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

Evidence-Base Update of Psychosocial and Combination Treatments for Child and Adolescent Depression

OBJECTIVE

This evidence-based update (EBU) builds on three previous reviews (1998, 2008, 2017) sponsored by the Society of Clinical Child and Adolescent Psychology with the aim of evaluating the empirical support for psychosocial interventions for depression in youth.

METHOD

In the current review period (2014-2022), 25 randomized controlled trials (RCT) were identified: four in children and 21 in adolescents. Descriptive effect sizes and number-needed-to-treat (NNT) ratios were calculated for primary outcomes. Results were integrated with prior reviews, and cumulative evidence used to classify treatments as well-established, probably efficacious, possibly efficacious, or experimental. Published secondary analyses of predictors, moderators, and mediators were examined.

RESULTS

For adolescents, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT-A), CBT in combination with antidepressant medication, and collaborative care programs were all classified as well-established. The evidence was considerably weaker for children, with no treatments achieving well-established or probably efficacious status. New developments include greater exploration of parent- and family-mediated treatment models and increasing evidence on technology-assisted interventions. Data on predictors, moderators, and mediators continued to be focused on adolescent depression samples and drawn from a limited number of RCT datasets.

CONCLUSION

Since the prior EBU, there has been incremental progress in youth depression treatment research. There is an urgent need to: (a) develop innovative approaches to substantially improve on the modest effects seen in most RCTs, (b) expand the evidence base for children and other underserved groups, (c) craft evidence-based guidelines for choosing between interventions when multiple efficacious treatments do exist, and (d) address issues of treatment effectiveness and scalability to ameliorate the wide prevalence and high impact of depression in youth.

Protocol for a randomized clinical trial to confirm the effectiveness of online guided self-help family-based treatment for adolescent anorexia nervosa

BACKGROUND

The leading evidence-based treatment for anorexia nervosa (AN) in adolescents is Family-based Treatment (FBT). However, due to the intensive training requirements and lack of practitioners, it is often difficult for families to access FBT. Thus, innovations that improve access to care are needed. A pilot randomized study of a guided self-help version of Family-based Treatment (GSH-FBT) that utilized approximately 1/4 the amount of therapist time compared to FBT found that the approach was acceptable and appeared to achieve similar outcomes. The study protocol detailed in this manuscript compares the efficiency (clinician time) of GSH-FBT to Family-based Treatment via Videoconferencing (FBT-V) in a fully powered study in achieving clinical outcomes through a multi-site randomized clinical trial across the US and Ontario, Canada.

METHODS

This study will randomize the families of adolescents ages 12-18 (n = 200) who meet DSM-5 criteria for AN to receive either GSH-FBT or FBT-V. Participants will be randomized to 15 sixty-minute sessions of FBT-V or to 10 twenty-minute sessions of online GSH-FBT. Major assessments will be conducted by a masked assessor at baseline, within treatment, at the end of treatment (EOT), and 6 and 12 months after the end of treatment (EOT). The primary outcomes of this study are changes to body weight and eating disorder cognitions relative to clinician time used (relative efficiency of treatment modality).

CONCLUSIONS

The findings of this study may help increase access to care by providing a time efficient, affordable, more scalable intervention for adolescent AN compared to standard FBT.

Parental Involvement in Adolescent Psychological Interventions: A Meta-analysis

Psychological interventions for adolescents have shown mixed efficacy, and including parents in interventions may be an important avenue to improve treatment outcomes. Evidence from meta-analyses examining the role of parents in interventions for youth is inconsistent and has typically combined findings for both children and adolescents together. No prior meta-analysis has examined the specific role of parents in adolescent interventions as compared with interventions focused solely on adolescents across several disorders. To address this gap, systematic literature reviews were conducted utilizing a combination of searches among keywords including (parent * OR family) AND (intervention OR therap * OR treatment OR prevent*) AND (adolescen*). Inclusion criteria were (1) a randomized controlled trial of an individual psychological intervention compared to the same intervention with a parental component, and (2) adolescents must have at least current symptoms or risk to be included. Literature searches identified 20 trials (N = 1251). Summary statistics suggested that interventions involving parents in treatment have a significantly greater impact on adolescent psychopathology when compared to interventions that targeted adolescents alone (g = - 0.18, p < .01, 95% CI [- 0.30, - 0.07]). Examination with symptom type (internalizing or externalizing) as a moderator found that the significant difference remained for externalizing (g = - 0.20, p = .01, 95% CI [- 0.35, - 0.05]) but not internalizing psychopathology (p = .11). Findings provide evidence of the importance of including parents in adolescent therapy, particularly for externalizing problems.

