Effects of psychotherapy for depression in children and adolescents: a meta-analysis

The effects of psychotherapy for adult depression are overestimated: a meta-analysis of study quality and effect size

BACKGROUND

No meta-analytical study has examined whether the quality of the studies examining psychotherapy for adult depression is associated with the effect sizes found. This study assesses this association.

METHOD

We used a database of 115 randomized controlled trials in which 178 psychotherapies for adult depression were compared to a control condition. Eight quality criteria were assessed by two independent coders: participants met diagnostic criteria for a depressive disorder, a treatment manual was used, the therapists were trained, treatment integrity was checked, intention-to-treat analyses were used, N >or= 50, randomization was conducted by an independent party, and assessors of outcome were blinded.

RESULTS

Only 11 studies (16 comparisons) met the eight quality criteria. The standardized mean effect size found for the high-quality studies (d=0.22) was significantly smaller than in the other studies (d=0.74, p<0.001), even after restricting the sample to the subset of other studies that used the kind of care-as-usual or non-specific controls that tended to be used in the high-quality studies. Heterogeneity was zero in the group of high-quality studies. The numbers needed to be treated in the high-quality studies was 8, while it was 2 in the lower-quality studies.

CONCLUSIONS

We found strong evidence that the effects of psychotherapy for adult depression have been overestimated in meta-analytical studies. Although the effects of psychotherapy are significant, they are much smaller than was assumed until now, even after controlling for the type of control condition used.

Culturally sensitive interventions and health and behavioral health youth outcomes: a meta-analytic review

Despite Census Bureau projections that youth from minority cultures will comprise the majority of the nation's youth in approximately a decade, little research has been conducted on culturally sensitive interventions (CSIs). Accordingly, this study sought to determine: (1) the effectiveness of CSIs designed to address health and behavioral health outcomes, (2) whether effectiveness varies depending on the class or type of outcome, and (3) whether race/ethnicity moderates effectiveness. The results suggest that CSIs (n = 21) are modestly effective (Hedges' g = .239, 95% C.I. = .139 to .339, p < .001). Effectiveness did not vary significantly by outcome class or by race/ethnicity. Especially in the latter case, however, the pattern of point estimates raises the possibility of moderation with an increase in power. Suggestions for future research conclude the article.

The longitudinal consistency of mother-child reporting discrepancies of parental monitoring and their ability to predict child delinquent behaviors two years later

This study examined the longitudinal consistency of mother-child reporting discrepancies of parental monitoring and whether these discrepancies predict children's delinquent behaviors 2 years later. Participants included 335 mother/female-caregiver and child (46% boys, >90% African American; age range 9-16 years [M = 12.11, SD = 1.60]) dyads living in moderate-to-high violence areas. Mother-child discrepancies were internally consistent within multiple assessment points and across measures through a 2-year follow-up assessment. Further, mothers who at baseline consistently reported higher levels of parental monitoring relative to their child had children who reported greater levels of delinquent behaviors 2 years later, relative to mother-child dyads that did not evidence consistent discrepancies. This finding could not be accounted for by baseline levels of the child's delinquency, maternal and child emotional distress, or child demographic characteristics. This finding was not replicated when relying on the individual reports of parental monitoring to predict child delinquency, suggesting that mother-child reporting discrepancies provided information distinct from the absolute frequency of reports. Findings suggest that mother-child discrepancies in reports of parental monitoring can be employed as new individual differences measurements in developmental psychopathology research.

Improving the mental health, healthy lifestyle choices, and physical health of Hispanic adolescents: a randomized controlled pilot study

BACKGROUND

Obesity and mental health disorders are 2 major public health problems in American adolescents, with prevalence even higher in Hispanic teens. Despite the rapidly increasing incidence and adverse health outcomes associated with overweight and mental health problems, very few intervention studies have been conducted with adolescents to improve both their healthy lifestyles and mental health outcomes. Even fewer studies have been conducted with Hispanic youth. The purpose of this study was to evaluate the preliminary efficacy of the COPE (Creating Opportunities for Personal Empowerment) Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, and Nutrition) program, a manualized educational and cognitive behavioral skills-building program, on Hispanic adolescents' healthy lifestyle choices as well as mental and physical health outcomes.

METHODS

A cluster randomized controlled pilot study was conducted with 19 Hispanic adolescents enrolled in 2 health classes in a southwestern high school. One class received COPE and the other received an attention control program.

