s metacognitive therapy was first applied to anxiety and then later depression. It addresses the positive beliefs (“If I can understand why I am depressed I will be able to find a way out”) and negative (“I can’t control this rumination”) beliefs that drive worry and rumination and associated attentional processes (Papageorgiou & Wells, 2009 ; Wells, 2011 ). A meta-analysis suggests this approach may be more effective than standard CBT (Normann, van Emmerik, & Morina, 2014 ). A related approach is Watkins’ rumination-focused CBT which helps depressed patients shift their thinking style from abstract, overgeneralized thinking that maintains depression to more concrete, problem-focused thinking (Watkins, 2018 ). A randomized controlled trial has demonstrated its superiority over treatment as usual in residual depression (Watkins et al., 2011 ). One of the most influential developments in CBT in recent years has been mindfulness-based cognitive therapy (MBCT). This was originally developed as a relapse prevention program for recurrent depression. Relapse is understood to involve “a reactivation, at times of lowering mood, of patterns of negative thinking similar to the thought patterns that were active during previous episodes of depression” (Segal, Williams, & Teasdale, 2013 , p. 65). Rather than working with the cognitive appraisals, MBCT seeks to help people develop a “meta-awareness” of thoughts, feelings, and physical sensations so that there is a decentering or defusion from these patterns rather than identification with them. Mindfulness is the awareness that arises when one pays attention to one’s experiences in the present moment and in an accepting, nonjudgmental way. MBCT is delivered in groups of from 8 to 15 people and uses a combination of regular formal and informal meditation practices and insights from CBT. Meta-analysis suggests there is a relative risk reduction of 43% for those with three or more depressive episodes (Piet & Hougard, 2011 ) and that MBCT may be more effective for those with residual or fluctuating depressive symptoms (Kuyken et al., 2016 ; Segal et al., 2010 ). Acceptance and Commitment Therapy (ACT) is another “third wave” approach that is now being applied to depression with evidence for its efficacy (Bai, Luo, Zhang, Wu, & Chi, 2020 ; Zettle, 2004 ). The initial results from these process-oriented therapies are very encouraging, but sample sizes are small and more research is needed to determine what benefits they may have over the established behavioral and cognitive therapies for depression.

Application of Cognitive Behavioral Therapy to Various Populations

Cognitive behavioral therapy (CBT) has been successfully applied across the life cycle. CBT for adolescent depression is an effective intervention and in many ways similar to individual CBT for adults; it has also been used in a group format and with parental involvement. Parental engagement is understandably more important with the younger depressed patient (see David-Ferdon & Kaslow, 2008 ) for a meta-analysis of CBT for depression in children and adolescents, and Amberg & Ost [ 2014 ] in children from 8 to 12 years of age). CBT has also been successfully adapted for older people (Chand & Grossberg, 2013 ; Pinquart, Duberstein, & Lyness, 2007 ). Studies generally support the delivery of CBT to people with physical illness and associated depression (Beltman, Voshaar, & Speckens, 2010 ). Adaptations may be required to take account of difficulties in carrying out behavioral activation strategies that require physical exertion, and sensitivity in the way therapists help patients manage negative thoughts that may often have some basis in reality (Moorey, 1997 ). CBT appears to be effective across a range of health conditions (Okuyama, Akechi, Mackenzie, & Furukawa, 2017 ), including life-threatening illnesses such as cancer (Anderson, Watson, & Davidson, 2008 ; Moorey & Greer, 2011 ). Many of these trials, however, have small samples and a recent large-scale RCT comparing CBT with treatment as usual in patients with depression and advanced cancer failed to find an effect of therapy (Serfaty et al., 2020 ). CBT originated in a Western context, and the concept of collaborative empiricism assumes a relationship of equals in which clients share their thoughts and feelings and work toward solving problems and achieving their goals. In Eastern cultures, however, relationships may be structured more hierarchically. People may be less used to openly expressing and sharing their thoughts and feelings, and they may have a far more interdependent view of their goals. Adaptations of CBT in non-Western countries have tended to keep the content of the intervention relatively unchanged but have modified the forms of language used, the context, and the mode of delivery (Chowdhary et al., 2014 ). Preliminary evidence suggests that CBT can be transported cross-culturally with no loss of its effectiveness (see, e.g., a discussion of CBT in Japan: Ono et al. [ 2011 ]; Kobori et al. [ 2014 ]).

Disseminating Cognitive Behavioral Therapy

Much of the research in cognitive behavioral therapy (CBT) has been in the form of efficacy trials carried out in academic settings delivered by well-trained therapists. More effectiveness studies are needed to establish its usefulness in depression in “real world settings,” but perhaps more importantly, ways are needed to disseminate the techniques to the wider population. Freud’s model of the weekly 50-minute hour consultation has persisted into the 21st century . The prevalence of depression means it will never be possible to train enough therapists to deliver face-to-face CBT to those who need it. One solution is to move the treatment out of the one-to-one setting using groups or technology to improve cost-effectiveness. Another innovation in the United Kingdom has been the Improving Access to Psychological Therapies program that attempts to standardize evidence-based therapy nationwide. Briefer CBT delivered by nonprofessionals has been trialed in low- and middle-income countries. These three areas are described here as examples of alternative ways to deliver CBT more widely.

Alternative Formats to Individual CBT: Group, Computer, Internet, and Telephone

Group CBT is widely practiced but has not received as much research attention as individual therapy. It is usually delivered in a psychoeducational structured format (Scott, 2011 ). It may not be acceptable to about one third of patients, and the need for individual orientation sessions to prepare and engage patients means that it may not be as cost-effective as it appears on the surface. A naturalistic study, however, found that individual CBT was 1.5 times more expensive than groups that included 8–12 participants (Brown et al., 2011 ). A meta-analysis found that individual CBT was slightly superior post-treatment, but there was no difference at 3 months follow-up (Huntley, Araya, & Salisbury, 2012 ). Computerized CBT (cCBT) has become very popular because of its potential cost-effectiveness. Hofman, Pollitt, Broeks, Stewart, and Van Stolk ( 2017 ) carried out a systematic review of the available cCBT platforms and their effectiveness. They found large within-group effect sizes averaging 1.23. The findings overall do support its use in depression, but it may not be reaching groups who are less computer literate: The average cCBT participant was a female in her late 30s with a university degree who was in full-time employment. There should also be caution in assuming that participants will make full use of the program without any assistance: Reviews have consistently found guided self-help to be more effective than unguided (Andersson & Cuijpers, 2009 ). With the increased availability of the internet, online CBT programs are also being used more widely. For instance, a web-based program for depression has been shown to be more effective than treatment as usual (Farrer, Christensen, Griffiths, & Mackinnon, 2011 ). Finally, telephone CBT also appears to be an effective treatment for depression (Castro et al., 2020 ). Cuijpers and colleagues carried out a network meta-analysis comparing individual, group, telephone-administered, guided self-help, and unguided self-help for people with depression (Cuijpers, Noma, Karyotaki, Cipriani, & Furukawa, 2019b ). All approaches were equally effective and superior to a waiting list and care as usual. Guided self-help appeared to be less acceptable than individual, group, or telephone formats.

The U.K. Improving Access to Psychological Therapies Initiative (IAPT)

Psychotherapy has traditionally been something of a “cottage industry,” with an emphasis on the individual skill and discretion of the therapist, but not organized in a systematic, nationwide fashion. Provision has been patchy and many patients have not had access to evidence-based therapies. The U.K. Improving Access to Psychological Therapies (IAPT) program has been developed to redress this balance and to show that locally based therapy services that have clear targets, the means to evaluate outcomes, and are cost effective can work. In 2007 , the economist Richard Layard and the psychologist David Clark joined forces to lobby for a much-needed expansion of psychological therapies in the United Kingdom. They argued that anxiety and depression had significant deleterious effects on the economy (Layard, 2006 ). They suggested that the costs of increasing psychological therapies services would be outweighed by the benefits in savings to the health service and treasury through increased tax revenues and reduced spending on benefits. The IAPT program implements psychological treatments that have been shown to be effective and monitors their impact. The services set challenging targets for access (16% of the community prevalence of anxiety and depression) and outcomes (50% recovery: defined as PHQ-9 and GAD-7 scores falling below 10). Treatment follows a stepped care model. Low-intensity (LI) therapy is delivered by Personal Wellbeing Practitioners (PWPs). LI treatment includes guided self-help, computerized CBT, behavioral activation, and psychoeducational groups.

High-intensity therapy (HI) involves weekly face-to-face therapy delivered by fully trained CBT therapists. Patients with less severe problems are initially treated with LI and stepped up to HI if necessary, while more severe problems are treated with HI as the first intervention. A total of 36% of people receive only LI, 28% HI, and 34% both (Clark, 2018 ). IAPT services now treat nearly one million patients a year and achieve recovery in 50% of cases as well as reliable improvement in 66% (Clark, 2018 ), with evidence of substantial change in depression scores and a moderate impact on functioning (Wakefield et al., 2020 ). Over the 10 years IAPT has been operating services, recovery rates have been improving year by year. IAPT has received criticism on the grounds that it relies too heavily on quantitative measures that may give a falsely optimistic indication of improvement: There may be a mismatch between outcome measures and the client’s reported experience of distress (Bendall & McGrath, 2020 ), and also for its “managerialism” and perceived emphasis on efficiency over person-centered care (Dalal, 2018 ). Services do not always deliver the full “dose” of CBT for depression recommended in the NICE guidelines, and there is evidence that comorbid personality difficulties and complexity affect outcome and re-referral after treatment (Cairns, 2014 ; Goddard, Wingrove, & Moran, 2015 ). That being said, recovery rates have climbed from a percentage in the mid-30s to over 50% over the past decade (Clark, 2018 ). There is nothing like these rates elsewhere in the world.

CBT in Low- and Middle-Income Countries

The challenge of delivering CBT in developing countries where there are few psychiatrists and psychotherapists is substantial, but a number of programs are rising to the challenge. Community mental health workers can be trained to carry out brief CBT interventions with beneficial effects (e.g., Rahman, Malik, Sikander, Roberts, & Creed’s [ 2008 ] study of CBT for perinatal depression in rural Pakistan, and Bolton et al.’s [ 2014 ] study of CBT for depression, anxiety, and PTSD in Burmese refugees). The World Health Organisation (WHO) is rolling out a program called Problem Management Plus which trains lay helpers to deliver five weekly individual face-to-face sessions of 90 minutes for a range of problems, including depression. They teach simple evidence-based strategies such as relaxation, problem-solving, behavioral activation, and ways to strengthen social support (Rahman et al., 2016 ; WHO, 2016 ). Patel and colleagues found that from six to eight sessions of a culturally adapted version of behavioral activation, called the Healthy Activity Program delivered by lay counselors with no prior psychiatric training, was more efficacious than enhanced treatment as usual in a general practice setting in rural India (Patel et al., 2017 ), and that gains made in treatment largely held across a 9-month follow-up (Weobong et al., 2017 ).

Future Directions

The cognitive and behavioral interventions (if adequately implemented) can be as efficacious as medications in the treatment of even more severe depression (DeRubeis et al., 2005 ; Dimidjian et al., 2006 ) and have an enduring effect that medications simply lack (Dobson et al., 2008 ; Hollon et al., 2005 ). That being said, not everyone responds to either intervention, and there is emerging evidence that differential response to CBT versus medications can be predicted in advance. DeRubeis and colleagues used regression equations to combine multiple predictors of differential response into a single Personalized Advantage Index (PAI) and found that overall response could have been improved by as much as the typical drug-placebo difference if each patient had been given his or her optimal intervention (DeRubeis et al., 2014 ). This group has now moved on to using machine learning to generate precision treatment rules (PTRs) that can predict the optimal treatment for a given patient, and it should revolutionize the field (Cohen & DeRubeis, 2018 ). Even in the absence of making treatments better, overall efficiency of mental health delivery can be improved by getting each patient what he or she most needs.

Dissemination can be improved as well. Efforts to task-shift to lay counselors in low- and middle-income countries (LMIC) have shown that lay counselors with no prior psychiatric experience can be trained to deliver cognitive and behavioral therapies in an efficacious manner (Singla et al., 2017 ). The treatment gap is clearly largest in LMICs, but too few resources are available in high-income countries as well and, as IAPT has shown so well, a stepped-care approach can extend resources in a most salubrious fashion. It may well be that task-sharing approaches developed out of necessity in LMICs may readily transfer to other parts of the world also.

Finally, there is reason to think that nonpsychotic common mental disorders (including depression and anxiety) may represent adaptations that evolved to increased inclusive fitness (the propagation of one’s gene line) in our ancestral past (Hollon, Cohen, Singla, & Andrews, 2019 ). Most such “disorders” revolve around negative affects that motivate a differentiated response to different environmental challenges (Hollon, DeRubeis, Andrews, & Thompson, in press). To the extent that that is true, then simply “anesthetizing the pain” with medications may do little to resolve the problems that brought the symptoms about. Those psychosocial interventions (cognitive and behavior therapies and interpersonal psychotherapy) that teach problem-solving and interpersonal skills are likely to have broader and more enduring effects that sole reliance on pharmacological interventions (Hollon, in press).