Cognitive Behavioral Therapy for Anxiety and Depression in Children and Adolescents

Anxiety and depression are prevalent and impairing psychiatric problems for children and adolescents. In this review, the authors summarize information about their prevalence and impact, the most common assessment methods, the main components of cognitive behavioral therapy (CBT), and research on the effectiveness of CBT for these disorders. Future directions, including improving access to CBT through technology-based approaches and increasing personalization of treatment, are discussed.

A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review

Background

Depression is a public health problem and common amongst adolescents. Cognitive behavioural therapy (CBT) is widely used to treat adolescent depression but existing research does not provide clear conclusions regarding the relative effectiveness of different delivery modalities.

Objectives

The primary aim is to estimate the relative efficacy of different modes of CBT delivery compared with each other and control conditions for reducing depressive symptoms in adolescents. The secondary aim is to compare the different modes of delivery with regard to intervention completion/attrition (a proxy for intervention acceptability).

Search Methods

The Cochrane Depression, Anxiety and Neurosis Clinical Trials Register was searched in April 2020. MEDLINE, PsycInfo, EMBASE, four other electronic databases, the CENTRAL trial registry, Google Scholar and Google were searched in November 2020, together with reference checking, citation searching and hand-searching of two databases.

Selection Criteria

Randomised controlled trials (RCTs) of CBT interventions (irrespective of delivery mode) to reduce symptoms of depression in young people aged 10-19 years with clinically relevant symptoms or diagnosis of depression were included.

Data Collection and Analysis

Screening and data extraction were completed by two authors independently, with discrepancies addressed by a third author. CBT interventions were categorised as follows: group CBT, individual CBT, remote CBT, guided self-help, and unguided self-help. Effect on depressive symptom score was estimated across validated self-report measures using Hedges' g standardised mean difference. Acceptability was estimated based on loss to follow-up as an odds ratio. Treatment rankings were developed using the surface under the cumulative ranking curve (SUCRA). Pairwise meta-analyses were conducted using random effects models where there were two or more head-to-head trials. Network analyses were conducted using random effects models.

Main Results

Sixty-eight studies were included in the review. The mean age of participants ranged from 10 to 19.5 years, and on average 60% of participants were female. The majority of studies were conducted in schools (28) or universities (6); other settings included primary care, clinical settings and the home. The number of CBT sessions ranged from 1 to 16, the frequency of delivery from once every 2 weeks to twice a week and the duration of each session from 20 min to 2 h. The risk of bias was low across all domains for 23 studies, 24 studies had some concerns and the remaining 21 were assessed to be at high risk of bias. Sixty-two RCTs (representing 6435 participants) were included in the pairwise and network meta-analyses for post-intervention depressive symptom score at post-intervention. All pre-specified treatment and control categories were represented by at least one RCT. Although most CBT approaches, except remote CBT, demonstrated superiority over no intervention, no approaches performed clearly better than or equivalent to another. The highest and lowest ranking interventions were guided self-help (SUCRA 83%) and unguided self-help (SUCRA 51%), respectively (very low certainty in treatment ranking). Nineteen RCTs (3260 participants) were included in the pairwise and network meta-analyses for 6 to 12 month follow-up depressive symptom score. Neither guided self-help nor remote CBT were evaluated in the RCTs for this time point. Effects were generally attenuated for 6- to 12-month outcomes compared to posttest. No interventions demonstrated superiority to no intervention, although unguided self-help and group CBT both demonstrated superiority compared to TAU. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking approaches were unguided self-help and individual CBT, respectively. Sixty-two RCTs (7347 participants) were included in the pairwise and network meta-analyses for intervention acceptability. All pre-specified treatment and control categories were represented by at least one RCT. Although point estimates tended to favour no intervention, no active treatments were clearly inferior. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking active interventions were individual CBT and group CBT respectively. Pairwise meta-analytic findings were similar to those of the network meta-analysis for all analyses. There may be age-based subgroup effects on post-intervention depressive symptoms. Using the no intervention control group as the reference, the magnitudes of effects appear to be larger for the oldest age categories compared to the other subgroups for each given comparison. However, they were generally less precise and formal testing only indicated a significant difference for group CBT. Findings were robust to pre-specified sensitivity analyses separating out the type of placebo and excluding cluster-RCTs, as well as an additional analysis excluding studies where we had imputed standard deviations.