RESULTS

Adolescents in the COPE program increased their healthy lifestyle choices and reported a decrease in depressive and anxiety symptoms from baseline to postintervention follow-up. A subset of 7 overweight adolescents in the COPE program had a decrease in triglycerides and an increase in high-density lipoproteins. In addition, these overweight adolescents reported increases in healthy lifestyle beliefs and nutrition knowledge along with a decrease in depressive symptoms.

CONCLUSION

The COPE TEEN program is a promising school-based strategy for improving both physical and mental health outcomes in adolescents.

How Goals and Beliefs Lead People into and Out of Depression

There is evidence that beliefs (cognitive vulnerabilities) and goals (to prove self-worth) contribute to depression but little consideration of how they work in tandem. Synthesizing research on beliefs and goals leads us to four propositions: (a) People with cognitive vulnerabilities often adopt self-worth goals (seeking to prove self-worth and to avoid proof of worthlessness). People with the opposite beliefs often adopt learning goals. (b) Stressors trigger depression largely because they lead people with self-worth goals to focus narrowly on goals to avoid proof of worthlessness. The same stressors do not lead people with learning goals to become depressed. (c) People with goals to avoid proof of worthlessness adopt defensive self-handicapping behaviors (e.g., effort withdrawal, rumination) when dealing with stressors, because those behaviors serve their goals. The same stressors lead people with learning goals to adopt constructive, problem-solving strategies. (d) A key to alleviating depression is fostering a shift from self-worth goals to learning goals and from the beliefs underlying self-worth goals to the opposite beliefs.

Developmental origins of cognitive vulnerabilities to depression: review of processes contributing to stability and change across time

Cognitive theories of depression have been shown to be potent predictors of future increases in depressive symptoms and disorder in children, adolescents, and adults. This article focuses on potential developmental origins of the main cognitive vulnerabilities, including dysfunctional attitudes, negative cognitive style, and rumination. We selectively review processes and factors that have been hypothesized to contribute to the emergence and stabilization of these cognitive risk factors. This review focuses on genetic factors, temperament, parents and peers as salient interpersonal influences, and stressful life events. We end with suggestions for future theory development and research. In particular, we emphasize the need for additional conceptual and empirical work integrating these disparate processes together into a coherent, developmental psychopathological model, and we highlight the coexistence of both stability and change in the development of cognitive vulnerabilities to depression across the lifespan.

An exploratory analysis of the impact of family functioning on treatment for depression in adolescents

This article explores aspects of family environment and parent-child conflict that may predict or moderate response to acute treatments among depressed adolescents (N = 439) randomly assigned to fluoxetine, cognitive behavioral therapy, their combination, or placebo. Outcomes were Week 12 scores on measures of depression and global impairment. Of 20 candidate variables, one predictor emerged: Across treatments, adolescents with mothers who reported less parent-child conflict were more likely to benefit than their counterparts. When family functioning moderated outcome, adolescents who endorsed more negative environments were more likely to benefit from fluoxetine. Similarly, when moderating effects were seen on cognitive behavioral therapy conditions, they were in the direction of being less effective among teens reporting poorer family environments.

Mood-related sleep problems in children and adolescents

Sleep problems are an essential part of the current diagnostic criteria for depressive and bipolar disorders in children and adolescents. Whereas many studies have reported subjective sleep problems in youth with depression or bipolar disorder, except for reduced rapid eye movement latency associated with depression, few objective mood-related sleep abnormalities have been consistently identified. Recent technologic advances, such as spectral EEG and actigraphy, hold promise for revealing additional objective disturbances. There are presently few evidence-based published practice recommendations for mood-related sleep problems in youth. In this article, the authors chronologically review research on the phenomenology and treatment of sleep difficulties in youth with depressive and bipolar disorders and present research-based and clinically guided recommendations for the assessment and treatment of these problems.

Depressive symptoms and clinical status during the Treatment of Adolescent Suicide Attempters (TASA) Study

OBJECTIVE

To examine the course of depression during the treatment of adolescents with depression who had recently attempted suicide.

METHOD

Adolescents (N = 124), ages 12 to 18 years, with a 90-day history of suicide attempt, a current diagnosis of depressive disorder (96.0% had major depressive disorder), and a Children's Depression Rating Scale-Revised (CDRS-R) score of 36 or higher, entered a 6-month treatment with antidepressant medication, cognitive-behavioral therapy focused on suicide prevention, or their combination (Comb), at five academic sites. Treatment assignment could be either random or chosen by study participants. Intent-to-treat, mixed effects regression models of depression and other relevant ratings were estimated. Improvement and remission rates were computed with the last observation carried forward.

