The general question of whether psychotherapy leads to better results than other therapies in children and adolescents with depression can be answered to some degree. Evidence was found for comparisons between psychotherapy and inactive comparator interventions or antidepressant treatment, but not for non-drug comparator interventions such as exercise or relaxation exercises or active monitoring (mental health education).

Both for CBT and for IPT, indications of benefit were found in comparison with inactive controls. Depressive symptoms in children and adults are reduced more effectively by CBT than by inactive controls [38]. This was shown for CBT in general as well as for the subtypes of “mindfulness-based CBT” and “computer-based CBT”, but not for the subtype of “problem-solving therapy” [36,42,47,48]. In a separate analysis of children and adolescents, CBT was found to be more effective than the control condition for each group [38]. Subgroup analyses show that CBT reduces depressive symptoms in children without comorbidities, but not in children with comorbidities. According to a subgroup analysis, CBT is more effective when parents are not involved than when they are [46]. Regarding subgroup analyses which show no statistically significant results, however, it must be noted that, in some cases, very few studies were included per subgroup, and, consequently, the absence of a statistically significant effect might also be due to lack of statistical power. IPT likewise resulted in more effective reduction in depressive symptoms and higher functioning than no active treatment [42,44,47,48]. A subgroup analysis showed that IPT both as one-on-one and group therapy was more effective than no active therapy [44]. Due to wide confidence intervals, no conclusions can be drawn from the evidence on CBT, IPT, or DYN with regard to suicide risk.

The direct comparison with other treatment options showed no evidence of any of the 3 types of psychotherapy being associated with greater or lesser benefit than treatment with an SSRI (typically fluoxetine). CBT, IPT, and DYN were similarly effective as antidepressant therapy in reducing depressive symptoms [37,47]. Likewise, there was no hint that children and adolescents receiving CBT are at lower risk of suicide than those on antidepressants [37].

Likewise, there was no hint of antidepressant therapy with add-on CBT being more effective than antidepressant monotherapy in achieving remission or improvement of depressive symptoms [37]. In the long term, add-on CBT led to better functioning, but this effect was not found in the short term or medium term. With regard to suicide risk and response, antidepressant therapy with add-on CBT did not produce any better results than antidepressant monotherapy [37,40,47]. The identified systematic reviews did not investigate IPT and DYN as add-ons.

None of the included systematic reviews reported on the effects of psychotherapy on mortality, health-related quality of life, or adverse events.

The calculation of intervention costs for the German healthcare context shows that higher direct costs result from psychotherapy than from treatment alternatives. In Germany, CBT and DYN (depth psychology-based and analytical psychotherapy) can be billed to the health insurance funds [13]. For 12 weeks of short-term one-on-one therapy with 12 sessions at 50 minutes or 2 x 25 minutes each, including all component services, the total cost for all CBTs and DYNs range from € 1793.08 to € 2104.68. The billing of IPT costs is not clearly regulated, since IPT is not defined as a guideline-recommended therapy. In clinical practice, however, SHI physicians can often bill its costs to the SHI [98]. The calculated costs for 12 weeks of one-on-one therapy with 12 sessions at 50 minutes or 2 x 25 minutes each, including all component services, equal € 1793.08 to € 2104.68. Fluoxetine is currently the only drug approved in Germany for the pharmacotherapy of depressive children and adolescents 8 years or older. In addition to the cost for the drug itself, costs arise for 1 initial interview, 4 follow-up visits, and 2 complete blood counts. Moreover, responses should be checked after 4 weeks and 8 weeks to document effectiveness and symptoms. In total, 8 weeks of therapy cost between € 311.23 and € 318.47 depending on the required dose (minimum of 10 mg, maximum of 20 mg) and drug product. The costs can be billed to the SHI. As an active monitoring intervention, mental health education was examined in more detail. For 9 units, including 4 units of psychotherapeutic consultation for the accompanying person, the costs total € 659.88. In addition, the costs for relaxation therapy as another nonmedicinal intervention were calculated. Six to 8 weeks of relaxation therapy with 8 to 10 sessions of relaxation therapy at 60 minutes each cost a total of € 349.36 to € 411.32. The cost of mental health education and relaxation exercises are likewise covered by the SHI funds. However, the above figures do not include the diverse (long-term) consequential costs of depression (e.g. lower income in adulthood).

Five studies, all examining CBT, were found on cost effectiveness. They demonstrated CBT not to be cost effective in comparison with no active treatment or antidepressant monotherapy [84]. The same applies to a combination of CBT and antidepressants versus antidepressant monotherapy – but only in the short term; it was in fact cost effective in the long term [84,88]. This concurs with the results of the benefit assessment, which likewise did not derive any greater benefit for CBT versus antidepressant treatment and showed a benefit of add-on CBT regarding the outcome of functioning only in the long term, but not the short term or medium term. Although the studies were not impeded by substantial methodological limitations, the differences between the systems are too great to allow the results to be applied directly to the German healthcare context

The diagnosis of depression presents social, ethical, and organizational challenges. While depression is an established disorder in children and adolescents which can lead to increased vulnerability and can persist into adulthood, it is often recognized late or not at all because other symptoms and comorbidities overlap with the disorder, or depressive symptoms are misinterpreted as typical adolescent behaviour [108,141,142]. Primary care providers such as general practitioners and paediatricians should therefore refer children and adolescents with suspected depression to qualified specialists.

Further reasons for professional help not being utilized by people with mental health issues include uncertainty whether the health problem is sufficiently serious, worries about potential stigmatization, lack of knowledge about contact points and treatment options as well as lack of available services [144]. In Germany, service availability for children and adolescents with depression is better in urban than in rural areas, and the service networks are denser in the west than in the east [151]. Adding qualified professionals as well as raising public awareness of available services might contribute to increasing the treatment rate.

Many people accept psychotherapy as a treatment option [143,145]. Adolescents view psychotherapy as a causative treatment option for their disorder, while antidepressants are perceived as symptomatic treatment [139]. Both parents and adolescents deem psychotherapy as being associated with few risks, while considering antidepressant treatment to be associated with risks such as dependency, loss of autonomy, and self-harming behaviours [139,147]. They fear that as a side effect of psychotherapy, trauma might be reawakened, leading to deterioration of the child’s health [168]. According to the experts, parents also worry about the child having excessive autonomy. Some children and adolescents worry about stigmatization [56].

Psychotherapy aims to strengthen the child’s or adolescent’s autonomy and self-esteem [131,132]. Therefore, it is ethically and legally necessary to obtain the child’s consent from the outset, provided that the child possesses the necessary mental maturity. Voluntary participation and a good, trustful patient-therapist relationship are prerequisites for treatment acceptance and long-term compliance. Although a subgroup analysis shows that psychotherapy without involvement of parents/guardians was more effective, a certain degree of involvement is necessary, especially in younger children. It must be noted, however, that the child’s or adolescent’s interests take priority and might not coincide with the needs of parents/guardians [122]. From an ethical and legal perspective, the duty of confidentiality by which healthcare professionals are bound can lead to conflicts between confidentiality and duties to notify parents or guardians.