A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy

Recovery and recurrence following treatment for adolescent major depression

CONTEXT

Major depressive disorder in adolescents is common and impairing. Efficacious treatments have been developed, but little is known about longer-term outcomes, including recurrence.

OBJECTIVES

To determine whether adolescents who responded to short-term treatments or who received the most efficacious short-term treatment would have lower recurrence rates, and to identify predictors of recovery and recurrence.

DESIGN

Naturalistic follow-up study.

SETTING

Twelve academic sites in the United States.

PARTICIPANTS

One hundred ninety-six adolescents (86 males and 110 females) randomized to 1 of 4 short-term interventions (fluoxetine hydrochloride treatment, cognitive behavioral therapy, their combination, or placebo) in the Treatment for Adolescents With Depression Study were followed up for 5 years after study entry (44.6% of the original Treatment for Adolescents With Depression Study sample).

MAIN OUTCOME MEASURES

Recovery was defined as absence of clinically significant major depressive disorder symptoms on the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version interview for at least 8 weeks, and recurrence was defined as a new episode of major depressive disorder following recovery.

RESULTS

Almost all participants (96.4%) recovered from their index episode of major depressive disorder during the follow-up period. Recovery by 2 years was significantly more likely for short-term treatment responders (96.2%) than for partial responders or nonresponders (79.1%) (P < .001) but was not associated with having received the most efficacious short-term treatment (the combination of fluoxetine and cognitive behavioral therapy). Of the 189 participants who recovered, 88 (46.6%) had a recurrence. Recurrence was not predicted by full short-term treatment response or by original treatment. However, full or partial responders were less likely to have a recurrence (42.9%) than were nonresponders (67.6%) (P = .03). Sex predicted recurrence (57.0% among females vs 32.9% among males; P = .02).

CONCLUSIONS

Almost all depressed adolescents recovered. However, recurrence occurs in almost half of recovered adolescents, with higher probability in females in this age range. Further research should identify and address the vulnerabilities to recurrence that are more common among young women.

Screening and managing depression in adolescents

Approximately 10%-15% of adolescents will experience a major depressive episode. The risk factors associated with depression in adolescence include a family history of depression, being female, subthreshold depression, having a nonaffective disorder, negative cognitions, interpersonal conflict, low social support, and stressful life events. Despite the availability of measures to identify depressed adolescents and efficacious interventions to treat these adolescents, a large number of depressed adolescents go undetected and untreated. This review describes several screening measures that can be used to identify adolescents with elevated depression symptoms who would benefit from a comprehensive diagnostic evaluation. If an adolescent is diagnosed with a depressive disorder, there are several efficacious treatment options, including pharmacotherapy, cognitive behavior therapy, and interpersonal psychotherapy. The research supporting each of these approaches is outlined, and recommendations are made to help health professionals determine the appropriate course of treatment. Although existing treatments are effective for many depressed adolescents, approximately one-third of adolescents remain depressed following treatment. Continuing research is needed to enhance the efficacy of existing treatments for adolescent depression and to develop and study novel treatment approaches.

Reward-related brain function as a predictor of treatment response in adolescents with major depressive disorder

The present study provides preliminary evidence that pretreatment reward-related brain function in the striatum and medial prefrontal cortex (PFC) could have relevance for predicting both final level and rate of change of clinical characteristics in adolescents with major depressive disorder. Adolescents with depression underwent a functional MRI scan during a monetary reward task, participated in an 8-week open trial of cognitive behavioral therapy (CBT) or CBT plus selective serotonin reuptake inhibitor, and completed reports of anxiety and depressive symptoms before, during, and after treatment. Clinicians rated adolescents' improvement and severity at the same time points. Growth models were used to examine change in clinical characteristics and its association with brain function. Severity, anxiety symptoms, and depressive symptoms decreased over treatment. Final levels of severity and anxiety symptoms were associated with pretreatment striatal reactivity, and rate of anxiety symptom reduction was associated with greater striatal reactivity and lower medial PFC reactivity.

Improving access to care and clinical outcome for pediatric behavioral problems: a randomized trial of a nurse-administered intervention in primary care

OBJECTIVE

To determine the effectiveness of an on-site modular intervention in improving access to mental health services and outcomes for children with behavioral problems in primary care relative to enhanced usual care. The study includes boys and girls from six primary care offices in metropolitan Pittsburgh, PA.

METHODS

One hundred sixty-three clinically referred children who met a modest clinical cutoff (75th percentile) on the externalizing behavior scale of the Pediatric Symptom Checklist-17 were randomized to a protocol for on-site, nurse-administered intervention or to enhanced usual care. Protocol for on-site, nurse-administered intervention applied treatment modules from an evidence-based specialty mental health treatment for children with disruptive behavior disorders that were adapted for delivery in the primary care setting; enhanced usual care offered diagnostic assessment, recommendations, and facilitated referral to a specialty mental health provider in the community. The main outcome measures such as standardized rating scales, including the Pediatric Symptom Checklist-17, individualized target behavior ratings, treatment termination reports, and diagnostic interviews were collected.

RESULTS

Protocol for on-site, nurse-administered intervention cases were significantly more likely to receive and complete mental health services, reported fewer service barriers and more consumer satisfaction, and showed greater, albeit modest, improvements on just a few clinical outcomes that included remission for categorical behavioral disorders at 1-year follow-up. Both conditions also reported several significant improvements on several clinical outcomes over time.

CONCLUSIONS

A psychosocial intervention for behavior problems that was delivered by nurses in the primary care setting is feasible, improves access to mental health services, and has some clinical efficacy. Options for enhancing clinical outcome include the use of multifaceted collaborative care interventions in the pediatric practice.

Interpersonal Psychotherapy for Depressed Adolescents (IPT- A): Extending the Reach from Academic to Community Settings1

Depression is a persistent and impairing illness for adolescents. Many adolescents have limited access to care and/or do not receive adequate treatment for their depression. Researchers have developed a number of empirically supported interventions for adolescent depression; the challenge is to bring these treatments into community settings and assess their effectiveness under real world conditions. This paper provides a critical examination of research conducted on the use of Interpersonal Psychotherapy for depressed adolescents (IPT-A). The paper presents evidence for the efficacy and effectiveness of IPT-A. Implementation and dissemination efforts are discussed in regard to lessons learned and directions for future research.