RESULTS

Most patients (n = 104 or 84%) chose treatment assignment, and overall, three fourths (n = 93) received Comb. In Comb, CDRS-R declined from a baseline adjusted mean of 49.6 (SD 12.3) to 38.3 (8.0) at week 12 and to 27.0 (10.1) at week 24 (p < .0001), with a Clinical Global Impression -defined improvement rate of 58.0% at week 12 and 72.2% at week 24 and a remission (CDRS-R ≤ 28) rate of 32.5% at week 12 and 50.0% at week 24. The CDRS-R and the Scale for Suicidal Ideation scores were correlated at baseline (r = 0.43, p < .0001) and declined in parallel.

CONCLUSIONS

When vigorously treated with a combination of medication and psychotherapy, adolescents with depression who have recently attempted suicide show rates of improvement and remission of depression that seem comparable to those observed in nonsuicidal adolescents with depression.

Adolescent depression: an update and guide to clinical decision making

Depression in adolescence and adulthood is common, afflicting up to 20 percent of these populations. It represents a significant public health concern and is associated with considerable suffering and functional impairment. Adolescent-onset depression tends to be a particularly malignant and recalcitrant condition, increasing the likelihood of recurrence and chronicity in adulthood. Clinical presentations for various medical and psychiatric conditions, as well as reactions to psychosocial stressors, can mimic or confound the picture of depression in adolescents. Therefore, careful assessment and differential diagnosis is essential. Effective treatments, both pharmacological and psychosocial in nature, exist, and so early detection and intervention is paramount. This article presents an overview of optimal prevention, assessment, and clinical decision-making strategies for managing depression in adolescents.

Early childhood depression

Although empirical evidence has recently validated clinical depression in children as young as age 3, few data are available to guide treatment of early childhood depression. Considering this gap in the literature, a novel dyadic psychotherapeutic model, Parent Child Interaction Therapy-Emotion Development, based on a well-known and effective manualized treatment for disruptive preschoolers, is currently being tested for use in depression. To balance safety and efficacy, dyadic developmental approaches are currently recommended as the first line of treatment for preschool depression. In the absence of data on the safety and efficacy of antidepressants in preschool depression, these agents are not recommended as a first- or second-line treatment at this time. This article provides an illustrative case example of preschool depression, outlines key considerations in differential diagnosis, and describes this novel form of treatment. It also clarifies parameters for the rare situations in which antidepressants may be tried when psychotherapeutic options fail and depression is severe and impairing.

The role of readiness to change in response to treatment of adolescent depression

The effect of readiness to change on treatment outcome was examined among 332 adolescents (46% male, 74% Caucasian), ages 12 through 17 years (M = 14.6, SD = 1.5), with major depressive disorder who were participating in the Treatment for Adolescents With Depression Study (TADS). TADS is a randomized clinical trial comparing the effectiveness of fluoxetine (an antidepressant medication), cognitive-behavioral therapy, their combination, and a pill placebo. An abbreviated Stages of Change Questionnaire was used to obtain 4 readiness to change scores: precontemplation, contemplation, action, and maintenance. The association between each readiness score and depression severity across 12 weeks of acute treatment for depression, as measured by the Children's Depression Rating Scale--Revised, was examined. Although treatment response was not moderated by any of the readiness scores, baseline action scores predicted outcome: Higher action scores were associated with better outcome regardless of treatment modality. Furthermore, treatment effects were mediated by change in action scores during the first 6 weeks of treatment, with increases in action scores related to greater improvement in depression. Assessing readiness to change may have implications for tailoring treatments for depressed adolescents.

Identifying Evidence-Based Interventions for Children and Adolescents Using the Range of Possible Changes Model

The article discusses a study involving a framework (range of possible changes [RPC] Model) developed and applied to identify patterns in consistent and inconsistent intervention outcomes effects by informant, measurement method, and method of statistical analysis to the meta-analytic study of trials testing two evidence-based interventions for children and adolescents (youth-focused cognitive-behavioral treatment for child anxiety problems; parent-focused behavioral parent training for childhood conduct problems). This article illustrates how findings gleaned from applying the RPC Model allow for unique opportunities for hypothesis generation based on the patterns of consistent outcomes effects. Based on the RPC Model, studies can be closely examined to identify the specific instances in which interventions yield robust effects, and the authors illustrate how examining effects in this way can lead to new understandings of interventions and the outcomes they produce. Findings suggest that researchers can employ previously underutilized patterns of consistencies and inconsistencies in outcomes effects as new resources for identifying evidence-based interventions.