• Abramson, L. Y. , Metalsky, G. I. , & Alloy, L. B. (1989). Hopelessness Depression: A Theory-Based Subtype of Depression . Psychological Review , 96 (2), 358–372.
• Anderson, T. , Watson, M. , & Davidson, R. (2008). The use of cognitive behavioural therapy techniques for anxiety and depression in hospice patients: A feasibility study. Palliative Medicine , 22 (7), 814–821.
• Andersson, G. , & Cuijpers, P. (2009). Internet-based and other computerized psychological treatments for adult depression: A meta-analysis . Cognitive Behaviour Therapy , 38 (4), 196–205.
• Andrews, P. W. , Kornstein, S. G. , Halberstadt, L. J. , Gardner, C. O. , & Neale, M. C. (2011). Blue again: Perturbational effects of antidepressants suggest monoaminergic homeostasis in major depression . Frontiers in Psychology , 2 , 159.
• Arnberg, A. , & Öst, L. G. (2014). CBT for children with depressive symptoms: A meta-analysis. Cognitive Behaviour Therapy , 43 (4), 275–288.
• Bai, Z. , Luo, S. , Zhang, L. , Wu, S. , & Chi, I. (2020). Acceptance and commitment therapy (ACT) to reduce depression: A systematic review and meta-analysis. Journal of Affective Disorders , 260 , 728–737.
• Barbato, A. , D’Avanzo, B. , & Parabiaghi, A. (2018). Couple therapy for depression . Cochrane Database of Systematic Reviews .
• Beck, A. T. (1963). Thinking and depression: I. Idiosyncratic content and cognitive distortions. Archives of General Psychiatry , 9 (4), 324–333.
• Beck, A. T. (1964). Thinking and depression: II. Theory and therapy. Archives of General Psychiatry , 10 (6), 561–571.
• Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects . New York, NY: Harper & Row.
• Beck, A. T. , Rush, J. , Shaw, B. F. , & Emery, G. (1979). The Cognitive Therapy of Depression . New York: Guilford Press.
• Beck, A. T. (1987). Cognitive models of depression. Journal of Cognitive Psychotherapy: An International Quarterly , 1 , 5–37.
• Beck, A. T. , & Alford, B. A. (2009). Depression: Causes and treatment . Philadelphia: University of Pennsylvania Press.
• Beltman, M. W. , Voshaar, R. C. , & Speckens, A. E. (2010). Cognitive-behavioural therapy for depression in people with a somatic disease: Meta-analysis of randomised controlled trials . British Journal of Psychiatry , 197 , 11–19.
• Bendall, C. , & McGrath, L. (2020). Contending with the minimum data set: Subjectivity, linearity and dividualising experiences in Improving Access to Psychological Therapies. Health , 24 (1), 94–109.
• Beshai, S. , Dobson, K. S. , Adel, A. , & Hanna, N. (2016). A cross-cultural study of the cognitive model of depression: Cognitive experiences converge between Egypt and Canada . PLOS ONE , 11 (3), e0150699.
• Bolton, P. , Lee, C. , Haroz, E. E. , Murray, L. , Dorsey, S. , Robinson, C. , . . . Bass, J. (2014). A transdiagnostic community-based mental health treatment for comorbid disorders: Development and outcomes of a randomized controlled trial among Burmese refugees in Thailand. PLOS Medicine , 11 , e1001757.
• Brown, J. S. , Sellwood, K. , Beecham, J. K. , Slade, M. , Andiappan, M. , Landau, S. , . . . Smith, R. (2011). Outcome, costs and patient engagement for group and individual CBT for depression: A naturalistic clinical study. Behavioural and Cognitive Psychotherapy , 39 (3), 355.
• Butler, A. C. , Chapman, J. E. , Forman, E. M. , & Beck, A. T. (2006). The empirical status of cognitive- behavioral therapy: A review of meta-analyses. Clinical Psychology Review , 26 (1), 17–31.
• Cairns, M. (2014). Patients who come back: Clinical characteristics and service outcome for patients re-referred to an IAPT service. Counselling and Psychotherapy Research , 14 (1), 48–55.
• Castro, A. , Gili, M. , Ricci-Cabello, I. , Roca, M. , Gilbody, S. , Perez-Ara, M. Á. , . . . McMillan, D. (2020). Effectiveness and adherence of telephone-administered psychotherapy for depression: A systematic review and meta-analysis. Journal of Affective Disorders , 260 , 514–526.
• Chand, S. P. , & Grossberg, G. T. (2013). How to adapt cognitive-behavioral therapy for older adults. Current Psychiatry , 12 (3), 10–15.
• Chowdhary, N. , Jotheeswaran, A. T. , Nadkarni, A. , Hollon, S. D. , King, M. , Jordans, M. J. D. , . . . Patel, V. (2014). The methods and outcomes of cultural adaptations of psychological treatments for depressive disorders: A systematic review. Psychological Medicine , 44 , 1131–1146.
• Christensen, A. , Atkins, D. C. , Yi, J. , Baucom, D. H. , & George, W. H. (2006). Couple and individual adjustment for two years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology , 74 , 1180–1191.
• Clark, D. A. , & Beck, A. T. (1999). Scientific foundations of cognitive theory and therapy of depression . New York, NY: Wiley.
• Clark, D. M. (2018). Realizing the mass public benefit of evidence-based psychological therapies: The IAPT program . Annual Review of Clinical Psychology , 14 , 159–183.
• Clarke, K. , Mayo-Wilson, E. , Kenny, J. , & Pilling, S. (2015). Can non-pharmacological interventions prevent relapse in adults who have recovered from depression? A systematic review and meta-analysis of randomised controlled trials. Clinical Psychology Review , 39 , 58–70.
• Cohen, Z. D. , & DeRubeis, R. J. (2018). Treatment selection in depression . Annual Review of Clinical Psychology , 14 , 15.1–15.28.
• Cuijpers, P. , Berking, M. , Andersson, G. , Quigley, L. , Kleiboer, A. , & Dobson, K. S. (2013a). A meta-analysis of cognitive- behavioural therapy for adult depression, alone and in comparison with other treatments. Canadian Journal of Psychiatry , 58 , 376–385.
• Cuijpers, P. , Cristea, I. A. , Karyotaki, E. , Reijnders, M. , & Hollon, S. D. (2019a). Component studies of psychological treatments of adult depression: A systematic review and meta-analysis. Psychotherapy Research , 29 (1), 15–29.
• Cuijpers, P. , Cristea, I. A. , Karyotaki, E. , Reijnders, M. , & Huibers, M. J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta‐analytic update of the evidence. World Psychiatry , 15 (3), 245–258.
• Cuijpers, P. , Hollon, S. D. , van Straten, A. , Bockting, C. , Berking, M. , & Andersson, G. (2013b). Does cognitive behavior therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? British Medical Journal Open , 3 (4), 1–8.
• Cuijpers, P. , Noma, H. , Karyotaki, E. , Cipriani, A. , & Furukawa, T. A. (2019b). Effectiveness and acceptability of cognitive behavior therapy delivery formats in adults with depression: A network meta-analysis. JAMA Psychiatry , 76 (7), 700–707.
• Cuijpers, P. , Sijbrandij, M. , Koole, S. L. , Andersson, G. , Beekman, A. T. , & Reynolds III, C. F. (2014). Adding psychotherapy to antidepressant medication in depression and anxiety disorders: A meta-analysis. Focus , 12 (3), 347–358.
• Dalal, F. (2018). CBT: The cognitive behavioral tsunami. Managerialism. politics and the corruption of science . London, UK: Routledge.
• David-Ferdon, C. , & Kaslow, N. J. (2008). Evidence-based psychosocial treatments for child and adolescent depression. Journal of Clinical Child & Adolescent Psychology , 37 (1), 62–104.
• Deckersbach T. , Gershuny, B. , & Otto, M. W. (2000). Cognitive behavioral therapy for depression. The Psychiatric Clinics of North America , 23 , 795–809.
• DeRubeis, R. J. , Cohen, Z. D. , Forand, N. R. , Fournier, J. C. , Gelfand, L. A. , & Lorenzo-Luaces, L. (2014). The Personalized Advantage Index: Translating research on prediction into individualized treatment recommendations. A demonstration . PLOS ONE , 9 (1), e83875.
• DeRubeis, R. J. , Hollon, S. D. , Amsterdam, J. D. , Shelton, R. C. , Young, P. R. , Salomon, R. M. , . . . Gallop, R. (2005). Cognitive therapy vs. medications in the treatment of moderate to severe depression . Archives of General Psychiatry , 62 , 409–416.
• DeRubeis, R. J. , Zajecka, J. , Shelton, R. C. , Amsterdam, J. D. , Fawcett, J. , Xu, C. , . . . Hollon, S. D. (2020). Prevention of recurrence after recovery from a major depressive episode with antidepressant medication alone or in combination with cognitive behavior therapy: Phase 2 of a 2-phase randomized clinical trial . JAMA Psychiatry , 77 (3), 237–245.
• Dimidjian, S. , Hollon, S. D. , Dobson, K. S. , Schmaling, K. B. , Kohlenberg, R. J. , Addis, M. E. , Gallop, R. , McGlinchey, J. B. , Markley, D. K. , Gollan, J. K. , Atkins, D. C. , Dunner, D. L. , & Jacobson, N. S. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression . Journal of Consulting and Clinical Psychology , 74 (4), 658–670.
• Dimidjian, S. , Barrera Jr., M. , Martell, C. , Muñoz, R. F. , & Lewinsohn, P. M. (2011). The origins and current status of behavioral activation treatments for depression. Annual Review of Clinical Psychology , 7 , 1–38.
• Dobson, K. S. , Hollon, S. D. , Dimidjian, S. , Schmaling, K. B. , Kohlenberg, R. J. , Gallop, R. J. , . . . Jacobson, N. S. (2008). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression . Journal of Consulting and Clinical Psychology , 76 , 468–477.
• Driessen, E. , Hollon, S. D. , Bockting, C. L. H. , Cuijpers, P. , & Turner, E. H. (2015). Does publication bias inflate the apparent efficacy of psychological treatment for major depressive disorder? A systematic review and meta-analysis of US National Institutes of Health-funded trials . PLOS ONE , 10 (9), e0137864.
• Ekers, D. M. , Dawson, M. S. , & Bailey, E. (2013). Dissemination of behavioural activation for depression to mental health nurses: Training evaluation and benchmarked clinical outcomes. Journal of Psychiatric and Mental Health Nursing , 20 (2), 186–192.
• Ekers, D. , Webster, L. , Van Straten, A. , Cuijpers, P. , Richards, D. , & Gilbody, S. (2014). Behavioural activation for depression: An update of meta-analysis of effectiveness and subgroup analysis. PLOS ONE , 9 (6), e100100.
• Evans, M. , Hollon, S. , DeRubeis, R. , Piasecki, J. M. , Grove, W. M. , Garvey, M. J. , & Tuason, V. B. (1992). Differential relapse following cognitive therapy and pharmacotherapy for depression. Archives of General Psychiatry , 49 , 802–808.
• Farrer, L. , Christensen, H. , Griffiths, K. M. , & Mackinnon, A. (2011). Internet-based CBT for depression with and without telephone tracking in a national helpline: Randomised controlled trial. PLOS ONE , 6 (11), e28099.
• Ferster, C. B. (1973). A functional analysis of depression. American Psychologist , 28 (10), 857.
• Goddard, E. , Wingrove, J. , & Moran, P. (2015). The impact of comorbid personality difficulties on response to IAPT treatment for depression and anxiety. Behaviour Research and Therapy , 73 , 1–7.
• Gortner, E. T. , Gollan, J. K. , Dobson, K. S. , & Jacobson, N. S. (1998). Cognitive–behavioral treatment for depression: Relapse prevention. Journal of Consulting and Clinical Psychology , 66 (2), 377.
• Hofman, J. , Pollitt, A. , Broeks, M. , Stewart, K. , & Van Stolk, C. (2017). Review of computerised cognitive behavioural therapies: Products and outcomes for people with mental health needs. Rand Health Quarterly , 6 (4), 1–83.
• Hollon, S. D. , Cohen, Z. D. , Singla, D. R. , & Andrews, P. W. (2019). Recent Developments in the Treatment of Depression . Behavior Therapy , 50 (2), 257–269.
• Hollon, S. D. , DeRubeis, R. J. , Fawcett, J. , Amsterdam, J. D. , Shelton, R. C. , Zajecka, J. , . . . Gallop, R. (2014). Effect of cognitive therapy with antidepressant medications vs antidepressants alone on the rate of recovery in major depressive disorder: A randomized clinical trial . JAMA Psychiatry , 71 (10), 1157–1164.
• Hollon, S. D. , DeRubeis, R. J. , Shelton, R. C. , Amsterdam, J. D. , Salomon, R. M. , O’Reardon, J. P. , . . . Gallop, R. (2005). Prevention of relapse following cognitive therapy versus medications in moderate to severe depression . Archives of General Psychiatry , 62 , 417–422.
• Hundt, N. E. , Mignogna, J. , Underhill, C. , & Cully, J. A. (2013). The relationship between use of CBT skills and depression treatment outcome: A theoretical and methodological review of the literature. Behavior Therapy , 44 (1), 12–26.
• Huntley, A. L. , Araya, R. , & Salisbury, C. (2012). Group psychological therapies for depression in the community: Systematic review and meta-analysis. The British Journal of Psychiatry , 200 (3), 184–190.
• Jacobson, N. S. , Dobson, K. , Fruzzeti, A. E. , Schmaling, K. B. , & Salusky, S. (1991). Marital therapy as a treatment for depression. Journal of Consulting and Clinical Psychology , 59 , 547–557.
• Jacobson, N. S. , Dobson, K. S. , Truax, P. A. , Addis, M. E. , Koerner, K. , Gollan, J. K. , . . . Prince, S. E. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology , 64 (2), 295–304.
• Jacobson, N. S. , Fruzzetti, A. E. , Dobson, K. , Whisman, M. , & Hops, H. (1993). Couple therapy as a treatment for depression: The effects of relationship quality and therapy on depressive relapse. Journal of Consulting and Clinical Psychology , 59 , 547–557.
• Kazantzis, N. , Whittington, C. , & Dattilio, F. (2010). Meta‐analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice , 17 (2), 144–156.
• Kendler, K. S. , Thornton, L. M. , & Gardner, C. O. (2000). Stressful life events and previous episodes in the etiology of major depression in women: An evaluation of the “kindling” hypothesis. American Journal of Psychiatry , 157 , 1243–1251.
• Kobori, O. , Nakazato, M. , Yoshinaga, N. , Shiraishi, T. , Takaoka, K. , Nakagawa, A. , . . . Shimizu, E. (2014). Transporting cognitive behavioral therapy (CBT) and the improving access to psychological therapies (IAPT) project to Japan: Preliminary observations and service evaluation in Chiba. The Journal of Mental Health Training, Education and Practice , 9 (3), 155–166.
• Kuyken, W. , Warren, F. C. , Taylor, R. S. , Whalley, B. , Crane, C. , Bondolfi, G. , . . . Segal, Z. (2016). Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: An individual patient data meta-analysis from randomized trials. JAMA Psychiatry , 73 (6), 565–574.
• Layard, R. (2006). The depression report: A new deal for depression and anxiety disorders . London, UK: London School of Economics and Political Science.
• Lewinsohn, P. M. (1974). A behavioral approach to depression. In R. J. Friedman & M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research (pp. 157–178). New York, NY: Wiley.
• Lewinsohn, P. M. , Hoberman, H. M. , Teri, L. , & Hautzinger, M. (1985). An integrative theory of depression. In S. Reiss & R. R. Bootzin (Eds.), Theoretical issues in behavior therapy (pp. 331–359). Orlando, FL: Academic Press.
• Luty, S. E. , Carter, J. D. , McKenzie, J. M. , Rae, A. M. , Frampton, C. M. , Mulder, R. T. , & Joyce, P. R. (2007). Randomised controlled trial of interpersonal psychotherapy and cognitive–behavioural therapy for depression. The British Journal of Psychiatry , 190 (6), 496–502.
• Martell, C. R. , Addis, M. E. , & Jacobson, N. S. (2001). Depression in context: Strategies for guided action . New York, NY: Norton.
• Martell, C. R. , Dimidjian, S. , & Herman-Dunn, R. (2010). Behavioral activation for depression: A clinician’s guide . New York, NY: Guilford Press.
• Moorey, S. (1997). When bad things happen to rational people: Cognitive therapy in adverse life circumstances. In M. Salkovskis (Ed.), Frontiers of Cognitive Therapy: State of the Art and Beyond (pp. 450–469). New York: Guilford Press.
• Moorey, S. , & Greer, S. (2011). Oxford guide to CBT for people with cancer . Oxford, UK: Oxford University Press.
• Moorey, S. , & Lavender, A. (Eds.). (2018). The therapeutic relationship in cognitive behavioral therapy . Thousand Oaks, CA: SAGE.
• Normann, N. , van Emmerik, A. A. , & Morina, N. (2014). The efficacy of metacognitive therapy for anxiety and depression: A meta‐analytic review. Depression and Anxiety , 31 (5), 402–411.
• Okuyama, T. , Akechi, T. , Mackenzie, L. , & Furukawa, T. A. (2017). Psychotherapy for depression among advanced, incurable cancer patients: A systematic review and meta-analysis. Cancer Treatment Reviews , 56 , 16–27.
• Ono, Y. , Furukawa, T. A. , Shimizu, E. , Okamoto, Y. , Nakagawa, A. , Fujisawa, D. , . . . Nakajima, S. (2011). Current status of research on cognitive therapy/cognitive behavior therapy in Japan. Psychiatry and Clinical Neurosciences , 65 (2), 121–129.
• Papageorgiou, C. , & Wells, A. (2009). A prospective test of the clinical metacognitive model of rumination and depression . International Journal of Cognitive Therapy , 2 (2), 123–131.
• Patel, V. , Weobong, B. , Weiss, H. A. , Anand, A. , Bhat, B. , Katti, B. , . . . Fairburn, C. G. (2017). The Healthy Activity Program (HAP), a lay counsellor delivered brief psychological treatment for severe depression, in primary care in India: A randomised controlled trial . The Lancet , 389 (10065), 176–185.
• Paykel, E. S. , Scott, J. , Cornwall, P. L. , Abbott, R. , Crane, C. , Pope, M. , & Johnson, A. L. (2005). Duration of relapse prevention after cognitive therapy in residual depression: Follow-up of controlled trial. Psychological Medicine , 35 (1), 59–68.
• Paykel, E. S. , Scott, J. , Teasdale, J. D. , Johnson, A. L. , Garland, A. , Moore, R. , . . . Pope, M. (1999). Prevention of relapse in residual depression by cognitive therapy. Archives of General Psychiatry , 56 , 829–835.
• Piet, J. , & Hougaard, E. (2011). The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clinical Psychology Review , 31 (6), 1032–1040.
• Pinquart, M. , Duberstein, P. R. , & Lyness, J. M. (2007). Effects of psychotherapy and other behavioral interventions on clinically depressed older adults: A meta-analysis. Aging & Mental Health , 11 (6), 645–657.
• Rahman, A. , Malik, A. , Sikander, S. , Roberts, C. , & Creed, F. (2008). Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: A cluster-randomised trial. The Lancet , 372 , 902–909.
• Rahman, A. , Riaz, N. , Dawson, K. S. , Hamdani, S. U. , Chiumento, A. , Sijbrandij, M. , . . . Farooq, S. (2016). Problem management plus (PM+): Pilot trial of a WHO transdiagnostic psychological intervention in conflict‐affected Pakistan. World Psychiatry , 15 (2), 182.
• Rush, A. J. , Beck, A. T. , Kovacs, M. , & Hollon, S. (1977). Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cognitive Therapy and Research , 1 (1), 17–37.
• Scher, C. , Ingram, R. , & Segal, Z. (2005). Cognitive reactivity and vulnerability: Empirical evaluation of construct activation and cognitive diatheses in unipolar depression. Clinical Psychology Review , 25 , 487–510.
• Scott, M. J. (2011). Simply effective group cognitive behaviour therapy: A practitioner’s guide . London, UK: Routledge.
• Segal, Z. V. , Bieling, P. , Young, T. , MacQueen, G. , Cooke, R. , Martin, L. , . . . Levitan, R. D. (2010). Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Archives of General Psychiatry , 67 (12), 1256–1264.
• Segal, Z. V. , Williams, M. W. , & Teasdale, J. (2002). Mindfulness-based cognitive therapy for depression . New York, NY: Guilford Press.
• Segal, Z. V. , Williams, M. W. , & Teasdale, J. (2013). Mindfulness-based cognitive therapy for depression . New York, NY: Guilford Press.
• Segal, Z. V. , Anderson, A. K. , Gulamani, T. , Dinh Williams, L.-A. , Desormeau, P. , Ferguson, A. , Walsh, K. , & Farb, N. A. S. (2019). Practice of therapy acquired regulatory skills and depressive relapse/recurrence prophylaxis following cognitive therapy or mindfulness based cognitive therapy . Journal of Consulting and Clinical Psychology , 87 (2), 161–170.
• Serfaty, M. , King, M. , Nazareth, I. , Moorey, S. , Aspden, T. , Mannix, K. , . . . Jones, L. (2020). Effectiveness of cognitive–behavioural therapy for depression in advanced cancer: CanTalk randomised controlled trial. The British Journal of Psychiatry , 216 (4), 213–221.
• Simons, A. D. , Murphy, G. E. , Levine, J. L. , & Wetzel, R. D. (1986). Cognitive therapy and pharmacotherapy for depression: Sustained improvement over one year. Archives of General Psychiatry , 43 , 43–48.
• Singla, D. R. , Kohrt, B. A. , Murray, L. K. , Anand, A. , Chorpita, B. F. , & Patel, V. (2017). Psychological treatments for the world: Lessons from low- and middle-income countries . Annual Review of Clinical Psychology , 13 , 149–181.
• Staats, A. W. , & Heiby, E. (1985). Paradigmatic behaviorism’s theory of depression: Unified, explanatory, and heuristic. In S. Reiss & R. Bootzin (Eds.), Theoretical issues in behavior therapy . New York, NY: Academic Press.
• Strunk, D. R. , DeRubeis, R. J. , Chiu, A. W. , & Alvarez, J. (2007). Patients’ competence in and performance of cognitive therapy skills: Relation to the reduction of relapse risk following treatment for depression . Journal of Consulting and Clinical Psychology , 75 , 523–530.
• Turner, E. H. , Matthews, A. M. , Linardatos, E. , Tell, R. A. , & Rosenthal, R. (2008). Selective publication of antidepressant trials and its influence on apparent efficacy . New England Journal of Medicine , 358 , 252–260.
• Wakefield, S. , Kellett, S. , Simmonds‐Buckley, M. , Stockton, D. , Bradbury, A. , & Delgadillo, J. (2020). Improving access to psychological therapies (IAPT) in the United Kingdom: A systematic review and meta‐analysis of 10‐years of practice‐based evidence . British Journal of Clinical Psychology .
• Watkins, E. R. (2018). Rumination-focused cognitive-behavioral therapy for depression . New York, NY: Guilford Press.
• Watkins, E. R. , Mullan, E. , Wingrove, J. , Rimes, K. , Steiner, H. , Bathurst, N. , Eastman, R. , & Scott, J. (2011). Rumination-focused cognitive-behavioural therapy for residual depression: Phase II randomised controlled trial . British Journal of Psychiatry , 199 (4), 317–322.
• Webb, C. A. , DeRubeis, R. J. , Amsterdam, J. D. , Shelton, R. C. , Hollon, S. D. , & Dimidjian, S. (2011). Two aspects of the therapeutic alliance: Differential relations with depressive symptom change. Journal of Consulting and Clinical Psychology , 79 , 279.
• Weitz, E. S. , Hollon, S. D. , Twisk, J. , van Straten, A. , Huibers, M. J. H. , David, D. , . . . Cuijpers, P. (2015). Baseline depression severity as a moderator of depression outcomes between cognitive behavioral therapy versus pharmacotherapy: An individual patient data meta-analysis. JAMA Psychiatry , 72 , 1102–1109.
• Wells, A. (2011). Metacognitive therapy for anxiety and depression . New York, NY: Guilford Press.
• Wells, A. , Fisher, P. , Myers, S. , Wheatley, J. , Patel, T. , & Brewin, C. (2009). Metacognitive therapy in recurrent and persistent depression: A multiple-baseline study of a new treatment . Cognitive Therapy and Research , 33 , 291–300.
• Weobong, B. , Weiss, H. A. , McDaid, D. , Singla, D. R. , Hollon, S. D. , Nadkarni, A. , Park, A.-L. , Bhat, B. , Katti, B. , Anand, A. , Dimidjian, S. , Araya, R. , King, M. , Vijayakumar, L. , Wilson, G. T. , Velleman, R. , Kirkwood, B. R. , Fairburn, C. G. , & Patel, V. (2017). Sustained effectiveness and cost-effectiveness of the Healthy Activity Programme, a brief psychological treatment for depression delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial . PLOS Medicine , 14 (9), e1002385.
• World Health Organization . (2016). Problem management plus (PM+): Individual psychological help for adults impaired by distress in communities exposed to adversity: WHO generic field-trial version 1.0 . Geneva, Switzerland: World Health Organization.
• Zettle, R. D. (2004). ACT with affective disorders. In S. C. Hayes & K. D. Strosahl (Eds.), A practical guide to acceptance and commitment therapy (pp. 77–102). New York, NY: Springer.