Authors' Conclusions

At posttreatment, all active treatments (group CBT, individual CBT, guided self-help, and unguided self-help) except for remote CBT were more effective than no treatment. Guided self-help was the most highly ranked intervention but only evaluated in trials with the oldest adolescents (16-19 years). Moreover, the studies of guided self-help vary in the type and amount of therapist support provided and longer-term results are needed to determine whether effects persist. The magnitude of effects was generally attenuated for 6- to 12-month outcomes. Although unguided self-help was the lowest-ranked active intervention at post-intervention, it was the highest ranked at follow-up. This suggests the need for further research into whether interventions with self-directed elements enable young people to maintain effects by continuing or revisiting the intervention independently, and whether therapist support would improve long-term outcomes. There was no clear evidence that any active treatments were more acceptable to participants than any others. The relative effectiveness of intervention delivery modes must be taken into account in the context of the needs and preferences of individual young people, particularly as the differences between effect sizes were relatively small. Further research into the type and amount of therapist support that is most acceptable to young people and most cost-effective would be particularly useful.

Systemic therapy in children and adolescents with mental disorders: a systematic review and meta-analysis

BACKGROUND

Systemic therapy (ST) is a psychotherapeutic intervention in complex human systems (both psychological and interpersonal). Cognitive behavioural therapy (CBT) is an established treatment for children and adolescents with mental disorders. As methodologically rigorous systematic reviews on ST in this population are lacking, we conducted a systematic review and meta-analysis to compare the benefit and harm of ST (and ST as an add-on to CBT) with CBT in children and adolescents with mental disorders.

METHODS

We searched MEDLINE, Embase, PsycINFO and other sources for randomised controlled trials in 14 mental disorder classes for the above comparisons in respect of effects on patient-relevant outcomes (search date: 7/2022). Where possible, meta-analyses were performed and results were graded into 3 different evidence categories: "proof", "indication", or "hint" (or none of these categories). PRISMA standards were followed.

RESULTS

Fifteen studies in 5 mental disorder classes with usable data were identified. 2079 patients (mean age: 10 to 19 years) were analysed. 12/15 studies and 29/30 outcomes showed a high risk of bias. In 2 classes, statistically significant and clinically relevant effects in favour of ST were found, supporting the conclusion of a hint of greater benefit of ST for mental and behavioural disorders due to psychoactive substance use and of ST as an add-on to CBT for obsessive-compulsive disorders. In 2 other classes (eating disorders; hyperkinetic disorders), there was no evidence of greater benefit or harm of ST. For affective disorders, a statistically significant effect to the disadvantage of ST was found for 1 outcome, supporting the conclusion of a hint of lesser benefit of ST.

CONCLUSIONS

Our results show a hint of greater benefit of ST (or ST as an add-on to CBT) compared with CBT for 2 mental disorder classes in children and adolescents (mental and behavioural disorders due to psychoactive substance use, obsessive compulsive disorders). Given the importance of CBT as a control intervention, ST can therefore be considered a beneficial treatment option for children and adolescents with certain mental disorders. Limitations include an overall high risk of bias of studies and outcomes and a lack of data for several disorders.