Randomised controlled trial of school-based humanistic counselling for emotional distress in young people: feasibility study and preliminary indications of efficacy

AIMS

The purpose of this study was to test the feasibility of a randomised controlled trial comparing six weeks of humanistic school-based counselling versus waiting list in the reduction of emotional distress in young people, and to obtain initial indications of efficacy.

METHODS

Following a screening procedure, young people (13 - 15 years old) who experienced emotional distress were randomised to either humanistic counselling or waiting list in this multi-site study. Outcomes were assessed using a range of self-report mental health measures, with the emotional symptoms subscale of the Strengths and Difficulties Questionnaire (SDQ) acting as the primary outcome indicator.

RESULTS

Recruitment procedures were successful, with 32 young people consenting to participate in the trial and 27 completing endpoint measures. Trial procedures were acceptable to all involved in the research. No significant differences were found between the counselling and waiting list groups in reductions in levels of emotional symptoms (Hedges' g = 0.03), but clients allocated to counselling showed significantly greater improvement in prosocial behaviour (g = 0.89) with an average effect size (g) across the nine outcome measures of 0.25. Participants with higher levels of depressive symptoms showed significantly greater change.

CONCLUSION

This study suggested that a randomised controlled trial of counselling in schools is acceptable and feasible, although initial indications of efficacy are mixed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68290510.

Effective components of TORDIA cognitive-behavioral therapy for adolescent depression: preliminary findings

In this report, we conducted a secondary analysis of the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study to explore the impact of specific cognitive-behavioral therapy (CBT) treatment components on outcome. In TORDIA, 334 youths (ages 12 to 18 years) with major depressive disorder who had failed to respond to an adequate course of selective serotonin reuptake inhibitor (SSRI) medication were randomized to a medication switch (either to an alternative SSRI or venlafaxine) with or without 12 weeks of adjunctive CBT. Participants who had more than 9 CBT sessions were 2.5 times more likely to have adequate treatment response than those who had 9 or fewer sessions. CBT participants who received problem-solving and social skills treatment components, controlling for number of sessions and other confounding variables, were 2.3 and 2.6 times, respectively, more likely to have a positive response. These preliminary findings underscore the importance of receiving an adequate number of sessions to attain an adequate clinical response. Finally, social skills and problem solving may be active elements in CBT for adolescent depression and should be considered in treatment by those working with seriously depressed youths.

The adolescent transplant recipient

Adolescents constitute a significant proportion of pediatric transplant patients, whether they have survived a transplant in early childhood (like most heart and liver recipients) or are transplanted in older childhood or adolescence, such as many renal transplant recipients. Their needs can be significantly different from either children or adults, as they are undergoing a major transformation that involves making educational and vocational decisions and commitments, establishing a new and more equal relationship with their parents, discovering their sexual identity, taking increasing responsibility for their health and creating the moral, philosophic, and ethical perspective that they will carry through their lives. This article discusses adolescent issues in transplantation.

Attachment-based family therapy for adolescents with suicidal ideation: a randomized controlled trial

OBJECTIVE

To evaluate whether Attachment-Based Family Therapy (ABFT) is more effective than Enhanced Usual Care (EUC) for reducing suicidal ideation and depressive symptoms in adolescents.

METHOD

This was a randomized controlled trial of suicidal adolescents between the ages of 12 and 17, identified in primary care and emergency departments. Of 341 adolescents screened, 66 (70% African American) entered the study for 3 months of treatment. Assessment occurred at baseline, 6 weeks, 12 weeks, and 24 weeks. ABFT consisted of individual and family meetings, and EUC consisted of a facilitated referral to other providers. All participants received weekly monitoring and access to a 24-hour crisis phone. Trajectory of change and clinical recovery were measured for suicidal ideation and depressive symptoms.

RESULTS

Using intent to treat, patients in ABFT demonstrated significantly greater rates of change on self-reported suicidal ideation at post-treatment evaluation, and benefits were maintained at follow-up, with a strong overall effect size (ES = 0.97). Between-group differences were similar on clinician ratings. Significantly more patients in ABFT met criteria for clinical recovery on suicidal ideation post-treatment (87%; 95% confidence interval [CI] = 74.6-99.6) than patients in EUC (51.7%; 95% CI = 32.4-54.32). Benefits were maintained at follow-up (ABFT, 70%; 95% CI = 52.6-87.4; EUC 34.6%; 95% CI = 15.6-54.2; odds ratio = 4.41). Patterns of depressive symptoms over time were similar, as were results for a subsample of adolescents with diagnosed depression. Retention in ABFT was higher than in EUC (mean = 9.7 versus 2.9).

CONCLUSIONS

ABFT is more efficacious than EUC in reducing suicidal ideation and depressive symptoms in adolescents. Additional research is warranted to confirm treatment efficacy and to test the proposed mechanism of change (the Family Safety Net Study).Clinical Trial Registry Information: Preventing Youth Suicide in Primary Care: A Family Model, URL: http://www.clinicaltrials.gov, unique identifier: NCT00604097.

Effects of befriending on depressive symptoms and distress: systematic review and meta-analysis

BACKGROUND

High rates of emotional distress and depressive symptoms in the community can reflect difficult life events and social circumstances. There is a need for appropriate, low-cost, non-medical interventions for many individuals. Befriending is an emotional support intervention commonly offered by the voluntary sector.

AIMS

To examine the effectiveness of befriending in the treatment of emotional distress and depressive symptoms.

METHOD

Systematic review of randomised trials of interventions focused on providing emotional support to individuals in the community.

RESULTS

Compared with usual care or no treatment, befriending had a modest but significant effect on depressive symptoms in the short term (standardised mean difference SMD = -0.27, 95% CI -0.48 to -0.06, nine studies) and long term (SMD = -0.18, 95% CI -0.32 to -0.05, five studies).

