CBT-Based Program Decreases Adolescent Depression Severity in Primary Care

The CBT-based COPE program decreased depression severity among adolescents at a primary care clinic during the COVID-19 pandemic.

Implementation of the Creating Opportunities for Personal Empowerment (COPE), a cognitive behavioral therapy (CBT)-based program, decreased depression severity among adolescents treated at a primary care clinic during the COVID-19 pandemic, according to data from a retrospective chart review presented at the National Association of Pediatric Nurse Practitioners (NAPNAP) National Conference on Pediatric Health Care held March 15 to 18, 2023, in Orlando, Florida.

The adolescent depression rates have been steadily increasing over the past 20 years, and this condition is significantly underdiagnosed and undertreated in teens, explained study author Emmalee Gerstenberger, MSN, APRN, CPNP-PC. “We know that nonpharmacologic treatments (such as CBT) can effectively improve or resolve depression in teens, and yet many adolescents still do not get any treatment. When we increase access to these evidence-based treatments, we can hopefully increase the number of adolescents who utilize these treatments, therefore, improving overall health and wellness for these people,” Gerstenberger said.

CBT-Based Program

The COPE program is an intervention for children and teens with depression or anxiety. The version used in this study was the 7-session Teen Manual-Based COPE program; sessions were 30 minutes long. In this study, researchers implemented the COPE program in March 2020 through December 2021 and conducted the sessions via telehealth and in-office visits. The program was implemented over 5 to 18 weeks depending on the patient.

“I was trained to be a COPE provider during my MSN program at Vanderbilt University School of Nursing, and knew that I wanted to try to offer this as an option for depression treatment when I started practicing as a PNP,” explained Gerstenberger.

Of the adolescents that we looked at in this project, seven met criteria for severe depression prior to the COPE program, and none met criteria for severe depression after completion of the program.

One benefit of this program is that it was developed to be delivered by health care providers who are not specialized in mental health. “This expands access to CBT skills for teens in this climate of severe shortage of mental health professionals (counselors, psychiatrists, etc),” Gerstenberger explained.

Researchers’ ability to offer COPE sessions via telehealth and in person visits, further increased access for these teens. “I could see a limitation being the feasibility of incorporating the COPE sessions into primary care flow,” Gerstenberger explained. “However, in the practice that I am working at, we have been able to do this fairly easily. Billing has also not been an issue.”

Although COPE is intended for mild and moderate depression/anxiety, because community wait times to get into counseling were 3 to 6 months, the researchers successfully provided the COPE program to teens with more severe depression “as a bridge to give them some support and skills while they are waiting to get into counseling,” Gerstenberger said. “Of the adolescents that we looked at in this project, 7 met criteria for severe depression prior to the COPE program, and none met criteria for severe depression after completion of the program.”

About the Study Participants

At a privately owned pediatric primary care clinic in the Pacific Northwest, 39 participants aged 12 to 18 years who met the DSM-5 criteria for depression enrolled in the study. Most (85%) of the participants were female; 15% were male, and 95% were White.

Researchers assessed each participant’s depression severity using the Patient Health Questionnaire Modified for Adolescents (PHQ-A): a total of 24 participants completed the PHQ-A both before and after completing the COPE program.

Of the 24 participants who completed both assessments, 7 had severe depression prior to starting COPE, 5 had moderate to severe depression, 8 had moderate depression, and 4 had mild depression.

COPE Program Reduces Depression Severity

After completing the COPE program, none of the adolescents had severe depression, 5 had moderate to severe depression, 5 had moderate depression, 5 had mild depression, and 9 had minimal to no depression (Table).

Table. Depression Severity Before and After COPE Program Implementation

Depression SeverityBaselinePost-COPE Program
Moderately severe55

The change in PHQ-A scores after the COPE Program was statistically significant (P =.00024). In response to a PHQ-A question about suicidal ideation in the past month, the proportion of patients who said they had suicidal thoughts decreased from 29.2% at baseline to 12.5% after the program. 

The results of this study are limited by the small sample size and lack of controls for confounding variables. Researchers did not take into account whether participants were seeing a counselor, taking medication, or had any other psychosocial support at the time they completed the COPE program.

Gerstenberger and colleagues concluded that the COPE program is effective for use in the primary care setting and significantly decreased depression severity among adolescents.

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This article originally appeared on Clinical Advisor


Gerstenberger E, Beaird S, Nelson B, et al. Cognitive behavioral skills intervention decreased adolescent depression severity during the COVID-19 pandemic. Presented at: NAPNAP National Conference; March 15-18, 2023; Orlando, FL.