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Research Article

In the here and now: Future thinking and social problem-solving in depression

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected] (SN); [email protected] (BD)

Affiliation Department of Psychology, De Montfort University, Leicester, England

Roles Conceptualization, Methodology, Writing – review & editing

Affiliation School of Psychology and Neuroscience, University of St Andrews, St Andrews, Scotland

• Saima Noreen, 
• Barbara Dritschel

• Published: June 30, 2022
• https://doi.org/10.1371/journal.pone.0270661
• Reader Comments

This research investigates whether thinking about the consequences of a problem being resolved can improve social problem-solving in clinical depression. We also explore whether impaired social problem solving is related to inhibitory control. Thirty-six depressed and 43 non-depressed participants were presented with six social problems and were asked to generate consequences for the problems being resolved or remaining unresolved. Participants were then asked to solve the problems and recall all the consequences initially generated. Participants also completed the Emotional Stroop and Flanker tasks. We found that whilst depressed participants were impaired at social problem-solving after generating unresolved consequences, they were successful at generating solutions for problems for which they previously generated resolved consequences. Depressed participants were also impaired on the Stroop task, providing support for an impaired inhibitory control account of social problem-solving. These findings advance our understanding of the mechanisms underpinning social problem-solving in depression and may contribute to the development of new therapeutic interventions to improve social-problem solving in depression.

Citation: Noreen S, Dritschel B (2022) In the here and now: Future thinking and social problem-solving in depression. PLoS ONE 17(6): e0270661. https://doi.org/10.1371/journal.pone.0270661

Editor: Anna Manelis, University of Pittsburgh, UNITED STATES

Received: December 20, 2021; Accepted: June 14, 2022; Published: June 30, 2022

Copyright: © 2022 Noreen, Dritschel. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data underlying the results presented in the study are available from the following URL DOI 10.17605/OSF.IO/SDNH7 .

Funding: The authors received no specific funding for this work.

Competing interests: No authors have competing interests.

Introduction

Social problem-solving reflects the process through which people generate effective solutions to problems experienced in everyday life [ 1 , 2 ]. Given that we frequently encounter social or interpersonal problems in everyday life, such as disagreements with friends, workplace disputes and marital conflicts, the ability to solve these problems effectively is not only important for our relationships with others, but also our psychological health and mental well-being [ 3 , 4 ]. Furthermore, the ability to maintain good social relationships is also important for our psychological well-being.

Deficits in social problem-solving are a central feature of depression [ 1 , 3 , 5 , 6 ]. Priester and Chun [ 7 ] for example, found that depressed individuals exhibit a negative orientation towards a social problem compared to non-depressed healthy individuals. Furthermore, Watkins and Baracaia [ 8 ] and Goddard, Dritschel & Burton [ 3 ] found that depressed individuals generated fewer relevant steps during problem-solving and their proposed solutions were less effective than their non-depressed counterparts.

Research also suggests that rumination, which involves individuals focusing their thoughts and behaviour on their depressive symptoms and the consequences of these symptoms [ 9 ] may be a key mechanism underlying poor social problem-solving in depression. The importance of rumination in depressive disorders has been well established [ 10 ] with rumination linked to depression maintenance, negative cognitions and enhanced accessibility of negative memories [ 11 – 13 ].

Research has also found that rumination impairs social problem-solving, with ruminative thinking having a detrimental impact on both problem orientation and problem-solving skill. Lyubomirsky et al. [ 14 ] had dysphoric and non-dysphoric participants complete the Means-End Problem-solving Task (MEPS, [ 15 ]). In the MEPS, participants are presented with a hypothetical social problem and a positive resolution to the problem. Participants are asked to generate a number of steps to reach the proposed solution. Lyubomirsky et al. [ 14 ] found that dysphoric individuals induced to ruminate generated fewer steps and produced fewer effective solutions on the MEPS compared to dysphoric individuals who distracted themselves from their mood and their non-dysphoric counterparts. Furthermore, they also found that dysphoric individuals who ruminated appraised their problems as overwhelming and unresolvable, thus reflecting a negative problem orientation.

It is also possible, however, that poor problem-solving contributes to the maintenance of rumination in depression. As rumination involves recurrent thinking, it can be conceptualised as an attempt to problem solve and resolve unfulfilled goals [ 16 , 17 ]. Indeed, research has found that the content of rumination in depression often focuses on trying to solve personal problems [ 14 ]. Furthermore, ruminative thinking continues to persist until a goal is attained or discarded. These findings suggest that a vicious cycle can ensue. There is considerable evidence that rumination impairs effective problem-solving [ 12 , 14 ], increasing the likelihood of the problem being unresolved. In turn, the lack of resolution continues to trigger and maintain further rumination [ 18 ].

Another important feature of depressive thinking is hopelessness, which is defined as the extent to which an individual is pessimistic about the future [ 4 , 19 – 21 ]. Research has found that depressed individuals generate fewer positive future events [ 22 ] which may impair social problem-solving. Noreen, Whyte & Dritschel [ 23 ], for example, had participants engage in future thinking by presenting them with a hypothetical social problem and asking them to generate the consequences of the social problem being resolved or remaining unresolved. Participants were presented with some of the solutions and were asked to solve the problem in order to achieve the resolution described. Participants were also asked to recall all of the consequences generated. The study found that participants reporting higher levels of depression and rumination were less effective at generating solutions. Furthermore, they also found that those reporting higher levels of rumination produced fewer effective solutions for social problems that they had previously generated unresolved consequences for. Individuals scoring high in rumination also recalled more of the unresolved consequences in a subsequent memory test. Taken together, these findings suggest that negative future thinking impairs the generation of effective solutions for individuals with high rumination tendencies.

One explanation for these findings may relate to the type of thinking evoked when participants were asked to think of the consequences of the problem being resolved or unresolved. According to the concreteness theory [ 24 ], there are two types of thinking; abstract and concrete. Abstract thinking is operationalised as ‘indistinct, equivocal, unclear and aggregated’ and reflects broad overarching general memories, whilst concrete thinking is ‘distinct, situational, specific and clear’ and reflects more specific individualised memories. As rumination is characterised by increased abstract thinking and reduced concrete thinking, it is possible that encouraging high ruminating individuals to think about the consequences of a problem remaining unresolved leads to greater abstract thinking, which subsequently impairs problem-solving. This is consistent with research by Watkins & Moulds [ 25 ] who found that abstract thinking, typical of rumination, impaired social problem-solving in depression. Similarly, Goddard, Dritschel & Burton [ 3 ] found that reduced social problem-solving performance in a clinically depressed sample was associated with the retrieval of spontaneous abstract categoric memories during problem-solving.

It is also possible, however, that encouraging participants to think about the consequences of a problem being resolved would encourage more concrete thinking and improve social problem-solving. Indeed, Watkins & Moulds [ 25 ] found that by encouraging participants to self-focus more concretely (i.e., focusing on the self in more concrete terms, such as, focusing on your experience of the way you feel inside) improved social problem-solving in depression. Given that Noreen, Whyte & Dritschel [ 23 ], did not have a baseline measure of problem-solving (one where no consequences were generated) it is unclear whether generating the consequences of a problem being resolved in individuals high in rumination may actually improve social problem-solving.

This is an important issue given that ineffective problem-solving has been linked to both the aetiology and maintenance of depression, which has led to the development of depression treatments that target social problem-solving [ 26 , 27 ]. These treatments have demonstrated some clinical improvements in social problem-solving [ 28 , 29 ], and have been found to alleviate some of the symptoms of depression [ 30 – 32 ]. However, these strategies do not address ruminative thinking directly associated with information related to social problem-solving. Therefore, it is possible that the task developed by Noreen, Whyte & Dritschel [ 23 ] may be an effective tool to improve social problem-solving in high ruminating individuals.

It is also possible that Noreen, Whyte & Dritschel’s [ 23 ] findings may be due to impaired inhibitory control. For example, people scoring high in rumination may be unable to inhibit the negative consequences they generated earlier. Difficulties inhibiting previously generated negative consequences may subsequently affect their ability to think clearly about the steps needed to solve a problem, thus resulting in impaired social problem-solving. It has been well established that inhibition is necessary to prevent irrelevant information from entering memory and instead focusing on relevant material [ 33 ]. Indeed, research has found that individuals scoring high on measures of rumination and depression demonstrate greater difficulty in inhibiting irrelevant information [ 34 , 35 ]. Joormann [ 36 ], for example, found that dysphoric participants were impaired in their ability to inhibit negative material in comparison to non-depressed controls. There were no group differences, however, for positive material. Taken together, these findings suggest that both depression and rumination are associated with poor inhibitory control.