CONCLUSIONS

Befriending has a modest effect on depressive symptoms and emotional distress in varied patient groups. Further exploration of active ingredients, appropriate target populations and optimal methods of delivery is required.

Predictors of placebo response in randomized controlled trials of psychotropic drugs for children and adolescents with internalizing disorders

OBJECTIVE

The aim of this study was to assess predictors of placebo response in all available short-term, placebo-controlled trials of psychotropic drugs for children and adolescents with internalizing disorders, major depressive disorder (MDD), obsessive compulsive disorder (OCD,) and anxiety disorders (ANX) exclusive of OCD and posttraumatic stress disorder (PTSD).

METHOD

We reviewed the literature relevant to the use of psychotropic medication in children and adolescents with internalizing disorders, restricting our review to double-blind studies including a placebo arm. Placebo response, defined according to each trial's primary response outcome variable and Clinical Global Impressions-Improvement, when available, and potential predictive variables were extracted from 40 studies.

RESULTS

From 1972 to 2007, we found 23 trials that evaluated the efficacy of psychotropic medication involving youth with MDD, 7 pertaining to youths with OCD, and 10 pertaining to youths with ANX (N = 2,533 patients in placebo arms). For all internalizing disorders combined, predictors of nonresponse to placebo were the percentage of Caucasian patients included in the study and the duration of the disorder: Both variables were negatively correlated with the percent of placebo responders. The type of disorder was found to predict the robustness of placebo response: (OCD < ANX < MDD). For a subset of MDD studies, we found that baseline illness severity tended to be negatively correlated with placebo response. Finally, trial "success" was significantly associated with lower placebo response rate.

CONCLUSION

Predictors of placebo response in internalizing disorders of youths parallel those in adult studies, with the exception of race. These predictors should be considered when designing placebo-controlled trials in youths to enhance findings of true drug-placebo differences.

Youth suicide prevention: does access to care matter?

PURPOSE OF REVIEW

Recent increases in adolescent suicide rates after a decade of decline highlight the relevance of pediatric suicide prevention. Existing strategies to intervene with youth at risk for suicide are largely based on the premise that access to effective services is of critical importance. This review aims to examine the relationship between youth suicide and access to care.

RECENT FINDINGS

Promising reductions in suicidal thinking and behavior have been associated with the application of manualized psychotherapies, collaborative interventions in primary care, lithium for mood-disordered adults, and clozapine in schizophrenia. Suicide rates correlate inversely with indices of care access across the lifespan, including antidepressant prescription rates.

SUMMARY

Suicide is a preventable cause of death, and any public health relevant effort to prevent youth suicide must include improving access to effective care for at-risk youth as a strategy. Education and training of professionals and consumers, the integration of mental health services in primary care, and the use of novel technologies to track and maintain contact with at-risk youth are worthy of study. Additional research on the relationship between specific treatments, especially antidepressants, and youth suicide risk reduction is desperately needed.

Double-blind placebo-controlled trial of fluoxetine in adolescents with comorbid major depression and an alcohol use disorder

OBJECTIVE

This study compared the acute phase (12-week) efficacy of fluoxetine versus placebo for the treatment of the depressive symptoms and the drinking of adolescents with comorbid major depression (MDD) and an alcohol use disorder (AUD). We hypothesized that fluoxetine would demonstrate efficacy versus placebo for the treatment of both the depressive symptoms and the drinking of comorbid MDD/AUD adolescents.

METHODS

We conducted the first double-blind placebo-controlled study of fluoxetine in adolescents with comorbid MDD/AUD. All participants in both treatment groups also received intensive manual-based Cognitive Behavioral Therapy (CBT) and Motivation Enhancement Therapy (MET).

RESULTS

Fluoxetine was well tolerated in this treatment population. No significant group-by-time interactions were noted for any depression-related or drinking-related outcome variable. Subjects in both the fluoxetine group and the placebo group showed significant within-group improvement in both depressive symptoms and level of alcohol consumption. End-of-study levels of depression and drinking were low in both treatment groups.

CONCLUSIONS

The lack of a significant between-group difference in depressive symptoms and in drinking may reflect limited medication efficacy, or may result from limited sample size or from efficacy of the CBT/MET psychotherapy. Large multi-site studies are warranted to further clarify the efficacy of SSRI medications in this adolescent MDD/AUD population.

Prevention of depression in at-risk adolescents: a randomized controlled trial

CONTEXT

Adolescent offspring of depressed parents are at markedly increased risk of developing depressive disorders. Although some smaller targeted prevention trials have found that depression risk can be reduced, these results have yet to be replicated and extended to large-scale, at-risk populations in different settings.

OBJECTIVE

To determine the effects of a group cognitive behavioral (CB) prevention program compared with usual care in preventing the onset of depression.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter randomized controlled trial conducted in 4 US cities in which 316 adolescent (aged 13-17 years) offspring of parents with current or prior depressive disorders were recruited from August 2003 through February 2006. Adolescents had a past history of depression, current elevated but subdiagnostic depressive symptoms, or both. Assessments were conducted at baseline, after the 8-week intervention, and after the 6-month continuation phase.

INTERVENTION

Adolescents were randomly assigned to the CB prevention program consisting of 8 weekly, 90-minute group sessions followed by 6 monthly continuation sessions or assigned to receive usual care alone.

MAIN OUTCOME MEASURE

Rate and hazard ratio (HR) of a probable or definite depressive episode (ie, depressive symptom rating score of > or = 4) for at least 2 weeks as diagnosed by clinical interviewers.

RESULTS

Through the postcontinuation session follow-up, the rate and HR of incident depressive episodes were lower for those in the CB prevention program than for those in usual care (21.4% vs 32.7%; HR, 0.63; 95% confidence interval [CI], 0.40-0.98). Adolescents in the CB prevention program also showed significantly greater improvement in self-reported depressive symptoms than those in usual care (coefficient, -1.1; z = -2.2; P = .03). Current parental depression at baseline moderated intervention effects (HR, 5.98; 95% CI, 2.29-15.58; P = .001). Among adolescents whose parents were not depressed at baseline, the CB prevention program was more effective in preventing onset of depression than usual care (11.7% vs 40.5%; HR, 0.24; 95% CI, 0.11-0.50), whereas for adolescents with a currently depressed parent, the CB prevention program was not more effective than usual care in preventing incident depression (31.2% vs 24.3%; HR, 1.43; 95% CI, 0.76-2.67).