Conceptualization about internalizing problems in children and adolescents

This review will discuss the concept of internalizing disorders. It will describe the two main types of internalizing disorder: depressive and anxiety disorders. It will discuss how they have much in common, but that there are also key differences. The review will use data from modern studies of symptom factor analysis, aetiology, treatment and prognosis to illustrate the commonalities and differences. It will conclude by trying to answer where internalizing disorders should be placed in future diagnostic classification schemes.

Research review: The relationship between childhood violence exposure and juvenile antisocial behavior: a meta-analytic review

BACKGROUND

The connection between childhood violence exposure and antisocial behavior in adolescence has received much attention and has important implications for understanding and preventing criminal behavior. However, there are a limited number of well-designed prospective studies that can suggest a causal relationship, and little is known about the magnitude of the relationship.

METHODS

This meta-analysis provides a quantitative comparison of 18 studies (N = 18,245) assessing the relationship between childhood (before age 12) violence exposure and adolescent antisocial behavior. An overall effect size (Cohen's d) was calculated for each study, an average for the 18 studies, and averages for subsets of analyses within studies.

RESULTS

Results indicated a small effect from prospective studies (d = .31) and a large effect from cross-sectional studies (d = .88). The effect for victimization (d = .61) was larger than for witnessing violence (d = .15).

CONCLUSIONS

Effect size varied across studies employing different methodologies, populations, and conceptualizations of violence exposure and antisocial behavior. These findings do not support a simple, direct link from early violence exposure to antisocial behavior but suggest that many factors influence this relationship.

The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM

Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder (ED) diagnosis. In this meta-analysis, the authors aimed to inform Diagnostic and Statistical Manual of Mental Disorders revisions by comparing the psychopathology of EDNOS with that of the officially recognized EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). A comprehensive literature search identified 125 eligible studies (published and unpublished) appearing in the literature from 1987 to 2007. Random effects analyses indicated that whereas EDNOS did not differ significantly from AN and BED on eating pathology or general psychopathology, BN exhibited greater eating and general psychopathology than EDNOS. Moderator analyses indicated that EDNOS groups who met all diagnostic criteria for AN except for amenorrhea did not differ significantly from full syndrome cases. Similarly, EDNOS groups who met all criteria for BN or BED except for binge frequency did not differ significantly from full syndrome cases. Results suggest that EDNOS represents a set of disorders associated with substantial psychological and physiological morbidity. Although certain EDNOS subtypes could be incorporated into existing Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) categories, others-such as purging disorder and non-fat-phobic AN-may be best conceptualized as distinct syndromes. (PsycINFO Database Record (c) 2009 APA, all rights reserved).

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.

Clinical case study: CBT for depression in a Puerto Rican adolescent: challenges and variability in treatment response

BACKGROUND

There is ample evidence of the efficacy of cognitive-behavioral therapy (CBT) for depression in adolescents, including Puerto Rican adolescents. However, there is still a high percentage of adolescents who do not respond to a standard "dose" of 12 sessions of CBT. This clinical case study explores the characteristics associated with treatment response in a Puerto Rican adolescent and illustrates the challenges and variability inherent in CBT treatment for major depressive disorder (MDD) in youth.

METHODS

The patient is a 15-year-old adolescent female who at pretreatment presented a diagnosis of MDD with severe depressive symptoms, high suicidal ideation, low self-concept, and highly dysfunctional attitudes. CBT treatment consisted of 12 standard individual therapy sessions plus four additional sessions, and one family intervention. A case study method was used. Both qualitative and quantitative data for the case are presented using self-report instruments, clinical case notes and recordings of therapy sessions.

RESULTS

Some of the characteristics she presented that have been associated with partial or no response to therapy were: increased severity of depressive symptoms, a prior MDD episode, co-morbidity with other mental disorders, and significant parental conflict. At termination the patient presented decreases in depressive symptoms, dysfunctional attitudes, and suicidal ideation, as well as improvements in self-concept. These improvements were maintained up to 1 year posttreatment.

CONCLUSIONS

Cultural issues are discussed in terms of the potential for parental conflict to perpetuate the patient's depressive symptoms.