Effectiveness of family-based therapy for depressive symptoms in children and adolescents: A systematic review and meta-analysis

Early-onset depression contributes significantly to the global health burden and has long-term negative effects. This meta-analysis collates and examines the effectiveness of family-based interventions, where family members are involved in the treatment of depression in children and adolescents. A literature search was performed up to 8th March 2023. Randomised controlled trials of family-based interventions were included for participants aged 3-18 years with a diagnosis of major depressive disorder or dysthymia, according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) or with a score above a cut-off on a standardised self-report depression measure. The overall effect size for treatment versus active control was g = 0.22 (95% confidence interval [CI]: -0.05-0.50) (nine studies; 659 participants), and for treatment versus non-active control it was g = 0.46 (95% CI: -0.09-1.01) (four studies; 385 participants). Effect sizes were not statistically significant, and heterogeneity was high, ranging between I2  = 64.3-81.1%. Subgroup analysis comparing attachment-based family therapy with family therapy using other theoretical frameworks did not yield a significant difference between the two. The effects of family-based therapies were larger than those in the comparison groups, but family-based therapy did not demonstrate a significant treatment benefit compared to the controls. More randomised controlled trials are warranted, considering that evidence for other psychotherapies for depression in children and adolescents, indicates modest effects. Family-based therapy may be an alternative for children and adolescents whose needs are not addressed by these treatments.

Development, reach, acceptability and associated clinical changes of a group intervention to improve caregiver-adolescent relationships in the context of adolescent depression

Background

Adolescents with depression often experience relationship problems with their caregivers, which predict poorer treatment outcomes. Personalising interventions by targeting factors associated with poor treatment outcomes may enhance the effectiveness of interventions. We report the development and initial evaluation of an intervention designed to target caregiver-adolescent relationship problems in the context of adolescent depression.

Methods

Following a literature search to identify established caregiver interventions, we developed a new group intervention for caregivers through an iterative process including six rounds of the group with n = 53 caregivers of adolescents age 13-18 in the context of an integrated care pathway for adolescent depression. Caregivers rated their family functioning at the beginning and end of the program and provided anonymous satisfaction ratings. Enrolment and attendance data were examined. Youth with lived experience of depression and their caregivers provided input that was incorporated in the final version of the intervention.

Results

The final intervention consists of 8 weekly, 1.5 h group sessions, delivered face-to-face, addressing: psychoeducation, the cognitive-behavioural model and caregiving, positive caregiving, listening and validation, expressing emotions effectively, and problem solving. Reach (56%), attendance (M = 63%, SD = 31%), and satisfaction (M = 92%; SD = 7%) supported the feasibility of the program. Caregivers reported significant improvements in family functioning, t(21) = 2.68, p = .014, d z = 0.56 [95% CI 0.11-1.0].

Discussion

A group intervention is acceptable to caregivers of adolescents with depression and may be associated with improved family functioning. Further research is needed, including a randomised controlled trial to test effects of the intervention on various dimensions of the caregiver-youth relationship and on youth depression outcomes.

Factors That Predict Magnitude, Timing, and Persistence of Placebo-Like Response in Patients With Irritable Bowel Syndrome

BACKGROUND AND AIMS

Placebo response impedes the development of novel irritable bowel syndrome (IBS) therapies and the interpretability of randomized clinical trials. This study sought to characterize the magnitude, timing, and durability of IBS symptom relief in patients undergoing a non-drug placebo-like control.

METHODS

One hundred forty-five Rome III-diagnosed patients (80% F, M age = 42 years) were assigned to education/nondirective support delivered over a 10-week acute phase. Treatment response was based on the IBS version of the Clinical Global Improvement Scale completed 2 weeks after treatment ended. Candidate predictors were assessed at baseline (eg, emotion regulation, pain catastrophizing, distress, neuroticism, stress, somatization, gastrointestinal-specific anxiety) or clinically relevant points during treatment (patient-provider relationship, treatment expectancy/credibility).

RESULTS

Midtreatment response was associated with lower levels of stress and somatization at baseline and greater patient-provider agreement on treatment tasks (P < .001). Treatment response was associated with baseline gastroenterologist-rated IBS severity, anxiety, ability to reappraise emotions to reduce their impact [cognitive reappraisal], and agreement that provider and patient shared goals from provider perspective (P < .001). The day-to-day ability to reappraise emotions at baseline distinguished rapid from delayed placebo responders (P = .011).