Whilst there have been a number of studies implicating the role of rumination in impairing social problem-solving, the role of inhibiting irrelevant information has not yet been examined. Thus, a key underlying process that could potentially contribute to the relationship between depression, rumination and impaired social problem-solving is currently unknown.

The aim of the present research is to provide further insight into the mechanisms that contribute to poor social problem-solving in depression. Specifically, we investigate whether thinking about the consequences of a problem being resolved can improve social problem-solving in a clinically depressed sample relative to non-depressed controls. We also examine whether thinking about the consequences of a problem being unresolved impairs social problem-solving in a clinically depressed sample significantly more than non-depressed controls. Furthermore, we also explore whether impaired social problem-solving is related to impaired inhibitory control.

To this end, participants took part in three sessions. In the first session, participants were screened for depression using the MINI-Plus. In the second session, depressed and non-depressed participants were presented with 8 vignettes that consisted of a series of interpersonal problems using a modified version [ 23 ] of the Means-End Problem-solving Task (MEPS; [ 15 ]). Participants were asked to generate four consequences of the problem being resolved for three of the vignettes and four consequences for the problem being unresolved for another three of the vignettes. Subsequently, participants were given six of the vignettes (including two that had not previously been presented, which acted as a baseline measure of problem-solving) with their resolutions and were asked to describe the steps they would take to solve the problem in order to achieve the resolution described. Following a ten-minute distraction task, participants were presented with all of the original six vignettes and were asked to recall all of the consequences that they had previously generated.

In the third session, participants were given the Flanker task [ 37 ] and the Emotional Stroop task (adapted from Strand, Oram & Hammar, [ 38 ]) to assess inhibitory control for both emotional and non-emotional stimuli. Comparing the performance on these two tasks would allow us to assess whether poor inhibitory control is greater for emotional stimuli. For social problem-solving we predicted that depressed individuals would perform poorer than non-depressed individuals in the baseline condition and also when they generate unresolved consequences. We also predicted that depressed individuals would recall more unresolved than resolved consequences, compared to non-depressed participants. For the Emotional Stroop and Flanker Tasks, we predicted that depressed participants would show inhibitory impairments on these tasks, compared to non-depressed participants. Finally, we also predicted that there would be a relationship between social-problem solving and inhibitory control, with poorer social problem-solving abilities related to impaired inhibitory control.

Participants

One hundred and thirteen participants (51M & 62F; age M = 23.41; SD = 3.46) took part in the initial screening session. Participants were university students that were recruited using posters advertising the study at Goldsmiths, University of London and were reimbursed for their participation (£5 per session). Participants completed the Mini-International Neuropsychiatric Interview-Plus (MINI-Plus; [ 39 ]) and the Beck Depression Inventory-II (BDI-II; [ 40 ]) in order to identify the depressed and non-depressed control groups. To be included in the depressed group, participants had to meet the criteria for current depression according to the MINI-Plus and have a minimum BDI-II score of 15. Eligibility for the controls required having no current or past Axis One disorders (e.g., anxiety disorders, dissociative disorders, mood disorders, psychotic disorders and substance use disorders) based on the MINI-Plus criteria and having a BDI-II score of 5 or below. These inclusion criteria resulted in a sample of 86 participants (41 White British; 23 British Asian (Pakistani, Indian or Bengali) and 22 Black British (African or Caribbean). A further 7 participants had to be excluded as they failed to complete all three study sessions. This resulted in 43 non-depressed control participants (17M, 26F; Mean age = 21.95; SD = 3.80) and 36 depressed participants (12M, 24F; Mean age = 21.06; SD = 4.41) in the final sample. For the currently depressed participants nine also met the criteria for dysthymic disorder, 11 met the criteria for panic disorder, 9 for social phobia, 2 for anorexia, 1 bulimia and 9 had mixed depression and anxiety. Seventeen reported taking antidepressant medications in the past and 12 had a history of past depression. The MINI-Plus was administered by a trained researcher. A second trained rater scored 25% of the interviews and there was 100% agreement regarding diagnostic status. The study was approved by the Psychology Ethics Committee, Goldsmiths, University of London. All participants provided written consent before taking part in the study.

The Beck Depression Inventory-II [ 40 ]. The BDI-II consists of 21 items that assess both psychological and physiological symptoms of depression. Participants rate the degree to which they experience each symptom over the past two weeks on a 4- point scale. The BDI-II scale has excellent psychometric properties with good internal consistency, re-test reliability and concurrent validity with other measures of depression [ 41 ]. In the present study BDI-II was found to be highly reliable (21 items; α = .97).

The Rumination Response Scale (RRS; [ 42 ]). The RRS scale consists of 22 items that assess how participants typically respond to sad or dysphoric mood. Each item is rated on a 4- point scale (with 1 = Almost never to 4 = Almost always ). Scores range from 22–88, with higher scores indicating greater rumination. RRS has good construct validity and internal consistency [ 43 ]. In the present study RRS was found to be highly reliable (22 items; α = .95).

The Spielberger State-Trait Anxiety Inventory (STAI; [ 44 ]). STAI is comprised of two questionnaires each containing 20-items that assess dispositional and situational anxiety, respectively. Each item is rated on a 4- point scale (with, 1 = not at all to 4 = very much ). Scores range from 20–80 on each questionnaire, with higher scores indicating increased anxiety. Research has found that STAI has good construct and concurrent validity [ 44 , 45 ]. The STAI also has good internal consistency with dispositional anxiety ranging from α = .92- α = .94 and situational anxiety ranging from α = .88 - α = .93 [ 44 , 46 ]. In the present study both state and trait measures were found to be highly reliable (20 items each scale; α = .96, α = .97, respectively).

Emotional Stroop task

The Emotional Stroop task (adapted from Strand, Oram & Hammar [ 38 ]) was used to investigate emotional inhibition and attention. The task consists of lexical and visual facial stimuli in the form of an emotional word (i.e., positive or negative) being superimposed on an emotional face (i.e., happy or sad). The task is to identify the emotional valence of the word and ignore the emotion displayed on the face. Half of the trials were congruent and the other half were incongruent. Congruent trials were defined as emotional words whose semantic meaning corresponded to the emotion of the face that it was superimposed on (i.e., the word ‘depressed’ superimposed on a sad face). Incongruent trials were defined as emotional words whose semantic meaning differed from the emotion expressed on the face that it was superimposed on (i.e., the word ‘elated’ superimposed on a sad face, or the word ‘miserable’ superimposed on a happy face).

The stimulus material consisted of 10 photographic colour images of faces (5 male & 5 female; Strand, Oram & Hammer, [ 38 ]) unknown to the participants. The images were developed at the University of St Andrews [ 47 ] with the emotional expressions and valence based on the Facial Acting Coding system developed by Ekman and colleagues [ 48 ]. Forty emotional (20 positive and 20 negative) words were superimposed in black font across the nose. All of the faces were used in the experimental session, with each face appearing with 2 positive and 2 negative words. Each word was presented twice, once with a happy face and once with a sad face. Thus, in a block of 80 trials, participants saw each of the 10 faces 8 times, and each of the 40 words twice, with half of the words superimposed on happy faces and the other half superimposed on the sad faces. The block of 80 stimuli was repeated in random order two times. The second block contained the same emotional words and faces as the first block but differed in terms of the word-face combinations. In total participants were given 160 trials.

In the task participants had to report the emotional valence of the word irrespective of the valence of the facial expression. Participants were asked to press the left arrow “<” when the word was positive and right arrow “>” when the word was negative. Prior to the experimental blocks, participants completed a practice block. This was similar to the main block but differed in terms of the faces and words that were presented. The practice block consisted of emotional words (20 positive and 20 negative) being superimposed on emotionally neutral faces. The practice block consisted of 40 trials with each emotional word-face combination presented once. To determine if there were any group differences, stroop responses were scored. In the task both correct and incorrect responses were recorded and error rates for incongruent trials were analysed. Furthermore, participant’s reaction times for correct responses were also analysed. Mean reaction times for congruent and incongruent trials were calculated. In the present study, the split half reliability for the Emotional Stroop task was found to be good (α = .42).

Flanker task [ 37 ]

In the flanker task, participants were presented with a string of 5 letters (e.g., CCHCC) and were asked to focus their attention solely on the middle letter. Participants were instructed to press the left arrow if the target letter was H or K (straight-lined stimulus) and the right arrow if the target letter was C or S (curvy-lined stimulus). The remaining letters were one of the remaining three possible letters (H, K, C or S) and were either the same type of stimuli (e.g., HHKHH; compatible) or were a different type (CCKCC; incompatible). For the task, participants must exercise inhibitory control by ignoring the irrelevant stimuli (i.e., the outlaying four letters) and instead focus on the central stimulus.

Each trial consisted of a 1000ms fixation cross followed by the presentation of the 5-letter string. Participants were given unlimited time to respond, but were told to respond as quickly and accurately as possible. Accuracy and response times were recorded. Participants were given 2 blocks of 48 experimental trials to complete. After one block, participants were given a short 2-min break. The order of the blocks was fully counterbalanced across participants. In order to learn the response keys, participants were initially given 12 practice trials to complete. The practice trials were similar to the experimental trials but participants were given accuracy feedback (i.e., correct or incorrect response) after each trial. In the present study, the split half reliability for the Flanker task was found to be adequate (α = .42).

Means End Problem-Solving (MEPS; [ 15 ]).

We constructed a modified version of the MEPS using eight hypothetical scenarios (adapted from Noreen, Whyte & Dritschel, [ 23 ]). The scenarios consisted of hypothetical interpersonal problems that could be encountered by a student population, such as, your supervisor finding fault with your work or your housemates not doing their chores etc. The scenarios were matched on word count, openness, difficulty in solving the hypothetical problem and the number of consequences generated (see Noreen, Whyte & Dritschel [ 23 ] for more information).

Each scenario consisted of a problem and a positive resolution. During the consequence generation phase, participants were only presented with the problem and asked to generate possible consequences for the problem either being resolved or remaining unresolved. During the problem-solving phase, participants were presented with both the problem and the positive resolution and were asked to describe the steps they would take to solve the problem and reach the proposed resolution.

The number of relevant means taken to reach the proposed solution and the effectiveness of the solutions was scored by an independent coder blind to the participant’s group status. The number of relevant means was defined as the number of relevant (and detailed) steps taken to reach the proposed solution. Effectiveness was rated using a 7- point scale with 1 being not at all effective and 7 being extremely effective. Solutions to problems were considered to be effective if they maximized positive and minimized negative consequences [ 49 ]. A second coder, also blind to participant’s group status was employed to validate findings. This coder rated 30% of the proposed solutions. Inter-rater reliability was calculated through a Pearson correlation coefficient (relevant means, r = . 92 , p < .001; effectiveness, r = . 95 , p < .001). In the present study, the split half reliability for MEPs was found to be good (α = .70).

The study consisted of three sessions. In the first session, participants completed the MINI-Plus, BDI II, RRS and STAI. In the second session, participants were presented with six of the eight hypothetical problems. For each problem they were given 4 minutes to generate 4 possible consequences of the problem either being resolved or remaining unresolved. Consequences were defined as “the possible long or short-term outcomes IF the scenario was [or was not] resolved” . Participants were asked to make sure they did not attempt to solve the scenario but only list the consequences of it being resolved or remaining unresolved. For half the hypothetical scenarios, participants generated consequences for the problem being resolved and for the remaining scenarios participants generated consequences for the problem remaining unresolved. The order of scenarios was counterbalanced so that no two ‘resolved’ or ‘not resolved’ scenarios appeared together.

Participants then completed the problem-solving task which consisted of solving six of the eight problem scenarios. These consisted of 4 scenarios that participants had generated consequences for (2 resolved and 2 unresolved) and the remaining two scenarios that participants did not generate any consequences for (a baseline measure of problem-solving).

The allocation of the scenarios to the consequence generation (resolved and unresolved) and the problem-solving phase were fully counterbalanced across participants.

For each problem-scenario, participants were presented with the problem and the positive resolution and were asked to complete the missing part of the story. Participants were given four minutes to generate a solution. Participants were subsequently given a 10-minute distraction task which involved completing some math problems. Finally, participants were given a recall test for the consequences generated earlier. Participants were presented with the 6 hypothetical scenarios presented in the recall generation phase. For each scenario, participants were given four minutes to recall all of the consequences that they had generated previously (prior to the problem-solving phase). Participants were asked to recall all of the consequences as accurately as possible. Participants were asked to recall the consequences for the baseline condition followed by the unresolved consequences and then the resolved consequences.

In a third session, participants completed the executive tasks (the Emotional Stroop task and the Flanker task). The order of the executive tasks was counterbalanced. Furthermore, the order of the administration of sessions 2 & 3 were fully counterbalanced across all participants.

Group characteristics

The depressed group scored significantly higher than the non-depressed group on the BDI, t(36.39) = 17.33, p < .001, RRS, t(70.02) = 9.13, p < .001, and state, t(73.20) = 9.86, p < .001 and trait anxiety scales t(60.34) = 12.90, p < .001. There were no differences, however, between the depressed and non-depressed groups in terms of age, t(69.62) = .96, p = .34. See Table 1 .

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https://doi.org/10.1371/journal.pone.0270661.t001

Social problem-solving ability: Relevant means

The mean number of relevant means (i.e., steps) taken to reach the proposed solution was assessed using a 2 (group: depressed vs. non-depressed) x 3 (condition: resolved vs. not resolved consequences vs. baseline) ANOVA. We found significant main effects of group, F (1, 77) = 33.66, p < .001, η 2 p = .30, and condition, F (2, 77) = 50.27, p < .001, η 2 p = .40. These were qualified by a group by condition interaction, F (2, 77) = 22.68, p < .001, η 2 p = .23, with the depressed group taking fewer steps than the non-depressed group in the baseline condition, t (61.36) = 3.32, p = .002, d = .76 and in the unresolved condition, t (67.54) = 7.04, p < .001, d = 1.60. There were no differences, however, in the relevant means between the depressed and non-depressed groups in the resolved condition, t (58.19) = 2.03, p = .047, d = .47.

Interestingly, we also found that the non-depressed group did not differ in the relevant means between the baseline condition and the resolved, t (42) = 1.25, p = .22, d = .24, and unresolved conditions, t (42) = 1.63, p = .11, d = .24. The non-depressed group, did, however, take significantly more steps in the resolved than unresolved conditions, t (42) = 2.36, p = .02, d = .46. The depressed group took significantly more steps in the resolved than baseline, t (35) = 3.47, p = .001, d = .57, and unresolved conditions, t (35) = 10.50, p < .001, d = 1.76. Depressed participants, however, took fewer steps in the unresolved than the baseline condition, t (35) = 6.29, p < .001, d = 1.12. We also investigated the effects of gender on social problem-solving, memory accuracy and on the Emotional Stroop and Flanker tasks. We did not find any significant main or interaction effects of gender on any of these variables, all p>.05.

Effectiveness

The effectiveness of the proposed solutions was assessed using a 2 (group: depressed vs. non-depressed) x 3 (condition: resolved vs. not resolved consequences vs. baseline) ANOVA. Our analysis found main effects of group, F (1, 77) = 11.35, p < .001, η 2 p = .13, and condition, F (2, 77) = 13.72, p < .001, η 2 p = .15. A significant group by condition interaction was also found, F (2, 77) = 3.96, p = .02, η 2 p = .05, with the depressed group less effective at generating solutions than the non-depressed group in the baseline, t (72.05) = 2.53, p = .01, d = .58 and the unresolved conditions, t (76.73) = 4.01, p < .001, d = .90. There were no differences, however in the effectiveness of solutions generated by the depressed and non-depressed groups in the resolved condition, t (72.73) = 1.0, p = .31, d = .23.