Depressive symptoms and glycemic control in adolescents with type 1 diabetes: mediational role of blood glucose monitoring

OBJECTIVE

To determine whether the association between depressive symptoms and glycemic control is mediated by blood glucose monitoring (BGM).

RESEARCH DESIGN AND METHODS

A total of 276 adolescents with type 1 diabetes (mean age +/- SD, 15.6 +/- 1.4 years) completed a measure of depressive symptoms. Sociodemographic and family characteristics were obtained from caregivers. BGM frequency and glycemic control were obtained at a clinic visit.

RESULTS

Separate regression analyses revealed that depressive symptoms were associated with lower BGM frequency (B = -0.03; P = 0.04) and higher A1C (B = 0.03; P = 0.05) and that lower BGM frequency was associated with higher A1C (B = -0.39; P < 0.001). With depressive symptoms and BGM frequency included together, only BGM frequency was associated with A1C and depressive symptoms became nonsignificant (B = 0.02; P = 0.19). The Sobel test was significant (Z = 1.96; P < 0.05) and showed that 38% of the depression-A1C link can be explained by BGM.

CONCLUSIONS

BGM is a mediator between depressive symptoms and glycemic control in adolescents with type 1 diabetes.

Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force

CONTEXT

Depression among youth is a disabling condition that is associated with serious long-term morbidities and suicide.

OBJECTIVE

To assess the health effects of routine primary care screening for major depressive disorder among children and adolescents aged 7 to 18 years.

METHODS

Medline, the Cochrane Central Registry of Controlled Trials, PsycInfo, the Cochrane Database of Systematic Reviews, recent systematic reviews, experts, and bibliographies from selected studies were the data sources. The studies selected were fair- and good-quality (on the basis of US Preventive Services Task Force criteria) controlled trials of screening and treatment (selective serotonin reuptake inhibitor and/or psychotherapy), diagnostic accuracy studies, and large observational studies that reported adverse events. Two reviewers quality-graded each article. One reviewer abstracted relevant information into standardized evidence tables, and a second reviewer checked key elements.

RESULTS

We found no data describing health outcomes among screened and unscreened populations. Although the literature on diagnostic screening test accuracy is small and methodologically limited, it indicates that several screening instruments have performed fairly well among adolescents. The literature on treatment efficacy of selective serotonin reuptake inhibitors and/or psychotherapy is also small but includes good-quality randomized, controlled trials. Available data indicate that selective serotonin reuptake inhibitors, psychotherapy, and combined treatment are effective in increasing response rates and reducing depressive symptoms. Not all specific selective serotonin reuptake inhibitors, however, seem to be efficacious. Selective serotonin reuptake inhibitor treatment was associated with a small absolute increase in risk of suicidality (ie, suicidal ideation, preparatory acts, or attempts). No suicide deaths occurred in any of the trials. CONCLUSIONS. Limited available data suggest that primary care-feasible screening tools may accurately identify depressed adolescents and treatment can improve depression outcomes. Treating depressed youth with selective serotonin reuptake inhibitors may be associated with a small increased risk of suicidality and should only be considered if judicious clinical monitoring is possible.

Characteristics of effective psychological treatments of depression: a metaregression analysis

Although many meta-analyses have shown that psychological therapies are effective in the treatment of depression, no comprehensive metaregression analysis has been conducted to examine which characteristics of the intervention, target population, and study design are related to the effects. The authors conducted such a metaregression analysis with 83 studies (135 comparisons) in which a psychological treatment was compared with a control condition. The mean effect size of all comparisons was 0.69 (95% confidence interval = 0.60-0.79). In multivariate analyses, several variables were significant: Studies using problem-solving interventions and those aimed at women with postpartum depression or specific populations had higher effect sizes, whereas studies with students as therapists, those in which participants were recruited from clinical populations and through systematic screening, and those using care-as-usual or placebo control groups had lower effect sizes.

Comparison of demographic and clinical characteristics between children and adolescents with major depressive disorder

OBJECTIVE

To compare clinical characteristics of major depressive disorder symptoms between children and adolescents.

METHOD

The subjects were 58 patients of a Child and Adolescent Affective Disorder Clinic consecutively admitted during a six-month period. Children aged 5-9 years old and adolescents from 10-17 years old currently meeting DSM-IV criteria diagnosis of major depressive disorder were chosen. Current MDD diagnosis and depressive psychopathology were assessed by a clinical interview and the Diagnostic Interview for Children and Adolescents-DSM-IV version. The Children's Depression Rating Scale-Revised Version and the Children Global Assessment Scale rated the severity and global functioning of major depressive disorder.