CONCLUSION

The CB prevention program had a significant prevention effect through the 9-month follow-up period based on both clinical diagnoses and self-reported depressive symptoms, but this effect was not evident for adolescents with a currently depressed parent.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00073671.

A critical evaluation of the role of cognitive behaviour therapy in children and adolescents with depression

Depressive disorders are relatively common in adolescents although less so in younger children. They accrue significant morbidity and frequent long-term sequelae as well as increased suicide risk in sufferers. Evidence-based treatment of depression in children and adolescents is the subject of intense investigation and debate. This article reviews the current evidence base for cognitive behaviour therapy in this group and makes recommendations for further areas of research.

Cognitive-behavioral therapy versus usual clinical care for youth depression: an initial test of transportability to community clinics and clinicians

Community clinic therapists were randomized to (a) brief training and supervision in cognitive-behavioral therapy (CBT) for youth depression or (b) usual care (UC). The therapists treated 57 youths (56% girls), ages 8-15, of whom 33% were Caucasian, 26% were African American, and 26% were Latino/Latina. Most youths were from low-income families and all had Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) depressive disorders (plus multiple comorbidities). All youths were randomized to CBT or UC and treated until normal termination. Session coding showed more use of CBT by CBT therapists and more psychodynamic and family approaches by UC therapists. At posttreatment, depression symptom measures were at subclinical levels, and 75% of youths had no remaining depressive disorder, but CBT and UC groups did not differ on these outcomes. However, compared with UC, CBT was (a) briefer (24 vs. 39 weeks), (b) superior in parent-rated therapeutic alliance, (c) less likely to require additional services (including all psychotropics combined and depression medication in particular), and (d) less costly. The findings showed advantages for CBT in parent engagement, reduced use of medication and other services, overall cost, and possibly speed of improvement--a hypothesis that warrants testing in future research.

University students' suicidal thoughts and influencing factors

This research was planned as a descriptive study for the purpose of examining the suicidal thoughts of first-year university students and the factors that might affect them. The research was conducted with the participation of first-year students (class of 1992) at Ege University between January 2003 and October 2004. The research data were collected on a form prepared by the researcher to determine the university students' socio-demographic characteristics and their suicidal thoughts, the trait anger, expression of anger inventory and the brief symptom inventory. It was determined that 2.4% of the students had suicidal thoughts, and 11.2% of the students had previously attempted suicide. The risk factors of the students' suicidal thoughts were determined to be issues of gender, school problems, family relationships, anger expression, somatization, hostility, psychotic symptoms, phobic anxiety, anxiety disorder and interpersonal sensitivity.

Effectiveness of psychoanalytic psychotherapy for adolescents with serious mental illness: 12 month naturalistic follow-up study

OBJECTIVE

The aim of this naturalistic longitudinal study was to examine the effectiveness of individual psychoanalytic psychotherapy in reducing symptoms and improving overall functioning for adolescents with severe mental illness beyond the changes observed with treatment as usual. Changes to family functioning were also examined.

METHOD

Participants at 12 month follow up were 55 of an initial group of 80 Child and Adolescent Mental Health Services patients with complex, severe mental illness (32 female, mean age = 15.11 years). At initial assessment 40 participants were offered psychoanalytic psychotherapy when a psychotherapist became available; 23 accepted and received once- or twice-weekly psychoanalytic psychotherapy for 4-12 months. Out of the initial 57 participants who received Child and Adolescent Mental Health Services treatment as usual, 33 were reassessed at 12 months. Self-reported depressive symptoms, parent-reported social and attention problems and researcher-evaluated overall functioning and family functioning were measured at initial assessment and 12 months later.

RESULTS

At 12 months, psychotherapy was associated with a greater reduction in depressive, social and attention problems than treatment as usual, alone, if these problems were initially in the clinical range. There was no effect on participant overall functioning or family functioning.

CONCLUSIONS

This naturally occurring sample of seriously ill adolescents referred to Child and Adolescent Mental Health Services for assessment were suffering complex mental illness and poor mental health. Empirical evidence is presented that psychoanalytic psychotherapy is an effective addition to Child and Adolescent Mental Health Services treatment as usual for mental illness in adolescence, particularly for more severe and complex cases. The naturalistic study design and participant attrition are possible study limitations.

The prevention of depression in children and adolescents: a review

OBJECTIVE

To review the recent literature on the prevention of clinical diagnoses of depression in children and adolescents.

METHOD

Several preventive intervention programs targeting depressive diagnoses in youth were reviewed. These programs based their prevention strategies on cognitive-behavioural and (or) interpersonal approaches, which have been found to be helpful in the treatment of depression. In addition, family-based prevention strategies were reviewed. Also, nonspecific risk factors for youth depression, including poverty and child maltreatment, were discussed as important considerations in prevention programs targeting youth depression.

RESULTS

In general, successful prevention programs targeting youth depression are based on evidence-based treatment programs for youth depression, structured and outlined in manuals, involve careful training of personnel implementing the protocols, and include assessment of fidelity to the intervention protocols. The programs were consistent with cognitive-behavioural and (or) interpersonal psychotherapy traditions. Overall, it appears that there is reason for hope regarding the role of interventions in preventing depressive disorders in youth.

CONCLUSIONS

Several new directions for future research on the prevention of depression in youth were outlined. Future research is needed to establish an empirical base for the prevention of depression in high-risk youth and should: focus on targeted and indicated prevention approaches, attend to moderators of intervention effects, include approaches that aim to enhance the family environment, attend to nonspecific risk factors for disorder, and focus on the dissemination phase of prevention research.