CONCLUSION

Patient beliefs (eg, perceived stress, cognitive reappraisal) impacted the magnitude, timing, and persistence of placebo response measured at midway point of acute phase and 2 weeks after treatment discontinuation. Baseline beliefs that patients could alter the impact of stressful events by rethinking their unpleasantness distinguished rapid vs delayed placebo responders. Collaborative agreement between doctor and patient around shared tasks/goals from the clinician perspective predicted placebo response.

Involving Parents in Child Mental Health Treatments: Survey of Clinician Practices and Variables in Decision Making

OBJECTIVE

Child therapy outcomes research has indicated that involving parents in child mental health treatments is generally beneficial. This study aimed to explore clinicians' decisions to involve parents in treatment for childhood disorders and child-, parent-, and clinician-related variables influencing these decisions.

METHODS

Data on decision making and reported use of parent involvement by 40 therapists with patients ages 6-12 were obtained from a self-report survey. Most clinicians were psychologists, White, and female and worked in community-based clinics. They reported using cognitive-behavioral and family system interventions considerably more than psychodynamic therapy.

RESULTS

Clinician-reported use of parent involvement was significantly greater for children with oppositional defiant or conduct disorder than for those with attention-deficit hyperactivity disorder, depression, anxiety, or posttraumatic stress disorder or trauma. A child's age and diagnosis (100% of clinicians), parental level of stress (85%), and parent interest in working with the clinician (60%) were frequently reported as being important to clinicians' decisions. Ninety percent of clinicians reported that they believed working with parents was effective, whereas only 25% reported their own training to be influential in decision making.

CONCLUSIONS

Findings regarding use of parent involvement stratified by common childhood disorder were not surprising, given the behavioral and treatment complexities of oppositional defiant or conduct disorder. Clinicians often reported parents' stress level and interest in working with the clinician as influencing decision making, reflecting the importance of lesser researched decision variables. The relatively limited influence of training on decision making suggests the need for better parent involvement education for clinicians treating children.

Randomized evaluation of a school-based, trauma-informed group intervention for young women in Chicago

This study explores whether a school-based group counseling program for adolescent girls, implemented at scale, can mitigate trauma-related mental health harms. In a randomized trial involving 3749 Chicago public high school girls, we find that participating in the program for 4 months induces a 22% reduction in posttraumatic stress disorder symptoms and find significant decreases in anxiety and depression. Results surpass widely accepted cost-effectiveness thresholds, with estimated cost-utility well below $150,000 per quality adjusted life year. We find suggestive evidence that effects persist and may even increase over time. Our results provide the first efficacy trial of such a program specifically designed for girls, conducted in America's third largest city. These findings suggest the promise of school-based programs to mitigate trauma-related harms.

Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Major and Persistent Depressive Disorders

OBJECTIVE

To enhance the quality of care and clinical outcomes for children and adolescents with major depressive disorder (MDD) and persistent depressive disorder (PDD). The aims are as follows: (1) to summarize empirically based guidance about the psychosocial and psychopharmacologic treatment of MDD and PDD in children and adolescents; and (2) to summarize expert-based guidance about the assessment of these disorders as an integral part of treatment, and the implementation of empirically based treatments for these disorders in clinical practice.

METHOD

Statements about the treatment of MDD and PDD are based upon empirical evidence derived from a critical systematic review of the scientific literature conducted by the Research Triangle Institute International-University of North Carolina at Chapel Hill (RTI-UNC) Evidence-based Practice Center under contract with the Agency for Healthcare Research and Quality (AHRQ). Evidence from meta-analyses published since the AHRQ/RTI-UNC review is also presented to support or refute the AHRQ findings. Guidance about the assessment and clinical implementation of treatments for MDD and PDD is informed by expert opinion and consensus as presented in previously published clinical practice guidelines, chapters in leading textbooks of child and adolescent psychiatry, the DSM-5-TR, and government-affiliated prescription drug information websites.