RESULTS

The most common depressive symptoms were: anhedonia (72.4%), depressed mood (72.4%), decreased concentration (62.1%), and irritability (58.6%). The intensity of depressive episodes of this sample ranged from mild to moderate. Fifty percent reported thoughts of death, and 29.3% presented a variety of psychotic symptoms. When compared with children, adolescents reported a significantly more depressed mood (p = 0.043), lower self-esteem (p = 0.002), and had more difficulty concentrating (p = 0.020). Female adolescents had lower self-esteem (p = 0.003), and male adolescents showed more decreased concentration (p = 0.016).

CONCLUSION

This study suggests that age and gender differences might influence the clinical presentation of major depressive disorder in children and adolescents. Further studies with larger samples are needed.

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.

A pilot study of self-esteem as a mediator between family factors and depressive symptoms in young adult university students

The aim of this study was to examine whether self-esteem mediates the relationship between family factors and depressive symptoms in young adults. Participants completed self-report questionnaires about overall family environment, conflict with mother or father, parental rearing, self esteem, and depressive symptoms. Self-esteem was found to mediate the relationship between the combined family factors and depressive symptoms. When examined simultaneously, none of the individual family variables uniquely predicted depressive symptoms or self-esteem. However, separate analysis of each of the three family factors provided evidence for self-esteem mediating the relationship between parental conflict and depressive symptoms, and the relationship between parental care and depressive symptoms. Self-esteem may play a role in the mechanism underlying the link between parent-offspring relationship factors and depressive symptoms.

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.

Mood disorders in children and adolescents

Childhood mood disorders such as major depression, dysthymia, and bipolar disorder have been found to be highly prevalent among children and adolescents. The emotional and behavioral dysfunction associated with these mood disorders can cause impairments across areas of functioning, including academic and social arenas. This article reviews the course, possible causes, assessment, and treatment of this group of disorders in youth and concludes by examining the implications for nurses and other health care providers of youth with mood disorders.

Is psychotherapy for depression equally effective in younger and older adults? A meta-regression analysis

BACKGROUND

It is well established that psychotherapy is effective in the treatment of depression in younger as well as in older adults. Whether these psychotherapies are equally effective in younger and older age groups has not been examined in meta-analytic research.

METHODS

We conducted a systematic literature search and included 112 studies with 170 comparisons between a psychotherapy and a control group (with a total of 7,845 participants). Twenty studies with 26 comparisons were aimed at older adults.

RESULTS

We found no indication that psychotherapies were more or less effective for older adults compared to younger adults. The effect sizes of both groups of comparisons did not differ significantly from each other (older adults: d = 0.74; 95% CI: 0.49-0.99; younger adults: d = 0.67; 95% CI: 0.58-0.76). In a multivariate meta-regression analysis, in which we controlled for major characteristics of the participants, the interventions and the study designs, no indication of a difference between psychotherapy in younger and older adults was found.

CONCLUSIONS

There appears to be no significant difference between psychotherapy in younger and older adults, although it is not clear whether this is also true for clinical samples, patients with more severe depression, and the older old.

Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems

This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month follow-up. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low interrater reliability for the competence ratings. Clinical and research implications for attending to both linear and curvilinear adherence effects in manualized treatments for behavior disorders are discussed.

Combined cognitive-behavioural therapy and pharmacotherapy for adolescent depression: Does it improve outcomes compared with monotherapy?

Adolescent depression can be effectively treated with selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, or with specific forms of psychotherapy, such as cognitive-behavioural therapy (CBT) and interpersonal therapy. A single course of any of these treatments, however, leaves between one-third and one-half of patients insufficiently improved and still depressed. In an effort to increase effectiveness, medication and CBT have been combined (COMB). A few controlled clinical trials have recently compared COMB with monotherapy. TADS (Treatment for Adolescents with Depression Study) randomly assigned 439 adolescents with major depressive disorder to fluoxetine, CBT, COMB or clinical management with placebo. After 12 weeks of treatment, both fluoxetine and COMB reduced depression more than CBT or placebo did, but only COMB was effective in inducing remission, achieving functional recovery and reducing suicidal ideation. After 36 weeks of treatment, there was no difference in improvement among treatments, but more suicidal events occurred in the medication only group than in the CBT only group. However, in another trial, ADAPT (Adolescent Depression and Psychotherapy Trial), involving 208 youths, no advantages of COMB over usual care with an SSRI could be detected. In a third trial, TORDIA (Treatment of Resistant Depression in Adolescence), which randomized 334 patients with an major depression unresponsive to previous SSRI treatment, COMB produced a greater response rate than medication monotherapy. These and other, smaller trials of COMB in adolescent depression are reviewed in this article. It is concluded that, while there is no univocal support for the superiority of COMB, two controlled trials indicate that COMB has a more favourable benefit/risk balance than monotherapy in adolescent depression. It remains to be determined for which patient subgroups and in which clinical settings COMB may be most advantageous.