Family processes in the development of youth depression: translating the evidence to treatment

There is strong evidence that family factors play a role in the development, maintenance and course of youth depression. However, to date few clinical trials of psychotherapy for youth depression employ family therapy interventions or target the known family risk factors. This is surprising given recent meta-analytic findings showing only modest effect sizes for psychotherapy for youth depression, and that cognitive therapies do not outperform non-cognitive therapies. The aim of this review is to 1) use a developmental systems approach to review empirical evidence on family risk factors for youth depression to identify potential targets for treatment, 2) examine the extent to which these family risk factors have been targeted in clinical trials for youth depression, and 3) provide a road map for the development of empirically validated family-based interventions for youth depression. Strong evidence was found supporting a relationship between family factors at multiple system levels and depressive symptoms or disorders. Support for several different hypothesized causal mechanisms as well as bidirectional effects was found. A comparison of the identified risk factors and psychotherapy trials for youth depression indicated that few RCT's target family factors; among those that do, only a few of the family risk factors are targeted. Recommendations for translation of empirical knowledge of family risk factors and mechanisms to develop empirically valid family-based interventions to enhance existing treatments for youth depression are provided.

Effectiveness of cognitive-behavioral therapy on depressive symptomatology, stress and coping strategies among Jordanian university students

The study examined the effectiveness of cognitive behavioral therapy (CBT) with university students suffering from moderate to severe depressive symptoms in Jordan. Eighty-four university students were recruited and assigned randomly to control and intervention groups. Intervention impact was assessed on measures of depressive symptoms, perceived stress, and coping strategies at three time points; baseline, postintervention, and 3-months postintervention. The interventional model used was the Modified Teaching Kids to Cope (MTKC), and the control group received no treatment. Overall, using CBT showed a significant improvement in the outcome measures. At postintervention, students had lower scores on perceived stress, lower depressive symptoms, less use of avoidance coping strategies, and more use of approach coping strategies. The findings are discussed in terms of treatment implications and recommendations for use at academic and health care settings.

Cognitive-behavioral therapy and dialectical behavior therapy; adaptations required to treat adolescents

Conducting psychotherapy with adolescents is qualitatively different from psychotherapy with adults. Cognitive-behavioral therapy and dialectical behavior therapy are two types of psychotherapy commonly used in the treatment of adolescents. A brief review of the current state of research on these treatments is provided with a focus on anxiety disorders and depressive disorders. This article also describes adaptations of these treatments that will help the general psychiatrist to effectively conduct these treatments with adolescents in their practice.

Remission and recovery in the Treatment for Adolescents with Depression Study (TADS): acute and long-term outcomes

OBJECTIVE

We examine remission rate probabilities, recovery rates, and residual symptoms across 36 weeks in the Treatment for Adolescents with Depression Study (TADS).

METHOD

The TADS, a multisite clinical trial, randomized 439 adolescents with major depressive disorder to 12 weeks of treatment with fluoxetine, cognitive-behavioral therapy, their combination, or pill placebo. The pill placebo group, treated openly after week 12, was not included in the subsequent analyses. Treatment differences in remission rates and probabilities of remission over time are compared. Recovery rates in remitters at weeks 12 (acute phase remitters) and 18 (continuation phase remitters) are summarized. We also examined whether residual symptoms at the end of 12 weeks of acute treatment predicted later remission.

RESULTS

At week 36, the estimated remission rates for intention-to-treat cases were as follows: combination, 60%; fluoxetine, 55%; cognitive-behavioral therapy, 64%; and overall, 60%. Paired comparisons reveal that, at week 24, all active treatments converge on remission outcomes. The recovery rate at week 36 was 65% for acute phase remitters and 71% for continuation phase remitters, with no significant between-treatment differences in recovery rates. Residual symptoms at the end of acute treatment predicted failure to achieve remission at weeks 18 and 36.

CONCLUSIONS

Most depressed adolescents in all three treatment modalities achieved remission at the end of 9 months of treatment.

Direct comparisons of treatment modalities for youth disorders: a meta-analysis

A meta-analysis was conducted to determine whether differences in efficacy exist among treatment approaches applied to youth. Included were all studies published between 1980 and 2005 involving participants 18 years of age or younger with diagnoses of depression, anxiety, conduct disorder, and attention-deficit/hyperactivity disorder that contained direct comparisons among two or more treatment methods intended to be therapeutic. Effect sizes were found to vary significantly, providing some evidence that differences in efficacy exist among treatments for these disorders in youth. However, the upper bound of the true difference in effects among treatments was small. Furthermore, researcher allegiance was found to be strongly associated with the difference in effect sizes so that when allegiance was controlled there was no evidence of any differences among treatments.

Developing Cognitive Behavioral Therapy to Prevent Depressive Relapse in Youth

Relapse rates for children and adolescents with major depressive disorder (MDD) range from 30% to 40% within 1 to 2 years after acute treatment. Although relapse rates are high, there have been relatively few studies on the prevention of relapse in youth. While acute phase pharmacotherapy has been shown to reduce symptoms rapidly in depressed youth, children and adolescents frequently report ongoing residual symptoms and often relapse following acute treatment. Recent adult trials have begun examining augmentation with psychosocial treatment after successful medication treatment to enhance medication response and prevent future relapse. This strategy has not yet been examined in youth with depression. Here we present initial efforts to develop a sequential, combination treatment strategy to promoting rapid remission and to prevent relapse in depressed youth. We describe efforts to adapt CBT to prevent relapse (RP-CBT) in youth who respond to pharmacotherapy. The goals of RP-CBT include: preventing relapse, increasing wellness, and developing skills to promote and sustain a healthy emotional lifestyle. We describe the rationale for, components of, and methods used to develop RP-CBT. The results from a small open series sample demonstrate feasibility and indicate that youth appear to tolerate RP-CBT well. A future test of the treatment in a randomized controlled trial is described.

Practitioner review: adolescent alcohol use disorders: assessment and treatment issues

BACKGROUND

Alcohol use disorders in adolescents are associated with significant morbidity and mortality. Over the past decade, there has been a burgeoning of research on adolescent alcohol use disorders.