Subsequent analysis also found that the non-depressed group showed no significant differences in the effectiveness of solutions generated between the baseline and resolved, t (42) = .11, p = .91, d = .02, and unresolved conditions, t (42) = 1.58, p = .12, d = .30. There were also no differences in the effectiveness of solutions generated between resolved and unresolved conditions, t (42) = 1.32, p = .20, d = .26. The depressed group, however, were more effective at generating solutions in the resolved than baseline, t (35) = 2.49, p = .02, d = .39 and unresolved conditions, t (35) = 6.47, p < .001, d = 1.18. The depressed group was also more effective at generating solutions in the baseline than the unresolved condition, t (35) = 4.35, p < .01, d = .65. See Table 2 .

https://doi.org/10.1371/journal.pone.0270661.t002

Memory accuracy for consequences

In order to assess recall accuracy for the consequences generated, a 2 (group: depressed vs. control) x 3 (condition: resolved vs. unresolved consequences vs. baseline) mixed design ANOVA was conducted. There were no main effects of either group, F (1, 77) = .94, p = .36, η 2 p = .01 or condition, F (1.84, 141.65) = 1.64, p = .20, η 2 p = .02. However, a significant group by condition interaction was found, F (1.84, 141.65) = 22.89, p < .001, η 2 p = .23, which revealed that whilst the depressed group recalled significantly fewer resolved consequences than the non-depressed group, t (65.55) = 5.12, p < .001, d = 1.17. they recalled significantly more unresolved consequences, t (76.28) = 3.66, p < .001, d = .82. There was no difference, however, between depressed and non-depressed groups in their recall of baseline consequences, t (76.19) = .17, p = .87, d = .04.

Subsequent analyses also revealed that the depressed group recalled significantly more unresolved than resolved consequences, t (35) = 6.79, p < .001, d = 1.25, and baseline consequences, t (35) = 2.41, p = .02, d = .54. The depressed group, however, recalled significantly fewer resolved than baseline consequences, t (35) = 4.22, p < .01, d = .76. Conversely, the non-depressed group recalled significantly fewer unresolved than baseline consequences, t (42) = 2.21, p = .03, d = .36, but recalled significantly more resolved than unresolved consequences, t (42) = 2.84, p = .007, d = .74. There was no difference, however, between the non-depressed groups recall of resolved and baseline consequences, t (42) = 1.70, p = .10, d = .40. See Table 2 .

A 2 (group: depressed vs. control) x 2 (valence: positive vs. negative) x 2 (distractor: happy vs. sad face) mixed design ANOVA on accuracy was conducted. The results revealed main effects of valence, F (1, 77) = 27.60, p < .001, η 2 p = .26, distractor, F (1, 77) = 5.07, p = .03, η 2 p = .06, and group, F (1, 77) = 11.08, p = .001, η 2 p = .13. These main effects were qualified by a 3-way valence by distractor by group interaction, F (1, 77) = 5.26, p = .03, η 2 p = .06, with the depressed group recalling significantly fewer positive words superimposed on negative faces than the non-depressed group, t (50.97) = 3.48, p = .001, d = .80. There were no differences, however, between depressed and non-depressed groups in their recall for positive words superimposed on positive faces, t (40.65) = 2.07, p = .045, d = .48, negative words superimposed on negative faces, t (72.38) = .36, p = .72, d = .08 or negative words superimposed on positive faces, t (58.12) = 1.07, p = .29, d = .25.

Reaction time

A 2 (group: depressed vs. control) x 2 (valence: positive vs. negative) x 2 (distractor: happy vs. sad face) mixed design ANOVA found a main effect of group, F (1, 77) = 24.0, p < .001, η 2 p = .24, with the non-depressed group significantly faster at responding than the depressed group. We also found a significant valence by distractor by group interaction, F (1, 77) = 5.18, p = .03, η 2 p = .06, with the non-depressed group significantly faster at responding to positive words superimposed on positive faces, t (61.43) = 3.44, p = .001, d = .79, positive words superimposed on negative faces, t (71.42) = 3.14, p < .01, d = .71, and for negative words superimposed on positive faces, t (68.64) = 4.65, p < .001, d = 1.06 than the depressed group. There were no significant differences in reaction times between depressed and non-depressed groups for negative words superimposed on negative faces, t (75.17) = 1.25, p = .21, d = .28. We also did not find a significant effect of valence, F (1, 77) = 3.43, p = .07, η 2 p = .04, and distractor, F (1,77) = .42, p = .52, η 2 p = .01. See Table 3 .

https://doi.org/10.1371/journal.pone.0270661.t003

Flanker task

A 2 (group: depressed vs. control) x 2 (congruency: congruent vs. incongruent) mixed design ANOVA found a main effect of congruency, F (1, 77) = 16.35, p < .001, η 2 p = .18, with participants, overall, more accurate on congruent than incongruent trials. However, we did not find a significant main effect of group, F (1, 77) = .13, p = .72, η 2 p = .002, nor a group by congruency interaction, F (1, 77) = .39, p = .53, η 2 p = .005.

Reaction time.

A 2 (group: depressed vs. control) x 2 (congruency: congruent vs. incongruent) mixed design ANOVA found a main effect of congruency, F (1, 77) = 4.47, p = .04, η 2 p = .06. Overall participants were faster at responding to congruent than incongruent trials. However, we did not find either a significant main effect of group, F (1, 77) = .32, p = .57, η 2 p = .004, or a group by congruency interaction, F (1, 77) = .007, p = .93, η 2 p = .0.

The relationship between depression, rumination and social problem-solving

In order to determine whether there was a relationship between depression, rumination and social problem-solving, we conducted Pearson correlations. Our analysis failed to find significant correlations between depression, rumination and problem-solving abilities for the non-depressed control group; all tests p > .05. However, the correlations between depression, rumination, and the social problem-solving measures of relevant means (i.e., steps) and effectiveness for the depressed group were significant. These are presented in Table 4 .

https://doi.org/10.1371/journal.pone.0270661.t004

Regression analyses for relevant-means

Given that we found significant correlations between depression, rumination and social problem-solving ability in the depressed group, hierarchical multiple regression analyses were conducted in order to determine whether rumination and depression predicted performance on the problem-solving task.

The analysis found that in the baseline condition (i.e., when no consequences were generated) depression predicted the number of relevant means, Beta = .55, t(35) = 2.78, p = . 009, with a significant model explaining approx. 26% of the variance (F (2, 33) = 7.16, p = .003, R 2 = . 30, R 2 Adjusted = .26). Rumination, however, failed to predict the number of relevant means, Beta = .01, t(35) = .03, p = .98. In the resolved condition, depression was also found to predict the number of relevant means, Beta = .56, t(35) = 2.92, p = . 006, with a significant model explaining approx. 32% of the variance (F (2, 33) = 9.11, p = .001, R 2 = . 36, R 2 Adjusted = .32). Rumination, however, again failed to predict the number of relevant means, Beta = .05, t(35) = .27, p = .79. In the unresolved condition, we found that both depression and rumination predicted the number of relevant means, (depression, Beta = .49, t(35) = 4.08, p< . 001; rumination, Beta = .46, t(35) = 3.83, p = .001). A significant model found that both depression and rumination explained approx. 74% of the variance (F (2, 33) = 49.57, p< .001, R 2 = . 75, R 2 Adjusted = .74).

Regression analyses for effectiveness of solutions

Regression analysis revealed that for the baseline condition, depression predicted the effectiveness of the proposed solutions, Beta = .49, t(35) = 2.77, p = . 01, with a significant model explaining approx. 43% of the variance (F (2, 33) = 13.95, p< .001, R 2 = . 46, R 2 Adjusted = .43). Rumination, however, failed to predict the effectiveness of solutions, Beta = .24, t(35) = 1.38, p = .18. For the resolved condition, it was found that both depression and rumination predicted the effectiveness of solutions (depression, Beta = .44, t(35) = 2.67, p = . 01; rumination, Beta = .35, t(35) = 2.12, p = .04). A significant model found depression and rumination explained approx. 50% of the variance (F (2, 33) = 18.16, p< .001, R 2 = .52, R 2 Adjusted = .50). For the unresolved condition, it was found that both depression and rumination predicted the effectiveness of the proposed solutions (depression, Beta = .47, t(35) = 3.20, p< . 01; rumination, Beta = .38, t(35) = 2.59, p = .01). A significant model found that both depression and rumination explained approx. 59% of the variance (F (2, 33) = 26.58, p< .001, R 2 = . 62, R 2 Adjusted = .59). Taken together, these findings suggest whilst depression predicts the effectiveness of the proposed solutions in the baseline condition, both depression and rumination predict the effectiveness of solutions in the resolved and unresolved conditions.

Regression analyses for consequences generated

Regression analysis were also conducted for the consequences that were generated. It was found that for the baseline condition (e.g., when no problems were solved) depression predicted the number of consequences recalled, Beta = .60, t(35) = 3.11, p< . 01. A significant model was found to explaining approx. 32% of the variance (F (2, 33) = 9.16, p< .01, R 2 = . 36, R 2 Adjusted = .32). Rumination, however, failed to predict the recall of consequences, Beta = .004, t(35) = .02, p = .98. In the resolved condition, it was found that depression predicted the number of consequences recalled, Beta = .44, t(35) = 2.34, p = . 03, with a significant model explaining approx. 34% of the variance (F (2, 33) = 10.11, p< . 001, R 2 = . 38, R 2 Adjusted = .34). Rumination, however, failed to predict the recall of consequences, Beta = .23, t(35) = 1.20, p = .24. In the unresolved condition, however, we found that rumination predicted the number of consequences recalled, Beta = .510, t(35) = 2.46, p = . 02, with a significant model suggesting that rumination explained approx. 22% of the variance (F (2, 32) = 5.79, p< .01, R 2 = . 26, R 2 Adjusted = .22). Depression, however, failed to predict recall of consequences, Beta = .01, t(35) = .04, p = .97. Taken together, these findings suggest that whilst depression predicts the recall of baseline and resolved consequences, rumination predicts the recall of unresolved consequences.

Emotional Stroop performance & problem-solving abilities

As depressed and non-depressed groups showed significant differences in only one condition of the Stroop task (i.e., positive word/negative face condition), we correlated depressed participants positive word/negative face accuracy & reaction times with relevant means, effectiveness ratings and recall of consequences across all three conditions: baseline, resolved and unresolved. The analysis revealed that Emotional Stroop accuracy performance was significantly positively correlated with self-reported depression and rumination, as well as with the number of means and effectiveness scores on the problem-solving task and the recall of baseline and resolved consequences. Furthermore, a negative correlation was found for the reaction times to the positive word negative face condition and self-reported depression, self-reported rumination, number of steps generated in the resolved and unresolved conditions, as well as, the effectiveness in the resolved condition. See Table 5 . We also correlated non-depressed participants positive word/negative face accuracy & reaction times with relevant means, effectiveness ratings and recall of consequences across baseline, resolved and unresolved conditions. This analysis only found a significant relationship between positive word/negative face reaction times and recall of unresolved consequences, r (43) = -.31, p = .02; all other tests, p > .05.

https://doi.org/10.1371/journal.pone.0270661.t005

The impact of thinking about the consequences being resolved versus unresolved on social problem-solving

The aim of the current study was to determine whether thinking about the consequences of social problems being resolved or remaining unresolved would have different effects on social problem-solving in a depressed versus non-depressed sample. To this end, we presented participants with a hypothetical problem and asked them to generate consequences of the problem being resolved and remaining unresolved. We also took a baseline measure of social problem solving (i.e., where no consequences were generated). Our study found that the depressed group, compared to the non-depressed group was less effective at generating solutions and produced fewer relevant means in the baseline and unresolved conditions. These findings are consistent with previous research demonstrating that depression has a detrimental impact on social problem-solving [ 3 , 50 ]. The findings are also consistent with Noreen, Whyte & Dritschel [ 23 ] who found that generating the consequences of a problem remaining unresolved impaired social problem-solving in individuals scoring high in depression.

Interestingly, however, we found that there were no significant differences in the effectiveness of generating solutions and the number of relevant means between the depressed and non-depressed group in the resolved condition. Furthermore, we also found that depressed participants generated more relevant means and proposed more effective solutions to the problems in the resolved than baseline conditions. These findings are of clinical importance as they suggest that encouraging depressed individuals to think about the consequences of a problem being resolved prior to problem-solving enhances their ability to solve the problem. Given that research has found that positive problem orientation is an important factor for successful problem-solving [ 26 ], it is possible that thinking about consequences being resolved may naturally induce a positive problem-focused approach. Thus, this style of positive thinking may represent an effective strategy to improve social problem-solving in depression. Furthermore, the fact that depressed individuals were as able as non-depressed participants at generating effective solutions in this condition, suggests that depressed individuals may have intact social skills but, other cognitive-behavioural factors, such as excessive rumination or a negative-problem orientation may render them unable to select and implement these skills effectively.

Examining the relative contributions of depression and rumination on social problem-solving as a function of thinking about the consequences being resolved versus unresolved

The regression analyses revealed that whilst depression predicted the number of relevant means in the baseline and resolved conditions, both depression and rumination predicted the number of relevant means in the unresolved condition. These findings are partially consistent with Noreen, Whyte & Dritschel [ 23 ] who found that depression predicted the number of relevant means in the resolved condition, but only rumination predicted the number of relevant means in the unresolved condition. One reason for the discrepancy in findings may relate to depression severity. The present study consisted of participants that met the diagnostic criteria for clinical depression, whilst Noreen, Whyte & Dritschel’s [ 23 ] study consisted of dysphoric participants scoring high on measures of self-reported depression and rumination. Thus, it may be that more severe levels of depressive symptomology result in impairing social problem-solving abilities. This is consistent with research which has found that depressed individuals are less skilful then nondepressed participants in solving interpersonal problems and report significantly more difficulties in making decisions concerning interpersonal problems [ 4 , 51 – 53 ].

The fact that rumination predicted the number of relevant means in the unresolved but not resolved condition suggests that rumination, when triggered by negative thoughts or consequences, may represent an unsuitable problem-solving strategy in individuals with high levels of depression [ 54 ] and impair social problem-solving. This is consistent with research which suggests that although individuals believe rumination can help solve problems, i.e., by replaying the problem over in one’s mind and appraising it [ 55 ], when rumination is focused on negative thoughts, it can have a debilitating effect on social problem-solving [ 8 ] with individuals perceiving the problem as being more difficult to solve [ 14 ] and being less confident with the solutions they generate [ 56 ]. Thus, in the present study, when participants were asked to generate unresolved consequences, this may have triggered negative ruminative thoughts in the depressed group which led them to believe the problem was more difficult to solve. As a result, they took less steps to attempt to solve the problem.

The regression analyses also found that whilst depression was the only predictor for the effectiveness of the solutions generated in the baseline condition, both depression and rumination predicted the effectiveness of the solutions generated in the resolved and unresolved conditions. These findings are partially consistent with Noreen, Whyte & Dritschel [ 23 ] who found that whilst rumination predicted the effectiveness of the proposed solutions in the unresolved condition, only depression predicted the effectiveness of the solutions in the resolved condition.

