Why is Major Depressive Disorder (MDD) in teenagers around the world not treated exclusively through talk therapies like Cognitive Behavioural Therapy instead of medicinal intervention?
13 Aralık 2022
Zain Muhammad Hassan
Major Depressive Disorder (MDD) is a form of mental disorder that results in a state of persistent and prolonged feelings of sadness along with a lack of motivation to complete day-to-day tasks and activities. It has been stated that around 11 percent of teenagers around the globe suffer from MDD, with the number being on a constant rise, which leads to performance slumps in school and trouble establishing social relationships, especially among young adolescents (Lu, 2019). Cognitive Behavioral Therapy (CBT) is a form of talk therapy aimed at altering negative behaviors in an individual’s life in order to treat mental illnesses such as panic disorders, depressive disorders, substance abuse issues, and many more. The prevalence of CBT is highest within the United States, according to which 69 percent of therapists employ the use of this form of therapy. CBT targets MDD by directly aiming to alter the behavior of an individual so that persistent, detrimental habits such as smoking, self-harm, or social anxiety can be changed and treated. Over the years, cases of MDD have risen exponentially among teenagers around the globe, but treatment for them has been largely drug-oriented, causing unwanted mental and physical side effects in the short and long term. For this reason, CBT should be used exclusively along with other talk therapies to treat MDD.
Selective Serotonin Reuptake Inhibitors (SSRIs) are a class of drugs used to prolong the duration for which the neurotransmitter Serotonin stays within the brain. This chemical is responsible for maintaining a regular sleep cycle and mood states and regulating levels of motivation. In those with MDD, this chemical may be taken up and removed from the neural circuits within the brain at abnormal levels resulting in adverse symptoms. Hence, SSRIs work by prolonging the duration for which this chemical lingers around. However, it has been identified that SSRIs lead to the recurrence of MDD symptoms in various modes. Vitiello (2009) observed that through mono-treatment involving just the use of SSRIs, there was a higher chance of symptom recurrence than when used with CBT. Additionally, between one-third and one-half of patients are left insufficiently treated with the use of SSRIs only (Vitiello, 2009). These examples illustrate the weaknesses of drug use along with the need for something more than just drugs or medication in order to reduce symptom recurrence within patients. This is significant as it directly relates to how teenagers are prescribed medication and the circumstances in which a drug approach may be necessary. Should the default treatment always lead to drug prescriptions even when symptom recurrence can be imminent? This is where the current system of disorder diagnoses and identification needs to shift in another direction, along with the need for a CBT-exclusive approach to become more viable and visible.
Current systems rely heavily on the efficacy of medications such as SSRIs to be quick resolvers of concurrent symptoms. This means that no matter what specific symptoms a teenager may report, if they match in the slightest with those of MDD, then generalized MDD medication is given. This is highly ineffective because disorders can have inter-lapping symptoms, which can lead to false diagnoses (Klinkman, 1998). A middle ground of depressed or not depressed creates a confusing situation for the psychologist, who has to make that decision based on their intuition if observational data is insufficient. Instead, if an individual-focused approach were taken whereby specific symptoms were carefully examined and compared to those of MDD along with other disorders, prescriptions would be more efficient and accurate for that particular case resulting in lower chances of recurrence. This approach, however, requires a structural shift in the field of mental disorder diagnosis and treatment, where pharmacotherapy is the leading solution today in order to minimize the cost and time along with maximizing the number of patients treated but as will be discussed below this does not always lead to the expected outcomes.
Selective Serotonin Reuptake Inhibitors (SSRIs) such as Fluoxetine and Escitalopram have been identified to cause various negative mental and physical side effects alongside treatment. Research conducted by Dubicka et al. (2010) showed that there were higher suicidal events with the use of Fluoxetine, where eight suicide ideations and two attempts occurred compared with CBT treatment. Additionally, usage of SSRIs leads to the reporting of headaches, nausea, sleep irritability, tiredness, and disinhibition among patients (Dubicka et al., 2010). Furthermore, Citrome (2017) built on the research presented by Dubicka et al. (2010) and illustrated the differences in individual tolerability, which need to be considered for identifying appropriate medication treatment; otherwise, the same negative side effects will occur due to generalization. The adverse side effects of medication for MDD pose a revolutionary stage for a change or alteration in treatment for teenagers as this approach affects current and future generations in terms of their physical and mental capabilities, whereby restrictions created by such medications have the capacity to make the lives of those under treatment just as or even more dull than they were before, under the influence of the disorder. Adolescents should have a vibrant and socially extensive experience of their teenage years where they can be motivated to achieve and progress rather than being confined to the destructive thoughts of their minds, which have no place to escape to. It also poses a critical junction for how we analyze disorders of the mind and behavior. It highlights the potential harm that such drugs are capable of causing, for which the long-term implications remain unknown. It is significant to understand these implications in order to minimize adverse effects and maximize recovery for those suffering from MDD.