METHODS

A summary of the alcohol assessment tools is provided, and randomized studies reviewed and synthesized to provide an overview of state of the art knowledge of treatment of adolescent alcohol use disorders. Animal models of addiction are also briefly reviewed, and the value of translational research approaches, using findings from basic studies to guide the design of clinical investigations, is also highlighted.

RESULTS

Comorbidity is the rule, not the exception in adolescent alcohol use disorders. Comprehensive assessment of psychiatric and other substance use disorders, trauma experiences, and suicidality is indicated in this population to optimize selection of appropriate clinical interventions. In terms of available investigated treatments for adolescents with alcohol use disorders, Multidimensional Family Therapy and group administered Cognitive Behavioral Therapies have received the most empirical support to date. There is a paucity of research on pharmacological interventions in this patient population, and no firm treatment recommendations can be made in this area.

CONCLUSIONS

Given the high rate of relapse after treatment, evaluation of combined psychosocial and pharmacological interventions, and the development of novel intervention strategies are indicated.

Family intervention effects on co-occurring early childhood behavioral and emotional problems: a latent transition analysis approach

This study used latent transition analysis (LTA) to examine changes in early emotional and behavioral problems in children age 2 to 4 years resulting from participation in a family-centered intervention. A sample of 731 economically disadvantaged families was recruited from among participants in a national food supplement and nutrition program. Families with toddlers between age 2 and 3 were randomized either to the Family Check-Up (FCU) or to a nonintervention control group. The FCU's linked interventions were tailored to each family's needs. Assessments occurred at age 2, 3, and 4. The FCU followed age 2 and age 3 assessments. Latent class analyses were conducted on mother reports of behavior and emotional problems from age 2 to 4 to study transitions among the following four groups: (a) externalizing only, (b) internalizing only, (c) comorbid internalizing and externalizing, and (d) normative. LTA results revealed that participation in the FCU increased the likelihood of transitioning from either the comorbid or the internalizing class into the normative class by age 4. These results suggest family interventions in early childhood can potentially disrupt the early emergence of both emotional and behavioral problems.

Core components of therapy in youth: do we know what to disseminate?

Bridging the gap between lab and clinic has become a rallying cry for a generation of treatment researchers, and identifying and overcoming barriers to successful dissemination of best-practice treatment has become a major public mental health priority. In this review, the authors argue that a key limit to accomplishing this goal may be found back in the original research laboratories where these treatments were developed. Despite 50 years of research and 1,500 clinical trials, there are surprisingly little data on what makes youth psychotherapy therapeutic. To illustrate the problem this poses for dissemination, the adolescent depression literature is reviewed in terms of (a) critical core components of intervention and (b) basic processes through which these techniques operate. Process-outcome relationships in cognitive-behavioral, interpersonal, and family therapy models are examined with descriptive meta-analytic techniques. Discussion of treatment dissemination follows, focusing on the value of basic research on core psychotherapeutic techniques and processes.

Alliance and outcome in cognitive-behavioral therapy for adolescent depression

This study examined predictive relations between therapeutic alliance and treatment outcomes in manual-guided, cognitive-behavioral therapy for adolescent depression. Fifty-four adolescents met criteria for a depressive disorder and were treated in school-based clinics. Alliance was measured after the third session from both therapist and adolescent perspectives, and change in depressive symptoms was assessed by structured interview and self-report. Two models of alliance-outcome relations were assessed, one direct and one through treatment participation. Results showed significant associations between adolescent-reported alliance and change in depressive symptoms, even after controlling for number of sessions completed. Therapist-reported alliance was only marginally related to outcomes but was predictive of number of sessions completed. On average, alliance showed a modest relation with outcomes (r = .26). Results are discussed in the context of differential alliance-outcome relations in prior studies of cognitive-behavioral compared to nonbehavioral therapy with children and adolescents.

A web-based mental health program: reaching parents at work

OBJECTIVE

The purpose of the project was to test a web-based program providing working parents with the knowledge and skills necessary for prevention and early intervention of mental health problems in youth.

METHOD

Study sample consisted of 99 parents who were randomized into either an experimental (program use) or waitlist control condition. Analysis of covariance and paired t-tests were used to compare response outcomes for the two groups.

RESULTS

Parents receiving the intervention had greater knowledge of youth mental health issues and greater self-efficacy in handling these issues compared to controls.

CONCLUSIONS

Findings suggest that referring parents to a multimedia web-based program can improve parents' knowledge of children's' mental health and their confidence in addressing mental health issues. Web-based programs can be offered to individuals in multiple settings, including the workplace, thereby reaching large numbers of parents.

Was wirkt in der Therapie von Depression bei Kindern und Jugendlichen wirklich?

Vor allem die kognitiv-verhaltenstherapeutische Behandlung depressiver Kinder und Jugendlicher gilt als recht gut untersucht und wirksam. Die Ergebnisse und Erkenntnisse aktueller Metaanalysen und Übersichtsarbeiten werden diskutiert. Bisher belegen keine Ergebnisse stichhaltig die Überlegenheit einer Therapierichtung über die andere. Es stellt sich die Frage, ob neben spezifischen, theoretisch begründeten Interventionen einzelner Therapieschulen nicht vielmehr unspezifische, allgemeine Wirkfaktoren die Effektivität psychotherapeutischer Behandlungen begründen. Vergleichende Therapiestudien sind nötig. Allgemeine Wirkfaktoren müssen in Forschung und Therapie stärker berücksichtigt werden.

Evidence-based psychosocial treatments for child and adolescent depression

The evidence-base of psychosocial treatment outcome studies for depressed youth conducted since 1998 is examined. All studies for depressed children meet Nathan and Gorman's (2002) criteria for Type 2 studies whereas the adolescent protocols meet criteria for both Type 1 and Type 2 studies. Based on the Task Force on the Promotion and Dissemination of Psychological Procedures guidelines, the cognitive-behavioral therapy (CBT) based specific programs of Penn Prevention Program, Self-Control Therapy, and Coping with Depression-Adolescent are probably efficacious. Interpersonal Therapy-Adolescent, which falls under the theoretical category of interpersonal therapy (IPT), also is a probably efficacious treatment. CBT provided through the modalities of child group only and child group plus parent components are well-established intervention approaches for depressed children. For adolescents, two modalities are well-established (CBT adolescent only group, IPT individual), and three are probably efficacious (CBT adolescent group plus parent component, CBT individual, CBT individual plus parent/family component). From the broad theoretical level, CBT has well-established efficacy and behavior therapy meets criteria for a probably efficacious intervention for childhood depression. For adolescent depression, both CBT and IPT have well-established efficacy. Future research directions and best practices are offered.