One reason why rumination predicted the effectiveness of the proposed solutions in the resolved condition in this study but not Noreen, Whyte & Dritschel’s [ 23 ] study may relate to depression severity and the relationship between rumination and depressive symptoms. Research has found that rumination is associated with more severe and longer episodes of depression [ 57 ] and also predicts the onset of depressive episodes as well as their severity and duration [ 58 – 60 ]. It is important to mention that in Noreen, Whyte & Dritschel’s [ 23 ] study participants had moderate levels of depressive symptoms whilst in this study participants met a diagnostic criterion for depression. Therefore, it is possible that when individuals have moderate levels of depression, ruminative thinking is only triggered when negative information is presented. However, with more severe depression it is possible that both positive and negative information may trigger ruminative thinking. This is consistent with research which suggests that when currently depressed individuals recall positive memories their mood worsens [ 61 ], but when the positive memories are consistent with current view of the self then their mood improves [ 62 ]. Thus, recalling positive memories that are discrepant with current views of the self, worsens mood. It is possible that when depressed individuals think about the resolved consequences they might begin to ruminate about how positive resolution is discrepant with their current situation where they may have interpersonal difficulties. Future research should examine the self-relevancy of the problems to provide further insight on this issue.

The finding that rumination predicts the effectiveness of the solutions is consistent with a large body of research which has found that rumination hampers depressed individual’s problem orientation and problem-solving skills [ 14 , 63 ]; see Nolen-Hoeksema, Wisco & Lyubomirsky [ 64 ] for a comprehensive review). Lyubomirsky & Nolen-Hoeksema [ 12 ], for example, found that by manipulating dysphoric participants response style by encouraging them to focus on their mood state impaired their ability to solve problems on the MEPS compared to dysphoric participants who were distracted from thinking about their mood state [ 14 ]. Taken together, these findings suggest that rumination may account for the deficits in social problem-solving in individuals high in depression.

The fact that our study found that depression, independent of rumination impaired social problem-solving in the unresolved condition may relate to the severity of depressive symptomology. Previous research has found that rumination, rather than depression impaired social problem-solving in individuals with high self-reported levels of depressive symptoms (Noreen, Whyte & Dritschel, [ 23 ]). Given that individuals who took part in the present study met the diagnostic criteria for clinical depression, it is possible that generating consequences for a problem remaining unresolved impairs social problem-solving in only those individuals that have more severe levels of depression. This is consistent with research which suggests that increased severity of depression is related to greater impairments in overall cognitive ability [ 65 ].

Impact of consequence instruction on recall of consequences

We also found that depressed participants recalled significantly more consequences in the unresolved than resolved and baseline conditions. In contrast the non-depressed controls retrieved more resolved than non-resolved consequences. One reason for these findings may relate to the valence of the consequences generated. Participants generated more positive consequences of the problem being resolved and more negative consequences of the problem remaining unresolved. These findings are consistent with research on mood congruency effects which suggests that depressed individuals exhibit enhanced memory for negative material whilst healthy individuals demonstrate the opposite pattern with a memory bias for positive material ([ 66 , 67 ]; see also Matt, Vazquez & Campbell, [ 68 ]) for a review of the early work in the area).

Alternatively, it is possible that depressed individuals may recall more unresolved consequences and be impaired at social problem-solving due to impaired inhibitory control. Indeed, it is possible that generating the consequences of a problem remaining unresolved encourages depressed individuals to ruminate on these consequences. As a result, they may mentally fixate on these items which subsequently impedes the generation of appropriate solutions. This is consistent with research finding that problem-solving relies on the ability to generate appropriate solutions whilst inhibiting inappropriate responses [ 69 , 70 ].

The role of inhibitory control in social problem-solving

The role of inhibitory control in impairing problem-solving is supported by the present findings. Our findings on the Emotional Stroop task revealed that depressed participants were significantly slower and less accurate at responding in the positive word/negative face condition compared to non-depressed participants. Furthermore, we also found that in the depressed group accuracy in this condition was positively correlated with the number of relevant means and the effectiveness of solutions generated on the problem-solving task, as well as self-reported rumination and depression. For response times, however, the opposite pattern of findings was observed with reaction times negatively correlated with the number of relevant means and the effectiveness of solutions generated on the problem-solving task, as well as self-reported rumination and depression. Given that the Stroop task is a measure of sustained attention and the depressed participants showed impairments in the incongruent (positive word/sad face) condition, suggests that depression is associated with an impaired ability to inhibit negative interfering information.

Interestingly, we found no effects of depression on the flanker test which was a measure of inhibitory control of non-valanced material. These findings are consistent with research which has found that both depression and rumination are associated with impairments in tasks that require inhibition of affective content [ 36 , 71 , 72 ]. Indeed, according to Koster, De Lissnyder, Derakshan & De Raedt [ 73 ], difficulty disengaging from negative material increases one’s susceptibility to rumination. Thus, it is possible that impaired cognitive control in depression leads to individuals ruminating on unresolved consequences which subsequently impairs problem-solving and leads to enhanced recall of the unresolved consequences.

Clinical implications

It is important to highlight that our findings have potentially useful clinical implications. The fact that depressed participants showed no deficits at solving social problems compared non-depressed participants when resolved consequences were generated suggests that this may be an effective strategy to improve social problem-solving. Indeed, it is possible that generating resolved consequences results in a more a positive problem orientation style, which is a belief that social problems can be solved with a positive outcome. As positive problem orientation is conceptualised as an adaptive problem-solving strategy (see D’Zurilla & Nezu [ 26 ] for a review), these findings suggest that generating resolved consequences may aid social problem-solving in depression. Furthermore, the fact that positive problem orientation is significantly related to good psychological health, such as adaptive behaviour, positive mood, life satisfaction, and a higher level of subjective well-being [ 25 ], generating resolved consequences prior to problem-solving may actually help to reduce or alleviate sad mood in depression. Future research may wish to investigate the impact of generating resolved consequences on depressed participants subsequent mood and well-being in a therapeutic context. It is important to mention that there may also be other benefits of thinking about the problem being resolved prior to problem-solving. One possibility is that having a more positive problem orientation may encourage greater motivation in thinking about strategies for solving problems. Increasing motivation has been identified as an important factor for increasing engagement with coping strategies that can reduce depression [ 74 ]. Thus, it may be that focusing on thinking about the consequences of a problem being resolved positively increases motivation to engage in more active problem- solving strategies. Future research should look at changes in motivation for solving problems as a function of thinking about the consequences in depression. Another benefit of thinking about the generation of positive consequences is that it might encourage more positive goal-directed imagination. There is evidence that positive goal-directed imagination predicts well-being even after controlling for baseline levels of mental health [ 75 ]. Given that therapists often ask their clients to describe current problems, encouraging them to think about positive resolutions before they think about how to solve the problem could be important to improve not only social problem-solving specifically, but well-being more generally.

Furthermore, given that our findings suggest that poorer inhibitory control on the Stroop task is related to less effective problem solutions in the depressed group, it suggests that interventions such as mindfulness -based interventions (MBI) which influence inhibitory control might be useful for improving problem solving performance in depression. Mindfulness is a form of meditation that involves sustaining attentional focus on a chosen object (e.g., part of your body, sounds, specific thoughts or your breathing) and returning it to this anchor every time your mind starts to wander [ 76 ]. Research has found that mindfulness meditation is effective at enhancing executive control ([ 77 – 79 ]; for a review see Casedas, Pirrucio, Vadillo, [ 80 ]) with inhibitory control being the most consistent executive function that is improved by mindfulness mediation training [ 78 ]. With improved inhibitory control, depressed individuals may more effective at ignoring inappropriate and negative interfering thoughts from memory when trying to generate effective solutions to social-problems Future research should examine the impact of mindfulness on inhibitory control and its subsequent impact on social problem-solving.

Limitations

It is important to mention however that the study does have some limitations. Firstly, although the study used participants that met the diagnostic criteria for clinical depression on the MINI Plus, participants were not clinically diagnosed with depression by a medical professional. Therefore, it is possible that the present findings may not be generalizable to clinically diagnosed depressed individuals. It is, however, important to mention that the MINI Plus is a structured diagnostic tool that is compatible with the diagnostic criteria of DSM-5 and is commonly used in clinical research. Furthermore, the fact that our findings of impaired social problem solving are consistent with previous studies [ 8 ] that have used clinically diagnosed depressed patients also supports the notion that our participants disorder related level of impairment is comparable to clinically depressed patients. It is also worth noting that our participants were also largely university students and therefore may not represent the general population. This is especially true of our depressed sample. By using university students, however, our depressed and non-depressed participants did not differ significantly in age or level of education, thus any differences across groups for social problem solving or inhibitory measures cannot be attributed to these factors. It is also worth noting that there are significantly higher rates of depression in university students compared to the general population [ 81 ], thus, making this population important to study.

An additional limitation concerns determining the impact of depression on social problem-solving relative to other mental disorders. There is evidence that social problem -solving is also impaired by other mental health disorders, such as, social anxiety disorder [ 82 ], eating disorders [ 83 ] and schizophrenia [ 84 ], which can co-occur with depression. In the present study we could not address this issue as we screened our participants for other psychological disorders. Therefore, the present findings cannot be attributed to the presence of any comorbid disorders. Nonetheless, future research may wish to use a larger and more clinically diverse sample size to explore the impact of comorbid disorders on social problem solving. Another limitation of the current study is that we did not ask participants whether they were currently on any psychopharmacological treatments for their depression. Indeed, it is possible that psychopharmacological treatments for depression may lead to individuals demonstrating a different pattern of findings on social problem solving and rumination. Thus, future research may wish to report whether participants are on any treatments and whether this impacts rumination and social problem solving. A final limitation is that the study was not preregistered, however it is important to note that the study predictions were based on robust previous research findings (Noreen, Whyte & Dritschel, [ 23 ]).

In conclusion, our study has found that depressed participants have intact social problem-solving skills when solving problems that they have previously generated resolved consequences for. We also found that depressed participants recalled significantly more consequences in the unresolved than resolved and baseline conditions. These findings suggest that encouraging depressed individuals to think about the consequences of a problem being resolved may be an effective strategy to improve social problem-solving skills in depression. Furthermore, we also found that depressed participants had difficulty disengaging from negative interfering material on an Emotional Stroop task, providing support for an impaired inhibitory control account of social problem-solving in depression. These findings advance our understanding of social problem-solving in depression by providing a more nuanced understanding of the mechanisms underpinning social problem-solving difficulties and have implications for therapeutic interventions.

• 1. D’Zurilla TN, Nezu AMProblem-solving therapy: A social competence approach to clinical intervention. 2 nd ed. New York: Springer; 1999.
• 2. D’Zurilla TJ, Nezu AM, Maydeu-Olivares A. Social problem solving: theory, research, and assessment. In Chang EC, D’Zurilla TJ, Sanna LJ, editors. Social Problem-Solving: Theory, Research, and Training. Washington, DC: American Psychological Association; 2004. pp. 11–27.
• View Article
• PubMed/NCBI
• Google Scholar
• 16. Pyszczynski T, Greenberg J Toward an integration of cognitive and motivational perspectives on social inference: A biased hypothesis-testing model. In Berkowitz Leditor Advances in experimental social psychology, Vol. 20. Academic Press; 1987. pp 297–340. https://doi.org/10.1016/S0065-2601(08)60417-7 .
• 17. Martin LL, Tesser A (Editors) Striving and feeling: Interactions among goals, affect, and self-regulation. Hove: Psychology Press;1996.
• 18. Harvey AG, Watkins E, Mansell W, Shafran RCognitive behavioral processes across psychological disorders: A transdiagnostic approach to research and treatment. New York. Oxford University Press Inc; 2004.
• 19. Beck AT. Cognitive therapy of depression. New York: International Universities Press; 1976.
• 20. Beck AT, Rush AJ, Shaw BFEmery G Cognitive therapy of depression. New York, NY: Guilford Press;1979.
• 26. D’Zurilla TJ Nezu AM Problem-solving therapy: A positive approach to clinical intervention (3rd ed). New York: Springer Publishing;2007.
• 33. Hasher L, Zacks RT Working memory, comprehension, and aging: A review and a new view. In Bower GH (editor) The Psychology of Learning and Motivation, 22, New York: Academic Press. 1988; pp.193–225.
• 40. Beck AT, Steer RA Brown GK (1996 Manual for the beck depression inventory-II. San Antonio, TX: Psychological Corporation; 1996.
• 44. Spielberger CD, Gorsuch RL, Lushene RE. Manual for the state-trait inventory. Palo Alto: Consulting Psychologists Press: 1970.
• 45. Spielberger CD. State-Trait Anxiety Inventory: Bibliography. 2 nd Edition, Palo Alto: Consulting Psychologists Press; 1989.
• 47. Young AW, Perrett D, Calder A, Sprengelmeyer R, Ekman P. Facial expressions of emotion: Stimuli and tests (FEEST). Bury St. Edmunds: Thames Valley Test Company; 2002.
• 48. Ekman P, Friesen WV, Hager JC. Facial action coding system: Manual and Investigator’s Guide. Salt Lake City, UT: Research Nexus; 2002.
• 69. Smith SM (The constraining effects of initial ideas. In: Paulus PB, Nijstad BA, editors. Group creativity: Innovation through collaboration New York, NY: Oxford University Press. 2003; pp 15–31.

Problem-solving therapy for depression: a meta-analysis

Affiliation.

• 1 Stony Brook University, USA. [email protected]
• PMID: 19299058
• DOI: 10.1016/j.cpr.2009.02.003

Problem-Solving Therapy (PST) is a cognitive-behavioral intervention that focuses on training in adaptive problem-solving attitudes and skills. The purpose of this paper was to conduct a meta-analysis of controlled outcome studies on efficacy of PST for reducing depressive symptomatology. Based on results involving 21 independent samples, PST was found to be equally effective as other psychosocial therapies and medication treatments and significantly more effective than no treatment and support/attention control groups. Moreover, component analyses indicated that PST is more effective when the treatment program includes (a) training in a positive problem orientation (vs. problem-solving skills only), (b) training in all four major problem-solving skills (i.e., problem definition and formulation, generation of alternatives, decision making, and solution implementation and verification), and (c) training in the complete PST package (problem orientation plus the four problem-solving skills).

Publication types

• Cognitive Behavioral Therapy / methods*
• Depressive Disorder, Major / psychology
• Depressive Disorder, Major / therapy*
• Problem Solving*

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Cognitive-behavioral therapy for adolescent depression and suicidality

Anthony spirito.

Box G – BH, Division of Clinical Psychology, Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI 02912, 401-444- 1929, 401-455-0516(fax)

Christianne Esposito-Smythers

Department of Psychology, George Mason University, Fairfax, VA 22030, 703-993-2039, 703-993-1359 (fax)

Jennifer Wolff

Department of Psychiatry and Human Behavior ,Rhode Island Hospital /Warren Alpert Medical School of Brown University, 593 Eddy Street, POB 122, Providence, RI 02903, 401-444-3790

Kristen Uhl

Rhode Island Hospital, 593 Eddy Street, POB 122, Providence, RI 02903, 401-444-8587

CBT has emerged as a well-established treatment for depression in children and adolescents but treatment trials for adolescents with suicidality are few in number, and their efficacy to date is rather limited. Although a definitive treatment for adolescent suicide attempters has yet to be established, the limited literature suggests that suicidal thoughts and behavior should be directly addressed for optimal treatment outcome. This chapter reviews the rationale underlying the use of CBT for the treatment of depression and suicidality in adolescents, the literature supporting the efficacy of CBT for depressed adolescents, and whether CBT for depression reduces suicidal thoughts and behavior. A description of some of the core cognitive, affective, and behavioral techniques used in CBT treatments of suicidal ideation and behavior in depressed adolescents is included.