RESULTS

Psychotherapy (specifically, cognitive-behavioral and interpersonal therapies) and selective serotonin reuptake inhibitor (SSRI) medication have some rigorous (randomized controlled trials, meta-analyses) empirical support as treatment options. Because effective treatment outcomes are predicated in part upon accuracy of the diagnosis, depth of the clinical formulation, and breadth of the treatment plan, comprehensive, evidence-based assessment may enhance evidence-based treatment outcomes.

CONCLUSION

Disproportionate to the magnitude of the problem, there are significant limitations in the quality and quantity of rigorous empirical support for the etiology, assessment, and treatment of depression in children and adolescents. In the context of a protracted severe shortage of child and adolescent-trained behavioral health specialists, the demonstration of convenient, efficient, cost-effective, and user-friendly delivery mechanisms for safe and effective treatment of MDD and PDD is a key research need. Other research priorities include the sequencing and comparative effectiveness of depression treatments, delineation of treatment mediators and moderators, effective approaches to treatment nonresponders and disorder relapse/recurrence, long-term effects and degree of suicide risk with SSRI use, and the discovery of novel pharmacologic or interventional treatments.

Family therapy for adolescents with depression and suicidal ideation: A systematic review and meta-analysis

OBJECTIVE

To systematically review and meta-analyze the effectiveness of family therapy compared to other active treatments for adolescents with depressive disorders or suicidal ideation.

METHOD

We conducted a systematic search of The Cochrane Central Register of Controlled Trials, Medline, Embase, PsycINFO, AMED, CINAHL and Web of Science and performed two meta-analyses of outcomes for depressive symptoms and suicidal ideation.

RESULTS

We screened 5,940 records and identified 10 randomized controlled studies of family therapy for depressive disorder or suicidal ideation in adolescents with an active treatment comparison group. Nine studies reported outcome measures of depressive symptoms and four reported outcome measures of suicidal ideation. The meta-analysis showed no significant difference between family therapy and active comparison treatments for end-of-treatment levels of depression. For suicidal ideation our meta-analysis showed a significant effect in favour of family therapy over comparison treatments for suicidal ideation.

CONCLUSIONS

Based on the current body of research, we found that family therapy is not superior to other psychotherapies in the treatment of depressive disorder. However, family therapy leads to significantly improved outcomes for suicidal ideation, compared to other psychotherapies. The evidence for the treatment of depression is of low quality needs more research.

Psychological therapists' perceptions of adolescent depression and its treatment: A mixed methods online survey

BACKGROUND

Challenges to implementating interventions for adolescent depression exist. Exploring the perceptions of key stakeholders in the treatment of adolescent depression is essential for improving implementation . This study aimed to explore psychological therapists' perceptions of, and experiences treating, adolescent depression to identify future avenues for exploration.

METHOD

Data were collected opportunistically via a survey integrated within an e-learning package about adolescent depression.

RESULTS

Participants believed that adolescent depression was characterised by adolescents' lack of understanding, isolation, and a lack of hope and knowledge. Participants overcame engagement barriers by building trust. Following the e-learning, participants expressed increased understanding of the risk factors associated with adolescent depression and of assessment using different measures. Several key areas for future research to explore were identified and discussed, including (1) whether clinicians of different modalities or at different career stages have difference perceptions, (2) how to meaningfully engage adolescents in treatment and (3) how to train clinicians on different modalities so patients have a choice over their treatment.

CONCLUSION

This study demonstrates the value of knowledge gained from understanding psychological therapists' perceptions and illustrates how this can contribute to the improved treatment of adolescent depression.

Overall goal of Cognitive-Behavioral Therapy in Major Psychiatric Disorders and Suicidality: A Narrative Review