Brief cognitive-behavioral depression prevention program for high-risk adolescents outperforms two alternative interventions: a randomized efficacy trial

In this depression prevention trial, 341 high-risk adolescents (mean age = 15.6 years, SD = 1.2) with elevated depressive symptoms were randomized to a brief group cognitive-behavioral (CB) intervention, group supportive-expressive intervention, bibliotherapy, or assessment-only control condition. CB participants showed significantly greater reductions in depressive symptoms than did supportive-expressive, bibliotherapy, and assessment-only participants at posttest, though only the difference compared with assessment controls was significant at 6-month follow-up. CB participants showed significantly greater improvements in social adjustment and reductions in substance use at posttest and 6-month follow-up than did participants in all 3 other conditions. Supportive-expressive and bibliotherapy participants showed greater reductions in depressive symptoms than did assessment-only controls at certain follow-up assessments but produced no effects for social adjustment and substance use. CB, supportive-expressive, and bibliotherapy participants showed a significantly lower risk for major depression onset over the 6-month follow-up than did assessment-only controls. The evidence that this brief CB intervention reduced risk for future depression onset and outperformed alternative interventions for certain ecologically important outcomes suggests that this intervention may have clinical utility.

Are child and adolescent responses to placebo higher in major depression than in anxiety disorders? A systematic review of placebo-controlled trials

BACKGROUND

In a previous report, we hypothesized that responses to placebo were high in child and adolescent depression because of specific psychopathological factors associated with youth major depression. The purpose of this study was to compare the placebo response rates in pharmacological trials for major depressive disorder (MDD), obsessive compulsive disorder (OCD) and other anxiety disorders (AD-non-OCD).

METHODOLOGY AND PRINCIPAL FINDINGS

We reviewed the literature relevant to the use of psychotropic medication in children and adolescents with internalized disorders, restricting our review to double-blind studies including a placebo arm. Placebo response rates were pooled and compared according to diagnosis (MDD vs. OCD vs. AD-non-OCD), age (adolescent vs. child), and date of publication. From 1972 to 2007, we found 23 trials that evaluated the efficacy of psychotropic medication (mainly non-tricyclic antidepressants) involving youth with MDD, 7 pertaining to youth with OCD, and 10 pertaining to youth with other anxiety disorders (N = 2533 patients in placebo arms). As hypothesized, the placebo response rate was significantly higher in studies on MDD, than in those examining OCD and AD-non-OCD (49.6% [range: 17-90%] vs. 31% [range: 4-41%] vs. 39.6% [range: 9-53], respectively, ANOVA F = 7.1, p = 0.002). Children showed a higher stable placebo response within all three diagnoses than adolescents, though this difference was not significant. Finally, no significant effects were found with respect to the year of publication.

CONCLUSION

MDD in children and adolescents appears to be more responsive to placebo than other internalized conditions, which highlights differential psychopathology.

How do adolescents with bulimia nervosa rate the acceptability and therapeutic relationship in family-based treatment?

OBJECTIVE

To describe therapeutic alliance and treatment acceptability ratings of adolescents with bulimia nervosa (BN) participating in family-based treatment (FBT-BN) and to explore how participant characteristics relate to these constructs.

METHOD

Adolescents with BN (n = 80) in a randomized controlled trial comparing FBT-BN and individual supportive psychotherapy (SPT), completed the Eating Disorder Examination, Rosenberg Self-esteem Scale, and Beck Depression Inventory prior to treatment. The Helping Relationship Questionnaire, patient expectancy for treatment, treatment suitability, and self-reported estimates of improvement ratings were obtained at multiple points throughout treatment.

RESULTS

Therapeutic alliance and treatment acceptability ratings were positive in both treatments and generally did not differ. Within FBT-BN, more severe eating disorder symptomatology pretreatment was related to lower alliance ratings mid-treatment (p < .05). However, reductions in binge and purge behaviors over the course of treatment were not related to alliance or acceptability for participants in FBT-BN (all p's > .10).

CONCLUSION

Contrary to expectations of FBT-BN, adolescents receiving both treatments develop a strong alliance with the therapist.

Dissonance and healthy weight eating disorder prevention programs: long-term effects from a randomized efficacy trial

Adolescent girls with body dissatisfaction (N = 481, SD = 1.4) were randomized to a dissonance-based thin-ideal internalization reduction program, healthy weight control program, expressive writing control condition, or assessment-only control condition. Dissonance participants showed significantly greater decreases in thin-ideal internalization, body dissatisfaction, negative affect, eating disorder symptoms, and psychosocial impairment and lower risk for eating pathology onset through 2- to 3-year follow-up than did assessment-only controls. Dissonance participants showed greater decreases in thin-ideal internalization, body dissatisfaction, and psychosocial impairment than did expressive writing controls. Healthy weight participants showed greater decreases in thin-ideal internalization, body dissatisfaction, negative affect, eating disorder symptoms, and psychosocial impairment; less increases in weight; and lower risk for eating pathology and obesity onset through 2- to 3-year follow-up than did assessment-only controls. Healthy weight participants showed greater decreases in thin-ideal internalization and weight than did expressive writing controls. Dissonance participants showed a 60% reduction in risk for eating pathology onset, and healthy weight participants showed a 61% reduction in risk for eating pathology onset and a 55% reduction in risk for obesity onset relative to assessment-only controls through 3-year follow-up, implying that the effects are clinically important and enduring.