Depression is one of the most common reasons adolescents seek treatment. While there are a number of treatment options available, Cognitive-Behavioral Therapy (CBT) has been the most widely researched psychotherapy approach to treating depression in adolescents. Among depressed adolescents, it is common for these youths to experience suicidal thoughts or engage in suicidal behaviors. While it is evident that such symptoms require psychological treatment, there is some debate over the best means of targeting these distressing thoughts and behaviors. Some clinical researchers have postulated that if you adequately treat the underlying depressive disorder, suicidal ideation and behavior will remit along with the disorder. However, there has been some evidence, with adults, 1 that suggests this is not the case. That is, suicidal thoughts and behavior need to be directly addressed if these problems are to improve. In this chapter we first review the rationale underlying the use of CBT for the treatment of depression and suicidality (defined as suicidal thoughts and suicide attempts) in adolescents. We then briefly review the literature supporting the efficacy of CBT for depressed adolescents. Because there are many excellent recent reviews of the efficacy of CBT for adolescent depression (see below), our review of the depression literature is brief. Instead, we focus primarily on whether CBT for depression reduces suicidal thoughts and behavior. A description of some of the core cognitive, affective, and behavioral techniques used in CBT treatments of suicidal ideation and behavior in depressed adolescents concludes the chapter.

Rationale for treating suicidal states with CBT

A developmentally sensitive cognitive-behavioral model of adolescent suicidal behavior 2 adapted from an adult model of suicidality 3 postulates that suicide attempts emerge from reciprocity among maladaptive cognition, behavior, and affective responses to stressors. This model posits that there is a predisposing vulnerability among youth who attempt suicide, which results from a significant genetic predisposition toward psychopathology 4 and/or exposure to significant negative life events, such as a history of abuse or neglect, 5 adverse parenting resulting from parental psychopathology 6 and peer victimization and bullying. 7 These same factors also place youth at risk for a depressive episode.

Stress, most commonly from an interpersonal conflict, may initially trigger a depressive episode and/or suicidal crisis in predisposed adolescents. In the face of stress, cognitive errors (e.g., catastrophizing, personalization) and negative views of self and the future may occur. Indeed, one study 8 that examined adolescents with a mood disorder in an inpatient setting found higher catastrophizing, personalization, selective abstraction, overgeneralization, and total cognitive errors, in those who were suicidal compared to non-suicidal adolescents with a mood disorder. In addition to cognitively distorting the severity and consequences of the stressor, predisposed youth may also experience difficulties generating and/or viewing solutions to the stressor. Suicidal adolescents report greater difficulty generating and implementing effective alternative solutions to problems compared to non-suicidal adolescents. 9 Suicidal youth are also more likely to view problems as irresolvable. 10 This difficulty in cognitive processing and problem-solving, which is also characteristic of depressed adolescents, can result in negative affect including anger 11 and a worsening of the current mood state. Suicidal adolescents report greater difficulty regulating their internal states and using affect regulation skills compared to non-symptomatic adolescents. 12

In response to distorted cognitive processing, lack of perceived adaptive solutions, and heightened affective arousal related to the stressor, adolescents may engage in maladaptive behavior as a means to cope with the stressor. This may include the use of passive and/or aggressive communication styles and behavior to address stressors resulting from conflict with peers 13 and family members. 14 Self-medication with alcohol or drugs, 15 and non-suicidal self-injury, such as superficially cutting or burning oneself, 16 may also be used as an means to reduce negative affect. The maladaptive behavior chosen may have been modeled by parents, peers, or other important figures in the life of suicidal, depressed adolescents.

Adolescents may cycle through this cognitive, affective, and behavioral process numerous times, with each cycle leading to greater dysfunction and depressed mood. This cycle may take place over a few days, weeks, or even months. Either way, the end result of this cycle, if not interrupted, is intolerable affect and the perception that the situation is hopeless. Adolescents may then begin to experience passive suicidal thoughts, such as “I would be better off dead” which over time may become active suicidal thoughts, and a suicide attempt, with or without prior planning, may result.

Once suicidal behavior occurs, it may sensitize adolescents to future suicide-related thoughts and behavior. 17 Suicidal behavior makes the suicidal cognitive schema more easily accessible and triggered in future stressful situations. 18 Joiner 17 suggests that suicide attempts habituate individuals to the experience of engaging in dangerous self-injurious behavior. When combined with interpersonally-related cognitive distortions, this habituation increases the possibility of future suicidal behavior. Once the taboo against suicide has been broken, it becomes easier to view suicide as a viable solution to life’s problems. CBT may be effective with depressed, suicidal adolescents because it is based on the premise that maladaptive cognitive, behavioral, and affective responses, such as those described in the model above, can be changed.

The efficacy of CBT in the treatment of adolescent depression

CBT treatments for adolescent depression place varying emphasis on the cognitive and behavioral components of care. The behavioral component of treatments for depression emphasizes various skill deficits in the domains of coping skills, interpersonal relationships, social problem solving, and participation in pleasant activities. 19 The cognitive component typically focuses on identifying and challenging schemas, automatic thoughts, and cognitive distortions that cast experiences in an overly negative manner. In all, CBT for depressed adolescents addresses lagging cognitive and behavioral skills that are needed to create and maintain supportive relationships and to regulate emotion.

The first reviews of the efficacy of CBT for adolescent depression demonstrated strong support for the use of CBT with depressed youth 20 21 For example, the effect sizes calculated in early meta-analytic reviews were 1.27 in one study 22 and 1.02 in another study 23 . A more recent meta-analysis of youth depression psychotherapy trials, including both CBT and non-CBT approaches to treatment 24 concluded that the mean effect size of treatment was 0.34 (i.e. somewhere between a small and medium effect). Five studies demonstrated large effects and three of these used CBT. Nonetheless, within the CBT category, effects were quite variable. In another meta-analysis using 11 randomized trials of CBT for adolescents who met diagnostic criteria for unipolar depression 25 , the authors found a mean effect size of .53, i.e. a medium effect. These smaller effects might be a function of the increasing severity of the samples studied or larger methodological differences in trials which can have a substantial influence on effect sizes.

In 2008, a review of the literature was conducted to determine what treatments for childhood depression could qualify as evidence-based. 26 Given that the childhood depression treatment literature includes primarily between group experiments, studies were rated using criteria for between-group designs. Interventions were deemed, from most to least rigorous, as well-established, probably efficacious, or experimental treatments. For a treatment to be considered well-established, there had to be at least two well conducted between group-design experiments, conducted by at least two independent researchers or research teams, which found the treatment to either be superior to pill or psychological placebo or to another treatment, or equivalent to an already established treatment in adequately powered experiments. Further, these studies had to employ treatment manuals and present detailed sample characteristics. Treatments were deemed probably efficacious if they were supported by at least two well conducted between-group experiments that found the treatment to be superior to a wait-list control group, or one or more well conducted experiments, that met the well-established treatment criteria, with the exception of the requirement that the treatment was tested by at least two independent researchers or research teams. Probably efficacious treatments also had to include a treatment manual and well specified sample characteristics. Experimental treatments were defined as treatments with at least one well conducted study that yielded a significant treatment effect. This review of the depression treatment literature 26 concluded that for children and adolescents, group CBT programs, with or without a parent component, are well-established treatment approaches. For adolescents, individual CBT, with or without a parent component, and individual Interpersonal Therapy, were deemed to be “probably efficacious” treatments. Other approaches, such as supportive group therapy and family systems-oriented treatments, were rated as experimental.

Notably, the aforementioned review included the multisite Treatment for Adolescents Depression Study (TADS) 27 , the largest multisite treatment study for adolescent depression. TADS examined the efficacy of four interventions (CBT alone, fluoxetine alone, a combination of both medication and CBT, and placebo pill alone) for adolescents with depression. The study was a randomized, masked effectiveness trial that included 439 adolescents between the ages of 12 and 17. Participants could attend up to 15 sessions during the first 12 weeks of treatment, weekly or biweekly sessions during the next 6 weeks, and booster sessions every 6 weeks thereafter. Results suggest that the combined treatment was more effective (73% response rate) than either fluoxetine alone (62%), CBT alone (48%) or the pill placebo in reducing clinician rated depressive symptoms. Further, fluoxetine alone was superior to CBT alone, and CBT alone was not more effective than placebo. Following 12 weeks of acute treatment, 71% of teens across groups no longer met diagnostic criteria, but 50% had residual symptoms. Follow-up results at longer time periods were more positive for CBT : at week 18, the response rates were 85% for combination therapy, 69% for fluoxetine therapy, and 65% for CBT. At week 36, response rates were 86% for combination therapy, 81% for fluoxetine therapy, and 81% for CBT 28 .

Since the time of this review, 26 several other studies have added to the literature supporting individual CBT for adolescent depression. In the multi-site Treatment of SSRI-Resistant Depression in Adolescents study (TORDIA) 29 , 334 depressed adolescents who failed to respond to a previous trial of a SSRI were randomized to one of four conditions: change to a different SSRI (n = 85), change to a different SSRI plus CBT (n = 83), change to venlafaxine (n = 83), or change to venlafaxine plus CBT (n= 83). CBT participants attended weekly sessions over the first 3 months of treatment then biweekly sessions. Results showed that switching to either medication regiment plus CBT resulted in a higher rate of clinical response (54.8%)than a medication switch alone. (40.5%). Most recently, Goodyer et al. 30 reported data from a study of British adolescents with moderate to severe MDD or probable MDD who had not responded to a brief initial intervention. They were randomized to either receive SSRI plus routine care (n=103) or an SSRI, routine care, and individual CBT (n = 75). At the end of the 12 week acute phase and 28 week maintenance phase, the addition of CBT had no benefit over treatment with the SSRI alone. These results stand in contrast to the TORDIA study which had a similar population of more severely depressed adolescents but did find an additive effect for CBT over medication alone. However, the authors note that there was relatively low attendance in the CBT condition, which may have affected their outcomes. Finally, one additional study 31 randomized 46 youths 11–18 years old who had responded to 12 weeks of fluoxetine to either medication management only (n = 24) or medication management with CBT (n= 22). The addition of CBT lowered the risk of relapse compared to medication management alone.

In sum, CBT for adolescent depression has received considerable support in the research literature. Individual and group CBT, with and without a parent component, appears to be well established and/or efficacious for the majority of participants. The next section will address the use of these treatments in addressing suicidality.

The effects of CBT for adolescent depression on suicidal ideation and attempts

There have been a number of treatment studies on adolescent depression that have examined CBT’s effect on participant suicidality. Below we review primarily studies that were conducted in the last decade. Overall, results have shown that CBT for depression in adolescents is effective in reducing suicidality. In general, these programs teach coping skills and affect regulation techniques that can be applied to suicidal ideation.

More specifically, in one of the first studies, 107 adolescents (13–18 years old) diagnosed with Major Depressive Disorder (MDD) were randomized into one of three treatment groups: individual CBT, Systematic Behavior Family Therapy (SBFT), or individual Nondirective Supportive Therapy (NST) 32 . Each treatment condition consisted of an active phase of 12–16 sessions over 12–16 weeks, and a booster phase of 2–4 sessions over 12–16 weeks. At baseline nearly a third of participants in each condition endorsed current suicidality, while close to 25% had a history of a suicide attempt. Participants in the CBT group showed a lower rate of MDD compared with those in the NST group at the end of the study, and a higher rate of remission than the SBFT group. There was also a significant decrease in suicidality across all three treatment conditions, with the greatest decrease occurring between intake and 6 weeks. These findings suggest that suicidality and depression in adolescents may be reduced through different processes, and that suicidality tends to drop in the early stages of treatment regardless of treatment modality. Similar results were found in a group CBT study 33 with a sample of 88 depressed adolescents, aged 13–18 years, who also had depressed parents. Adolescents exhibited comparable reductions in suicidal ideation, regardless of whether they were randomized to a 16-week group CBT program or care as usual. 33

Suicidal ideation in depressed adolescents has also been examined in studies that evaluate the effectiveness of combined CBT therapy and medication. One study 34 evaluated combined CBT and a Selective Serotonin Reuptake Inhibitor (SSRI) in comparison to either treatment on its own. In this study, 73 adolescents (age 12–18 years) diagnosed with MDD, dysthymic disorder, or depressive disorder not otherwise specified, were randomized to 12 weeks of CBT, CBT and sertraline, or sertraline alone. Results from the three treatment groups showed comparable, statistically significant improvement in suicidal ideation after acute treatment that was maintained at the 6 month follow-up. 34

In another study, 30 208 depressed adolescents (ages 11–17) were randomized into groups that received 12 weeks of both CBT and an SSRI (primarily fluoxetine), or clinical care and SSRI. Suicidality was rated at baseline, 6, 12, and 28 weeks. At each follow-up point, the number of participants experiencing suicidal symptoms and the frequency of these symptoms (thoughts, ideation, attempts, and self-harm) was lower in both groups in comparison to baseline. There was no significant difference found between adolescents receiving SSRIs and clinical care or those receiving CBT along with SSRIs. 30

Treatment with fluoxetine and CBT was also examined in a study of 13–19 year old adolescents with major depression, behavior problems, and substance use disorders 35 . In this study, 126 adolescents were randomized to a fluoxetine and CBT group or a placebo and CBT group. Each group had 16 weekly therapy and medication monitoring sessions. Participant suicidality was assessed monthly and found to be comparable in both groups; however five participants were hospitalized during the course of treatment for increased suicidality (4 in the Fluoxetine-CBT condition). For all five of these participants, suicide severity ratings decreased during the first month of treatment, but worsened during weeks 8 and 12 in response to psychosocial stressors. Thus, although suicidality showed an initial response to treatment, these adolescents did not respond well when additional psychosocial stressors arose. However, given the small number of hospitalizations in this trial, it is difficult to draw conclusions.

Rohde and colleagues 36 examined depressed adolescents, ages 13–17, with comorbid conduct disorder. Depressed adolescents with conduct disorder were randomized to a CBT intervention designed for adolescents with this comorbid symptomatology (CWD-A) or a life skills/tutoring control (LS) program. Each treatment option offered 16 group sessions over 8 weeks. Of the 93 participating adolescents, 40% had a history of suicide attempts. Results showed that CWD-A intervention was initially more effective at reducing MDD than the LS program. However, post-treatment, 6-, and 12-month assessments revealed no significant difference in number of suicide attempts. 36

Two large multisite studies examining combined pharmacotherapy and CBT for MDD, also examined the effects of their protocols on suicidality. In TADS 27 , which was discussed above, 30% of participants had clinically significant suicidal ideation at baseline. At 12 weeks, reductions in suicidality were greater for youth randomized to combination therapy than fluoxetine therapy, CBT only, and the placebo condition, though suicidal ideation was lower than baseline in all conditions. Further, participants who received CBT (4.5%), placebo (5.4%), or combination therapy (8.4%) were less likely to experience a suicidal event during treatment than those who received fluoxetine alone (11.9%). The authors concluded that there was a slight protective effect of CBT on both suicidal ideation and suicidal behavior. At 36 weeks of treatment, suicidal events were more common in patients treated with fluoxetine alone (14.7%), compared with 8.4% for combination therapy and 6.3% for CBT alone in the intent-to-treat analyses. 41

In the multi-site Treatment of SSRI-Resistant Depression in Adolescents study (TORDIA) 29 described previously, 58.5% of participants reported clinically significant suicidal ideation and 23.7% reported a prior suicide attempt. During the trial, suicidal ideation decreased from baseline to post-treatment for participants across all conditions. Approximately 5% of participants attempted suicide and 20% experienced a self-harm related event (suicidal ideation, suicide attempt, self-injurious behavior) during treatment, with no differences across conditions.

In summary, the majority of studies of CBT for depressed adolescents have found a reduction in suicidal ideation regardless of CBT format (i.e., individual, group). It should be noted that reductions in suicidality have also been found in response to family therapy, 32 supportive therapy 32 and pharmacotherapy 30 . 34 Nonetheless, while various forms of therapy resulted in comparable reductions in adolescent suicidality, CBT has shown the most promise in concurrently reducing MDD diagnoses/symptoms and suicidal ideation.

