Review: How has cognitive behaviour therapy been adapted for adolescents with comorbid depression and chronic illness? A scoping review – video abstract by Maria Loades

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Video abstract from Dr. Maria Loades, Clinical Psychologist (HCPC, BPS & BABCP Registered), Senior Lecturer/Clinical Tutor and NIHR Research Fellow, Department of Psychology, University of Bath.

Authors: Alice Morey, Maria E. Loades

First published: 20 September 2020.

Dr. Maria Loades
Dr. Maria Loades

Dr. Maria Loades is a Senior Lecturer/Clinical Tutor for the Doctorate in Clinical Psychology programme at the University of Bath. She is a qualified Clinical Psychologist, working in a variety of mental health settings, including adult mental health, a children’s inpatient unit, and various community CAMHS. She has a post-graduate diploma in CBT for children, young people and families from the Anna Freud Centre/University College London, and a Postgraduate Certificate in the Supervision of Applied Psychology Practice at the University of Oxford. She secured an NIHR doctoral research fellowship in 2016 to further her research into depression in paediatric Chronic Fatigue Syndrome at the University of Bristol, and the Paediatric CFS team at the Royal United Hospital in Bath. Her research interests include: developing and delivering CBT for children and young people with depression, including those with chronic illnesses, therapist competence in delivering CBT, particularly in the field of child and adolescent mental health, and CBT supervision.

Follow on Twitter @MariaLoades


My name is Maria Loades and I’m a senior lecturer in clinical psychology at the University of Bath. In this Review Paper myself and Alice looked at how cognitive behavior therapy has been adapted for adolescents with comorbid depression and chronic illness by doing a scoping review.

So the background is that we know chronic illness, which can be defined as a chronic or long-term health condition lasting for at least three months where a cure is unlikely, is associated with higher than usual levels of depression, particularly in adolescence, around 10 to 20 percent of young people who have a chronic illness also have depression.

Now, these higher rates are more likely because of cognitive and behavioral responses to the illness, biological processes such as inflammation, which might make depression, more likely perhaps shared genetic vulnerability to both conditions, and also things like disruptions to sleep, so the way in which the chronic illness impacts on the young person’s life.

In terms of the aims of our study um we knew that there was emerging evidence for cbt and depression in adolescence with chronic illnesses but we also know that actually cbt might need to be adapted for this population because of two reasons.

One is the relationship between depressive symptoms com chronic illness symptoms are complex, but the other is that actually the symptoms of chronic illness itself might get in the way of doing cbt as we normally would, and prior to our review no review had been undertaken of how studies that have looked at cbt interventions in young people with chronic illness have delivered that cbt in practice, so we aimed to scope the literature to find all the studies that might inform us about that.

We chose to search two of the academic databases and we conducted our searches between May and August of 2019 and we looked to include all the studies we could find that had adolescents who were aged between 11 and 19 years old, who had measured depression at baseline and that exceeded a clinical threshold or where the primary aim of the study was to address depression, those adolescents had a chronic illness that had been going on for at least three months, and the cbt intervention was aimed at the young person.

What we found was 12 studies which spanned a number of different chronic illness conditions including diabetes, inflammatory bowel disease, polycystic ovary syndrome, chronic headache, chronic pain, chronic fatigue syndrome, and fanconi anemia. We found that the delivery of cbt was adapted so for example we found that symptoms like fatigue were accommodated for in the way that cbt was done so um therapists offered shorter sessions or there were shorter simpler worksheets. Families tended to be more involved for a number of reasons so not only to help implement cbt strategies but also to think about the family’s wider narrative about the chronic illness and how that might be contributing to or maintaining the problem, or indeed how it could be used as a protective strategy as a source of resilience and coping for the young person.

There also tended to be more flexibility around how cbt was delivered including telephone sessions, so a combination of things like telephone and face to face, and there was also some adaptations made to scheduling so there might be  cbt sessions to coincide with other visits to a hospital or clinic or to work around those and to work around medical treatments.

There was also changes to the content of the interventions, so we found that there was an expanded focus in the chronic illness context, so psycho was broader so it included thoughts feelings and behaviors associated with chronic illness and links between the chronic illness and mood and cognitive restructuring was also broader, so thought challenging was addressing not only more general negative thoughts but also illness specific thoughts. Stress management tended to focus on links between chronic illness and stress and strategies to reduce stress in the chronic illness context and behavioral activation had to take into account what the young person needed to do in terms of managing their chronic illness.

Relationship building was important not only within the therapy but also with other health professionals that might be involved, and skills building was done dependent on the chronic illness, so for example in diabetes there might be an increased focus on healthy eating or relaxation skills to particularly cope with pain for instance so the implications.

Of this that we drew out are that chronic illness does present some unique barriers to engaging in cognitive behavior therapy and that therapists may need to adapt both the delivery and content of cbt when working with a young person who’s depressed who’s also got a chronic illness.

If you’d like any more information or to read our paper um our paper is published in Child and Adolescent Mental Health but please also do tweet me or email me at the University of Bath.

Many thanks.

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