Cognitive-behavioral therapy (CBT) is a form of psychological treatment that is based on the underlying assumption that mental disorders and psychological distress are maintained by cognitive factors, that is, that general beliefs about the world, the self, and the future contribute to the maintenance of emotional distress and behavioral problems. The overall goal of CBT is to replace dysfunctional constructs with more flexible and adaptive cognitions. The most relevant cognitive-behavioral techniques in clinical practice are: i. Cognitive Restructuring (also known as the ABCDE method) is indicated to support patients dealing with negative beliefs or thoughts. The different steps in the cognitive restructuring process are summarized by the letters in the ABCDE acronym that describe the different stages of this coaching model: Activating event or situation associated with the negative thoughts, Beliefs and belief structures held by the individual that explain how they perceive the world which can facilitate negative thoughts, Consequences or feelings related to the activating event, Disputation of beliefs to allow individuals to challenge their belief system, and Effective new approach or effort to deal with the problem by facilitating individuals to replace unhelpful beliefs with more helpful ones. ii. Problem-Solving (also known as SOLVE) to raise awareness for specific triggers, and evaluate and choose more effective options. Each letter of the SOLVE acronym identifies different steps of the problem-solving process: Select a problem, generate Options, rate the Likely outcome of each option, choose the Very best option, and Evaluate how well each option worked. For example, a suicide attempt is reconceptualized as a failure in problem-solving. This treatment approach attempts to provide patients with a better sense of control over future emerging problems. iii. Re-attribution is a technique that enables patients to replace negative self-statements (eg, "it is all my fault") with different statements where responsibility is attributed more appropriately. Furthermore, decatastrophizing may help subjects, especially adolescents decide whether they may be overestimating the catastrophic nature of the precipitating event, and by allowing them to scale the event severity they learn to evaluate situations along a continuum rather than seeing them in black and white. iv. Affect Regulation techniques are often used with suicidal adolescents to teach them how to recognize stimuli that provoke negative emotions and how to mitigate the resulting emotional arousal through self-talk and relaxation.

How mobile phone addiction is associated with suicidal ideation in university students in China: Roles of depression and online social support

Background

Recent studies have highlighted mobile phone addiction (MPA) as a potential risk of suicidal ideation. However, the mechanisms underlying that association require attention.

Objective

This investigation aims to examine whether the relationship between MPA and suicidal ideation would be mediated by depression, and buffered by online social support (OSS) in university students.

Methods

A convenient sample of 1,042 Chinese university students completed the measures of mobile phone addiction, depression, suicidal ideation, OSS in classroom settings. Moderated mediation analyses were performed to test the roles of depression and OSS in the association between MPA and suicidal ideation.

Results

MPA was positively associated with suicidal ideation through depression (indirect effect =. 23, 95% CI: 0.18, 0.28, p < 0.001); OSS moderated the association between depression and suicidal ideation (B = - 0.09, 95% CI: -0.13, -0.04, p < 0.001). Specifically, the effect of depression on suicidal ideation was weaker in individuals with high (versus low) OSS. OSS moderated the association between MPA and suicidal ideation (B = 0.06, 95% CI: 0.02, 0.10, p = 0.001). The influence of MPA on suicidal ideation was non-significant among individuals with high OSS but negatively significant among students with low OSS.

Conclusion

The results enrich the understanding of how MPA may increase suicidal ideation, and highlight the potential importance of reducing depression and enhancing OSS to prevent suicidal ideation in university students.

Family involvement in psychotherapy for depression in children and adolescents: Systematic review and meta-analysis

PURPOSE

Depressive disorders in children and adolescents have an enormous impact on their general quality of life. There is a clear need to effectively treat depression in this age group. Effects of psychotherapy can be enhanced by involving caregivers. In our systematic review and meta-analysis, we examine for the first time the effects of caregiver involvement in depression-specific interventions for children and adolescents.

METHODS

We included randomized controlled trials examining the effects of interventions for children and adolescents with depression involving their caregivers or families compared to interventions without including caregivers. Primary outcome was the severity of childhood and adolescent depression.

RESULTS

Overall, 19 randomized controlled trials could be included (N = 1553) that were highly heterogeneous regarding outcome measures or the extent of caregiver integration. We were able to include k = 17 studies in our meta-analysis and find a small but significant effect for family-involved interventions against active control conditions without family-involvement at post intervention (α = 0.05, d = 0.34; [0.07; 0.60]; p = .01).

CONCLUSIONS

We detected an overall significant but small effect of family/caregivers' involvement compared to control groups without it. Structured, guideline-based research is urgently needed to identify for which children/adolescents with depression, under what circumstances, and in what form the family should be effectively involved in their psychotherapy.