CBT studies specifically treating suicidality in adolescents

Only a few studies have used CBT to specifically treat suicidal ideation and behavior. One study 37 used a quasi-experimental design to compare the treatment efficacy of dialectical behavior therapy (DBT), a treatment to approach that heavily employs cognitive behavioral techniques, to treatment-as-usual (TAU), for suicidal adolescents. The DBT protocol was designed to improve distress tolerance, emotional regulation, and interpersonal effectiveness. Though adolescents in the DBT condition reported more severe baseline symptomatology than those in the TAU condition, they had fewer psychiatric hospitalizations and higher rates of treatment completion than the TAU group at follow-up. No differences were found on repeat suicide attempts. About 40% of adolescents re-attempted over the course of treatment.

In another trial, 38 individual CBT was compared to an individual problem-oriented supportive therapy with adolescents immediately following a suicide attempt. More than half of the sample reported at least one prior suicide attempt. Adolescents were randomized to either 10 sessions of CBT (N = 15) or the problem-oriented supportive treatment (N = 16). The CBT condition focused on teaching adolescents problem solving and affect management skills. Each session included an assessment of suicidality, instruction in a skill, and skill practice (both in-session and homework assignments). Participants were taught steps of effective problem solving and cognitive and behavioral strategies for affect management (e.g., cognitive restructuring, relaxation). Homework assignments were given to assist in skill acquisition and generalization. Participants in both conditions reported significant reductions in suicidal ideation and depression at 3 month follow-up but there were no between-groups differences. At 6 months, both groups retained improvement over baseline but levels of suicide ideation and depression were slightly higher (though not statistically significant) than at 3 month follow-up. Only 5% of adolescents re-attempted during the course of the study.

A more recent study 39 compared an integrated cognitive behavioral treatment (I-CBT; N = 19) protocol for adolescents with co-occurring suicidality (suicidal ideation and/or attempt) and substance use disorders to enhanced treatment as usual (E-TAU; N = 17) in a randomized clinical trial. Approximately 77% of adolescents had a prior suicide attempt and 94% a current depressive disorder. I-CBT included a 6 month active, 3 month continuation, and 3 month maintenance treatment phase. The protocol included individual, parent training, and family therapy sessions and used a two-therapist model. One therapist worked with the adolescent and a second therapist worked with the parents. E-TAU included psychotherapy services through community providers. However, adolescents in both treatment conditions were offered medication management for free with the same study employed child psychiatrist. I-CBT was associated with a lower incidence of suicide attempts (5% in I-CBT vs. 35% in E-TAU) as well as fewer psychiatric hospitalizations, heavy drinking days, and days of cannabis use relative to E-TAU over 18 months. Further, there was a trend for fewer youth in I-CBT than E-TAU to have a depressive disorder (7% vs. 31%) by 18 months. Comparable reductions in adolescent self-report of suicidal ideation, number of drinking days, and depressive symptoms were reported across groups.

In a multi-site study, referred to as Treatment of Adolescent Suicide Attempters (TASA), 40 124 depressed adolescents who made a suicide attempt in the prior three months were entered in one of three conditions: SSRI (n =15), Cognitive-Behavior Therapy for Suicide Prevention (CBT-SP; n =18), or combination therapy (n = 93). Treatment assignment could be random or chosen by study participants. Most participants (84%) chose their treatment condition. CBT-SP incorporated a risk reduction and relapse prevention approach to treatment and integrated CBT techniques, dialectical behavior therapy techniques, and other intervention techniques for depressed youth with suicidality. Participants could attend up to 22 sessions over the course of 6 months, including individual adolescent and conjoint parent-adolescent sessions. All participants showed a significant decrease in suicidal ideation from baseline to the end of treatment. Approximately 12% of participants re-attempted suicide and 19% experienced a suicidal event (suicide attempt, suicide completion, preparatory acts toward suicidal behavior, significant suicidal ideation) during treatment. After controlling for baseline differences across treatment conditions, there was no differential effect of monotherapy versus combination therapy on suicide outcomes. 40

In all, treatment studies that target adolescent suicidality suggest that CBT results in improvements in suicidal ideation and depressed mood, though results are generally comparable to active comparison treatments. Similarly, with one exception, 39 the incidence of suicide attempts rarely differs between CBT and other active interventions. A significant percentage of adolescents re-attempt suicide (5%–40%) during the course of treatment for suicidal behavior.

CBT techniques commonly used to address depression and suicidality

In our studies and treatment manuals for suicidal adolescents, 38 39 individual CBT sessions follow a standard format. They begin with a medication adherence check, if applicable, followed by an assessment of suicidal thoughts or behavior as well as any alcohol or drug use since the last session. If the adolescent does appear to be at significant risk for suicidal behavior, we conduct an assessment of current suicidality, and either review or negotiate a safety plan, adapted from other important work in this area 41 . The safety plan includes a “personal reasons to live” list with at least five reasons to live (e.g., “to have a family of my own and to see my little brother grow up”). A coping card is created in which the adolescent generates a list of strategies that he or she can use in stressful situations, as well as phone numbers to contact in an emergency. A copy of the coping card is given to the adolescent to place in his or her wallet for immediate access.

A typical cognitive-behavioral session that follows the format used in TADS 27 and TORDIA 29 is as follows: the adolescent is first asked to identify an agenda item that will be discussed in the session, homework from the prior session is reviewed, a new skill is introduced or a previously taught skill reviewed, the skill is practiced, the agenda item is discussed and whenever possible the newly taught skill or a previously taught skill is applied to the agenda item. Worksheets and handouts for each skill taught are used to assist in the learning process. All individual sessions also include a parent check-in at the end and a personalized homework assignment is created.

Below, we describe cognitive and behavioral techniques that can be used to address both depression and suicidality in the skill portion of a CBT session. First, we present the approach our group uses to teaching cognitive restructuring and problem-solving, two key cognitive interventions with this population. More details on how to implement these techniques have been described elsewhere. 42 We then describe a number of cognitive techniques specifically useful for suicidalilty which are based on suggestions by Freeman and Reinecke. 43 A more in-depth description of how to adapt these techniques with adolescents is also available. 44 We conclude with a description of affect regulation techniques.

Cognitive Restructuring

In our studies we have modified techniques based on Rational Emotive Therapy 45 for children and adolescents 46 to teach cognitive restructuring. We call our techniques the ABCDE method and introduce this method to adolescents as a skill that helps adolescents deal with negative beliefs or thoughts. Each letter of the ABCDE method stands for a different step in the cognitive restructuring process. The first step in changing negative thought is to identify the A , activating event, that is associated with negative thoughts. In teaching the ABCDE method, the letter C ( C onsequences) is described next to the adolescent as the C onsequences or Feelings related to the A ctivating Event. Next, the adolescent is taught that the B of the ABCDE method stands for B eliefs, and that it is one’s beliefs that lead to negative affect. The adolescent is then taught that, in order to feel better, he/she must confront these negative beliefs or D ispute them. We explain to the adolescent that most people don’t dispute their negative beliefs, are left feeling very upset, and that is when they make unsafe decisions, such as hurting themselves. The last step begins with an E and stands for E ffect. Effecting something is presented as trying to change something. Adolescents are taught that they may not be able to change the fact that a negative activating event happened but they can change negative beliefs and feelings surrounding the event.

When adolescents begin to use this method, the therapist helps the adolescent question the evidence that is used to support a negative view through Socratic questioning. 47 Questions that we commonly use include: Is this belief true? What is the evidence for or against this belief?; Does this belief help you feel the way that you want?; What would your friend say if he/she heard this belief?; and Is there another explanation for this event? This technique is based on findings that suicide attempters often selectively attend to a particular set of evidence which confirms their negative interpretation. We also give the adolescent a handout on “Thinking Mistakes” , e.g., black/white thinking, predicting the worst, missing the positive, feelings as facts, jumping to conclusions, expecting perfection, which we simplified from a similar worksheet for adults. 48 We ask the adolescent to identify any thinking mistakes in his/her beliefs and then to dispute these mistakes.

Problem-Solving

Deficits in problem-solving include difficulty generating alternative solutions and identifying positive consequences of potential solutions. We use the acronym “SOLVE”, 49 to cover the basic steps in problem-solving. We begin with generating a list of triggers for suicidality, typically two to five events, and then the therapist teaches the adolescent the SOLVE system. Each letter in the word SOLVE stands for a different step of the problem-solving process: S stands for “Select a problem,” O for “generate Options,” L for rate the “Likely outcome” of each option, V for choose the “Very best option,” and E stands for “Evaluate” how well each option worked. A worksheet is used to assist in the SOLVE process. The therapist may need to model the skills necessary to progress through the problem-solving steps. The typical depressed adolescent will have difficulties generating “Options” but usually improves with practice. After each option is rated, the therapist helps the adolescent select the “Very best option” or combination of options to try out. Lastly, the adolescent is asked to evaluate how well the process works. If it appears the option will work out well, then this option is selected. If it does not appear to lead to a workable solution, then the adolescent is instructed to go back to the list of “Options,” weigh them again, and pick another option to try. The adolescent does this until a solution to the problem is generated. A simpler version of problem-solving is to ask the adolescent to list the pros and cons of an action such as breaking up with a boyfriend/girlfriend.

When working with adolescents who have attempted suicide, the therapist reframes the suicide attempt as a failure in problem solving. This explanation helps provide adolescents with a better sense of control over future problems that arise. The therapist points out that many teenagers who attempt suicide pick the only option that they think that have, which is to hurt themselves. The therapist emphasizes that the more adolescents practice coming up with a list of “Options”, the more potential solutions they have to choose from when stressed, and the less likely they will feel that the only thing they can do is to hurt themselves.

One contentious aspect of problem-solving is whether to have a suicidal individual include suicide as an option during the brainstorming portion of SOLVE. Some therapists feel that allowing suicide as an option facilitates the problem-solving discussion. Others fear that a cognitively restricted suicidal individual will not be able to generate other options beside kill oneself. Schneidman 50 described one way to include suicide as an option with a suicidal young adult who was pregnant. After allowing his client to list suicide as an option to her problem, Schneidman had her write a list of alternatives without regard to their feasibility, (e.g., have an abortion, put the child up for adoption, raise the child on her own, etc.). Then he had her rank order the options from the least onerous to most onerous. Although she said that none of the options were good ones, this procedure helped her to see that there were other options besides suicide. Moreover, once she no longer ranked suicide as her first or second option, her suicidal ideation decreased significantly.

Other Cognitive Techniques

A number of other techniques to address suicidal thinking have been outlined in detail elsewhere. 43 44 We briefly review a few techniques here. First, re-attribution is a technique that can be used to help the adolescent change the self-statement, “It's all my fault” to a new statement in which responsibility is attributed more appropriately, perhaps to friends or parents, or chance. The therapist may initially support the adolescent's view that it is his/her fault but then asks the adolescent to break down what he/she contributes to the situation and what other people contribute. Second, decatastrophizing helps the adolescent decide whether he/she is overestimating the catastrophic nature of the precipitating event. The therapist asks the adolescent, “What would be the worst thing that will arise if __________ occurs?” “If __________ does occur, how will it affect your life in 3 months? 6 months?” “What is the most likely thing to happen here?” “How will you handle it?” A third cognitive approach is scaling the severity of an event. In this technique, the therapist asks the adolescent to scale the suicidal precipitant or anticipated future stressful event on a scale from 0 to 100. Scaling the severity of an event provides a way for adolescents to view situations along a continuum rather than in a dichotomous fashion.

Affect Regulation Techniques

Affect regulation techniques, i.e. training adolescents to recognize stimuli that provoke negative emotions and teaching them to reduce physiological arousal via self-talk and relaxation, are also commonly used with suicidal adolescents. Below we describe our approach to affect management with suicidal adolescents. Another useful approach to affect management with these adolescents is Dialectal Behavior Therapy 51 a therapy designed to specifically target affect dysregulation in individuals with borderline personality disorder and self-injurious behavior. The reader is referred to the Klein and Miller chapter in this volume for a review of DBT with suicidal adolescents.

In our approach to affect management, we first review the rationale for managing emotions. Specifically, we relate the notion that when negative activating events trigger negative or untrue beliefs, these beliefs can cause depressed mood and anger. These negative feelings can also cause the body to start feeling out-of-control which can be experienced as muscle tightness, a faster heart rate, sweating, or shortness of breath. The more one’s body feels out of control, the harder it is to use problem-solving or dispute negative beliefs. Therefore, it is important to learn ways to keep negative affect under control.

The therapist then shows the adolescent a series of feelings cards and asks him/her to choose the card that best describes how he/she was feeling when a recent event resulted in upset. With suicidal adolescents, it is useful to focus on events that result in suicidal ideation or behavior. Next, the therapist presents the adolescent with a list of physiological and behavioral symptoms associated with negative affect, referred to as “body talk,” and asks the adolescent to pick out the symptoms he/she experienced when in the stressful situation.. The adolescent is then introduced to the concept of a “feelings thermometer.” 52 The bottom of the thermometer has a rating of “1” and stands for “calm and cool” and the top is “10” and stands for “extremely upset” or whatever the predominant feeling, e.g. anger, was for the adolescent at the time of the stressful event. Next, the adolescent is asked to indicate his/her personal “danger zone” on the thermometer or the point where his/her body spirals so far out-of-control that he/she is at risk for unsafe or suicidal behavior. Finally, the adolescent is asked to create a “stay cool” plan to use when he/she begins to notice early “body talk” and negative beliefs to prevent him/her from reaching the point of “extreme upset” and unsafe behavior. Relaxation training is often taught to the adolescent as a means of managing physiologic arousal. There are numerous approaches to relaxation training including progressive muscle relaxation, guided imagery, and autogenics which have been described elsewhere. 53

Anger is a very common emotion experienced by depressed youth who attempt suicide. There are some specific techniques for managing anger that may be useful when dealing with this population. One anger management protocol for adolescents 54 integrates cognitive restructuring and affect regulation technique described previously. Steps in this protocol include identifying the trigger for one’s anger, altering the thoughts which lead to the angry feelings, using self-statements to guide oneself through angry provocations, and relaxation techniques to modulate physiologic arousal. Modeling and behavioral rehearsal are used to help teach the adolescent how to use these skills in anger-provoking situations.

Conclusions

In summary, considerable progress has been made over the past several years in the treatment of depression and suicidality in adolescence. CBT has emerged as a well-established treatment approach for children and adolescents. 26 While the number of efficacy studies for depression has increased, there is still little evidence based information indicating how or why these treatments work. In addition, treatment trials for adolescents with suicidality are few in number, and their efficacy to date is rather limited, especially with regard to repeat suicidal behaviors. Although, a definitive treatment for adolescent suicide attempters has yet to be established, the limited literature suggests that suicidal thoughts and behavior should be directly addressed for optimal treatment outcome. Training adolescents in specific coping skills and affect regulation techniques that can be applied to thoughts and behaviors associated with suicidality, shows some initial promise. However, future trials are necessary to inform best practices in treating this high-risk population.

The authors have nothing to disclose.

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Contributor Information

Anthony Spirito, Box G – BH, Division of Clinical Psychology, Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI 02912, 401-444- 1929, 401-455-0516(fax)

Christianne Esposito-Smythers, Department of Psychology, George Mason University, Fairfax, VA 22030, 703-993-2039, 703-993-1359 (fax)

Jennifer Wolff, Department of Psychiatry and Human Behavior ,Rhode Island Hospital /Warren Alpert Medical School of Brown University, 593 Eddy Street, POB 122, Providence, RI 02903, 401-444-3790.

Kristen Uhl, Rhode Island Hospital, 593 Eddy Street, POB 122, Providence, RI 02903, 401-444-8587.