It is quite vital to discuss and analyze the efficacy of Cognitive Behavioral Therapy (CBT) when it comes to the treatment of MDD. Keles et al. (2018) conducted research through which they concluded the ability of CBT to effectively treat the symptoms and roots of MDD by stating the fact that symptom recurrence is much lower within CBT usage as the recurrence rate is capped at six months, providing a much longer period of symptom suppression compared to the use of drugs such as SSRI’s. Building on this, Keles et al. (2018) also identify and explain how CBT has the ability to have a widespread effect on teenagers even outside the clinic or treatment location by encouraging peer discussion of mental hardships and therapist conclusions. Vitiello (2009) clearly shows the effectiveness of CBT by illustrating its ability to reduce suicidal tendencies among adolescents successfully. Understanding the efficacy of CBT and how effective it is against disorders such as MDD is crucial to establish a safer and longer-lasting treatment for teenagers suffering from mental illness as it allows the adolescent to understand the situation, discuss it and figure out what kind of solutions are necessary with their therapists but also with their fellow peers who may be going through the same situation, increasing the level of ambition and motivation for treatment. It challenges the idea that CBT or other talk therapies are inadequate for the treatment of MDD in comparison to medication just because they do not have a direct effect on chemical balances. Medication has had the label of being a swift and effective solution for physical ailments, but its ability to properly treat mental disorders is an entirely different aspect of its capabilities. Widespread use of CBT for MDD among teens would result in higher levels of negative mood suppression in the long term, the ability to tackle specific behaviors, allowing the patient to be in the loop of what is happening, and providing a framework of progression for the psychologist or therapist. It also provides a safe space for the individual being treated to express their emotions and concerns openly and extensively, which reduces the levels of suppressed thoughts, behaviors, and negative presumptions present in their minds. This is significant because, in a situation where such thoughts are compressed and kept inside, medication will not do much to resolve the root cause of those negative ideas or let them be free, which leads to those behaviors and thought processes recurring shortly after the discontinuation of medicinal treatment.
A statement that may then be posed against using CBT is that it requires long time frames of action and a comparatively higher cost compared to medicinal treatment. One might say this is a hurdle to using CBT exclusively to treat MDD and that medication works faster and requires lower costs. Further, Dubicka et al. (2010) concluded that the addition of CBT to medicinal treatment did little to change the outcome in a positive or negative way. Although it is true that CBT requires a longer time period in order to take effect and that it does cost considerably more to hold repeat sessions with a therapist, this argument is not entirely valid. Research by Keles et al. (2018) showed that through the use of group CBT techniques whereby patients are put into groups and given simultaneous CBT sessions, the cost could be minimized and considerably reduced. In fact, within the United States, the usage of group CBT has been at the forefront of treating mental depressive disorders in veterans of war with little cost. Furthermore, it can be questioned whether a shorter period of treatment through medication is in any way effective if the recurrence is high. Is immediate treatment really the better option if the patient is left insufficiently treated? CBT, though a long-term approach, has the ability to make sure that recurrence is kept at a minimum and behaviors are altered to remain treated with time. If we accept the former argument, even medicinal use is impractical because the repeated purchase of drugs such as SSRIs would lead to the same level of costs over time as CBT. The physical and mental side effects of using medication are enough reasons to reconsider treatment through the use of CBT instead. To tackle the conclusions of Dubicka et al. (2010), although the results of their study showed no changed effect of CBT inclusion with medication, it can be argued that it is more dependent on the individual under consideration rather than the efficacy of CBT itself because, in studies conducted by Keles et al. (2018) and Vitiello (2009), the conclusions stated the betterment of treatment when CBT was added to the procedures alongside medication.
In conclusion, it seems that the majority of the various experimental and secondary research points towards an optimal method of treating MDD. This involves the combination of various CBT methods, which tackle the behavioral aspect along with the use of different medications targeted at the chemical aspect in order to reach a balanced treatment strategy, whereby both methods are used in co-ordinance with each other to achieve the desired treatment outcome. In all the studies mentioned above, the outcome pointed to the inability of CBT and medication to function effectively by themselves. This provides a balanced conclusion to the question of why CBT is not used exclusively to treat MDD in teenagers because it highlights the fact that although medication has various negative side effects, the best way of treating MDD, as explained by Citrome (2017) is by analyzing individual situations according to specific cases and then deciding the level of medication needed along with the duration of CBT treatment methods which should be employed to treat the illness. It is also important to understand that CBT may not always be completely effective in treating teenagers because different types of personalities and social upbringings can cause the individual not to be interested in the opinion of a peer or even a therapist, as it is typical for teenager behavior. Additionally, effective CBT requires a level of mental maturity and understanding, which may not be entirely present in a developing, young mind making it much harder to convey solutions that can be used to treat certain negative behavior. These evaluations further add to the conclusion drawn above, highlighting the need to establish a balanced system of treatment focused on individual cases.
References
Citrome, L. (2017). Activating and sedating adverse effects of second-generation antipsychotics in the treatment of schizophrenia and major depressive disorder. Journal of Clinical Psychopharmacology, 37(2), 138-147. https://doi.org/10.1097/JCP.0000000000000665
Dubicka, B., Elvins, R., Roberts, C., Chick, G., Wilkinson, P., & Goodyer, I. M. (2010). Combined treatment with cognitive-behavioural therapy in adolescent depression: meta-analysis. The British Journal of Psychiatry: The Journal of Mental Science, 197(6), 433–440. https://doi.org/10.1192/bjp.bp.109.075853
Keles, S., & Idsoe, T. (2018). A meta-analysis of group Cognitive Behavioral Therapy (CBT) interventions for adolescents with depression. Journal of Adolescence, 67, 129–139. https://doi.org/10.1016/j.adolescence.2018.05.011
Klinkman, M. S., Coyne, J. C., Gallo, S., & Schwenk, T. L. (1998). False positives, false negatives, and the validity of the diagnosis of major depression in primary care. Archives of Family Medicine, 7(5), 451–461. https://doi.org/10.1001/archfami.7.5.451
Lu, W. (2019). Adolescent depression: national trends, risk factors, and healthcare disparities. American Journal of Health Behavior, 43(1), 181–194. https://doi.org/10.5993/AJHB.43.1.15
Vitiello, B. (2009). Combined cognitive-behavioral therapy and pharmacotherapy for adolescent depression: Does it improve outcomes compared with monotherapy? CNS drugs, 23(4), 271–280. https://doi.org/10.2165/00023210-200923040-00001