Single-Participant Assessment of Treatment Mediators

Determining the means by which effective psychotherapy works is critical. A generally recommended strategy for identifying the potential causal variables is to conduct group-level statistical tests of treatment mediators. Herein the case is made for also assessing mediators of treatment outcome at the level of the individual participant. Single-participant assessment of mediators requires documenting, for each participant, that treatment was received, that change occurred on the mediator and relevant clinical outcome measures, and that the change on the mediator happened at an expected time in the treatment protocol and prior to substantive change on the dependent variable. Data from four depressed adolescents who demonstrated remission following a behavioral activation intervention illustrate the use of the approach in assessing whether changes in activation level or negative thinking mediated the changes in depression. For two participants, increased activation appeared to be a mediator, whereas decreased dysfunctional thinking never emerged as a plausible mediator. It is concluded that single-participant assessment of mediators of treatment outcome offers a useful additional tool for determining possible mechanisms of action in effective psychotherapy.

Vagus nerve stimulation: can it be used in adolescents or children with treatment-resistant depression?

Vagus nerve stimulation (VNS) therapy has been approved by the US Food and Drug Administration for treatment-resistant depression in patients 18 years of age and older and for intractable epilepsy. Long-term studies suggest VNS has an antidepressant effect in adults. This paper reviews the available clinical data for VNS therapy. Its potential application for treatment-resistant depression in adolescents and children is also discussed.

Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial

CONTEXT

Only about 60% of adolescents with depression will show an adequate clinical response to an initial treatment trial with a selective serotonin reuptake inhibitor (SSRI). There are no data to guide clinicians on subsequent treatment strategy.

OBJECTIVE

To evaluate the relative efficacy of 4 treatment strategies in adolescents who continued to have depression despite adequate initial treatment with an SSRI.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial of a clinical sample of 334 patients aged 12 to 18 years with a primary diagnosis of major depressive disorder that had not responded to a 2-month initial treatment with an SSRI, conducted at 6 US academic and community clinics from 2000-2006.

INTERVENTIONS

Twelve weeks of: (1) switch to a second, different SSRI (paroxetine, citalopram, or fluoxetine, 20-40 mg); (2) switch to a different SSRI plus cognitive behavioral therapy; (3) switch to venlafaxine (150-225 mg); or (4) switch to venlafaxine plus cognitive behavioral therapy.

MAIN OUTCOME MEASURES

Clinical Global Impressions-Improvement score of 2 or less (much or very much improved) and a decrease of at least 50% in the Children's Depression Rating Scale-Revised (CDRS-R); and change in CDRS-R over time.

RESULTS

Cognitive behavioral therapy plus a switch to either medication regimen showed a higher response rate (54.8%; 95% confidence interval [CI], 47%-62%) than a medication switch alone (40.5%; 95% CI, 33%-48%; P = .009), but there was no difference in response rate between venlafaxine and a second SSRI (48.2%; 95% CI, 41%-56% vs 47.0%; 95% CI, 40%-55%; P = .83). There were no differential treatment effects on change in the CDRS-R, self-rated depressive symptoms, suicidal ideation, or on the rate of harm-related or any other adverse events. There was a greater increase in diastolic blood pressure and pulse and more frequent occurrence of skin problems during venlafaxine than SSRI treatment.

CONCLUSIONS

For adolescents with depression not responding to an adequate initial treatment with an SSRI, the combination of cognitive behavioral therapy and a switch to another antidepressant resulted in a higher rate of clinical response than did a medication switch alone. However, a switch to another SSRI was just as efficacious as a switch to venlafaxine and resulted in fewer adverse effects.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00018902.

Depression in children and adolescents

INTRODUCTION

Prevalence rates for depression in children and adolescents are estimated up to 8.9%. Symptoms in this age group are different from those of depression in adults. Both neurobiological and psychosocial factors are involved in its development.

METHODS

Selective literature review.

RESULTS

Of note are both the high rate of spontaneous remissions in childhood (33%), and the high rate of depressions continuing into adulthood (80%). In addition far fewer evidence based treatments are available than for adults. Fluoxetine is currently the only medication licensed for use in children and adolescents for this indication. Tri- and tetracyclic antidepressants have not been shown in meta-analyses to be effective in children and adolescents. Most antidepressants lead to age related side effects, including attention deficit and in particular behavioral toxicity, which has to be taken seriously wherever there is a suicide risk.

DISCUSSION

The treatment of depression in childhood and adolescence should be based on multimodal interventions including psychotherapy, including cognitive behavioral therapy, which has proven effectiveness, psychosocial interventions and medications in severe cases. Patients with severe depression, especially suicidal minors, should be treated in patients units.

The role of randomized trials in testing interventions for the prevention of youth suicide

Epidemiological considerations point to a small handful of prevention strategies that have the potential for dramatically reducing suicide rates. Nearly all of those prevention approaches involve population-based strategies to either find an increased number of individuals at high risk for suicide or to reduce the prevalence of risk factors in members of a population that, as a whole, has a relatively low rate of suicide. Few of these approaches have been evaluated in rigorous trials. We argue that there are rigorous randomized trial designs that are both feasible and ethical and can be used to test both programmes and implementation strategies for population-based suicide prevention. We review existing suicide prevention trials and introduce two new randomized trial designs that are likely to achieve sufficient statistical power. The 'dynamic wait-listed design' randomizes across different time periods and is now being used to test a gatekeeper training programme in 32 schools. It could also be used to examine suicide prevention programmes in rural areas. The multi-trial follow-up study builds on the large number of successful population-based preventive interventions aimed at reducing known risk factors for suicide in youths to see whether these also cause a reduction in rates of completed suicide.

Depression in children and adolescents: optimizing treatment

Depression is a severe and prevalent illness among children and adolescents. Recent controversies regarding antidepressant use among pediatric patients have left healthcare providers, particularly primary-care providers, feeling uncertain of how to approach the care of depressed pediatric patients. Several large-scale studies of the treatment of pediatric depression have been completed. In addition, substantial progress has been made in our understanding of benefit versus risk in the treatment of pediatric depression. This paper presents the most updated scientific evidence in pediatric depression treatment. The review covers a wide range of treatment modalities including psychotherapy, antidepressant and alternative remedies. Recommendations based on both the scientific evidence and the most current guidelines and treatment algorithms are outlined.