Pediatric depression: is there evidence to improve evidence-based treatments?

Although there have been advances in our ability to treat child and adolescent depression, use of evidence-based treatments still results in many patients with residual symptoms. Advances in our understanding of cognitive, emotional, and ecological aspects of early-onset depression have the potential to lead to improvements in the assessment and treatment of depression. A search for endophenotypes, i.e., traits that are related to depression, mediate the familial transmission of depression, and are genetically determined, may help in understanding etiology and in personalizing treatment. However, advances in treatment may also come from the identification of biomarkers, i.e., modifiable neurocognitive, physiological, or biochemical indices that are correlated with, or mediate, treatment outcome. More effective treatments may emerge from being able to personalize interventions to the patient's cognitive, emotional, and developmental profile.

[Efficacy of psychiatric and psychotherapeutic interventions in children and adolescents with psychiatric disorders--a systematic evaluation of meta-analyses and reviews. Part I: Anxiety disorders and depressive disorders]

OBJECTIVE

In recent years, a large and growing body of research on the effectiveness of treatments for psychiatric disorders in childhood and adolescence has been published; however, the large number makes it difficult to get an overview on the current status of research. The aim of this article is to systematically review the existing meta-analyses and reviews on the four most frequent childhood and adolescent psychiatric disorders (anxiety disorder, depression, ADHD, conduct disorder) and to present an up-to-date summary on the effects of treatment for those disorders.

METHODS

This article is based on a systematic literature search, which produced 112 meta-analyses and reviews on efficacy of psychological and psychiatric interventions in childhood and adolescence published between 2000 and 2007. The articles resulting from the literature search were evaluated according to clearly defined criteria. Presentation of the results follows a dichotomous classification (internalizing vs. externalizing disorders), with Part I of this article reporting the results on anxiety disorders and depressive disorders.

RESULTS

The majority of reviews published between 2000 and 2007 focuses on the treatment of depressive disorders and ADHD. Only for ADHD is the use of medication (stimulants) considered to be the most efficacious treatment option available. For the remaining three disorders, psychotherapy is recommended as the most effective treatment of choice. A combination of psychological and pharmacological treatments is an important option in ADHD and depressive disorders. Considering the efficacy, treatments for ADHD and anxiety disorders produce higher effect-sizes than do interventions for depressive and conduct disorders. For all disorders, there are several desiderata (content and methodological aspects) to be incorporated into future research.

DISCUSSION

Empirically supported treatment recommendations can be derived for anxiety disorders, depressive disorders, ADHD and conduct disorders. Finally, important implications for research and practice are discussed.

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.

Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder

OBJECTIVE

We present results of a feasibility test of a sequential treatment strategy using continuation phase cognitive-behavioral therapy (CBT) to prevent relapse in youths with major depressive disorder (MDD) who have responded to acute phase pharmacotherapy.

METHOD

Forty-six youths (ages 11-18 years) who had responded to 12 weeks of treatment with fluoxetine were randomized to receive either 6 months of continued antidepressant medication management (MM) or antidepressant MM plus relapse prevention CBT (MM+CBT). Primary outcome was time to relapse, defined as a Childhood Depression Rating Scale-Revised score of 40 or higher and 2 weeks of symptom worsening or clinical deterioration warranting alteration of treatment to prevent full relapse.

RESULTS

Cox proportional hazards regression, adjusting for depression severity at randomization and for the hazard of relapsing by age across the trial, revealed that participants in the MM treatment group had a significantly greater risk for relapse than those in the MM+CBT treatment group (hazard ratio = 8.80; 95% confidence interval 1.01-76.89; chi = 3.86, p =.049) during 6 months of continuation treatment. In addition, patient satisfaction was significantly higher in the MM+CBT group. No differences were found between the two treatment groups on attrition rate, serious adverse events, and overall global functioning.

CONCLUSIONS

These preliminary results suggest that continuation phase CBT reduces the risk for relapse by eightfold compared with pharmacotherapy responders who received antidepressant medication alone during the 6-month continuation phase.

Emotion (Dys)regulation and Links to Depressive Disorders

Clinical depression is a significant mental health problem that is associated with personal suffering and impaired functioning. These effects underscore the continuing need for new approaches that can inform researchers and clinicians when designing interventions. We propose that individual differences in the self-regulation of sadness and distress provide an important link between stress, depressed mood, and the onset of depressive disorder, and that if we have a better understanding of the ways children successfully manage negative emotions, we can better prevent and treat pediatric depression. In this article, we therefore examine the normative development of responses that children use to attenuate sadness, and aspects of the neurobiological infrastructure that both enable and constrain such self-regulatory efforts. We also address the emerging literature on affect regulation among children at familial risk for depressive disorders. We conclude that problems with adaptively self-regulating sadness and distress represent one pathway that can lead to juvenile-onset depression. And we need integrated, developmental studies of the psychosocial and neurobiological aspects of self-regulatory responses to sadness and distress in order to better understand this process, and to design age-sensitive intervention strategies for pediatric depression.

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.

How do school connectedness and attachment to parents interrelate in predicting adolescent depressive symptoms?

In this study, we tested whether school connectedness mediated or moderated the effect of parental attachment on adolescent depressive symptoms. A sample of 153 secondary school students ranging from 8th to 12th grade were assessed using measures of parental attachment, school connectedness, and depressive symptoms. Independently, parental attachment and school connectedness accounted for 28% and 49% of the variance in depressive symptoms respectively, whereas collectively they accounted for 53% of the variance. School connectedness only partially mediated the relationship between parental attachment and depressive symptoms, and there was no significant moderation effect.

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.

Relaxation for depression

BACKGROUND

Many members of the public have negative attitudes towards antidepressants. Psychological interventions are more acceptable but require considerable therapist training. Acceptable psychological interventions that require less training and skill are needed to ensure increased uptake of intervention. A potential intervention of this sort is relaxation techniques.

OBJECTIVES

To determine whether relaxation techniques reduce depressive symptoms and improve response/remission.

SEARCH STRATEGY

The register of trials kept by the Cochrane Collaboration Depression, Anxiety and Neurosis Group was searched up to February 2008. We also searched the reference lists of included studies.

SELECTION CRITERIA

Studies were included if they were randomised or quasi-randomised controlled trials of relaxation techniques (progressive muscle relaxation, relaxation imagery, autogenic training) in participants diagnosed with depression or having a high level of depression symptoms. Self-rated and clinician-rated depression scores and response/remission were the primary outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers selected the trials, assessed the quality and extracted trial and outcome data, with discrepancies resolved by consultation with a third. Trial authors were approached for missing data where possible and missing data were estimated or imputed in some cases. Continuous measures were summarised using standardised mean differences and dichotomous outcomes by risk ratios.

MAIN RESULTS

There were 15 trials with 11 included in the meta-analysis. Five trials showed relaxation reduced self-reported depression compared to wait-list, no treatment, or minimal treatment post intervention (SMD -0.59 (95% CI -0.94 to -0.24)). For clinician-rated depression, two trials showed a non-significant difference in the same direction (SMD -1.35 (95% CI -3.06 to 0.37)).Nine trials showed relaxation produced less effect than psychological (mainly cognitive-behavioural) treatment on self-reported depression (SMD = 0.38 (95% CI 0.14 to 0.62)). Three trials showed no significant difference between relaxation and psychological treatment on clinician-rated depression at post intervention (SMD 0.29 (95% CI -0.18 to 0.75)).Inconsistent effects were found when comparing relaxation training to medication and there were few data available comparing relaxation with complementary and lifestyle treatments.

AUTHORS' CONCLUSIONS

Relaxation techniques were more effective at reducing self-rated depressive symptoms than no or minimal treatment. However, they were not as effective as psychological treatment. Data on clinician-rated depressive symptoms were less conclusive. Further research is required to investigate the possibility of relaxation being used as a first-line treatment in a stepped care approach to managing depression, especially in younger populations and populations with subthreshold or first episodes of depression.

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.