Interventions in Chinese Undergraduate Students' Mental Health: Systematic Review

BACKGROUND

Over 30% of university students from 8 countries were afflicted with mental distress according to a World Health Organization survey. Undergraduate students in increasing numbers in China have also been reported to suffer from different mental problems. Various psychological distresses significantly impact their academic and daily life, thereby causing role impairments and unsatisfactory academic achievements. While the prevalence of, diverse underlying factors for, and interventions of social support in college students' mental health have extensively been investigated in China, there is no study exclusively focusing on the impact of interventions on their psychological well-being.

OBJECTIVE

The aim of this review was to identify and synthesize the interventions in the mental health concerns of Chinese undergraduate students studying in China reported in the literature to inform educational authorities, college and university management, students' affairs counselors, and mental health providers.

METHODS

We performed a systematic review and reported the research findings of previous studies according to the protocol of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 statement. First, based on the predefined search strategy, keyword searches were performed in the PubMed and ProQuest databases to retrieve relevant studies. Subsequently, we screened the candidate articles based on predefined inclusion and exclusion criteria. Finally, we analyzed the included papers for qualitative synthesis.

RESULTS

We retrieved a total of 675 studies from the PubMed and ProQuest databases using the search strategy on March 15, 2022. Among these candidate studies, 15 that were not written in English, 76 duplicates, and 149 studies of other document types were removed before screening. An additional 313 studies were excluded in the screening process, with 73 articles ruled out for being not relevant to interventions, not related to mental health, or not focused on undergraduate students in the full-text review. As a result, 49 papers were eligible and included in this systematic review. In the qualitative synthesis, we divided the interventions reported in the selected studies into two categories: (1) social support from government authorities, university authorities, students' affairs counselors and teachers, family members, health care authorities and professionals, and the media (various online platforms), and (2) various coping strategies adopted by undergraduate students themselves. We identified further research on mental health interventions that may be delivered by digital medical platforms, conversational agents (eg, chatbots), and researchers.

CONCLUSIONS

This was the first systematic review of interventions to address the mental health concerns of Chinese undergraduate students studying in China. The categorization of reported interventions and the identification of new intervention channels can effectively inform stakeholders. Interventions for undergraduate students' mental health is a research topic worth further investigation.

Predictors, Moderators, and Mediators Associated With Treatment Outcome in Randomized Clinical Trials Among Adolescents With Depression: A Scoping Review

Importance

The application of precision medicine principles for the treatment of depressive disorders in adolescents requires an examination of the variables associated with depression outcomes in randomized clinical trials (RCTs).

Objective

To describe predictors, moderators, and mediators associated with outcomes in RCTs for the treatment of depressive disorders in adolescents.

Evidence Review

A scoping review of RCTs for the treatment of depression in adolescents was conducted. Databases searched included MEDLINE, Embase, APA PsycInfo, and CINAHL. Included publications tested predictors, moderators, and/or mediators associated with depression symptom outcomes (eg, symptom reduction, response, remission) in RCTs pertaining to the treatment of adolescents, ages 13 to 17 years. Predictors were defined as variables that were associated with depression outcomes, independent of treatment group. Moderators were defined as baseline variables that were associated with differential outcomes between treatment groups. Mediators were defined by a formal mediation analysis. In duplicate, variables were extracted and coded with respect to analysis type (univariable or multivariable), statistical significance, direction of effect size, reporting of a priori hypotheses, and adjustment for multiple comparisons. Aggregated results were summarized by variable domain and RCT sample.

Findings

Eighty-one articles reporting on variables associated with outcomes across 33 RCTs were identified, including studies of biological (10 RCTs), psychosocial (18 RCTs), and combined (4 RCTs) treatments as well as a service delivery model (1 RCT). Fifty-three variable domains were tested as baseline predictors of depression outcome, 41 as moderators, 19 as postbaseline predictors, and 5 as mediators. Variable domains that were reported as significant in at least 3 RCTs included age, sex/gender, baseline depression severity, early response to treatment, sleep changes, parent-child conflict, overall psychopathology, suicidal ideation, hopelessness, functional impairment, attendance at therapy sessions, and history of trauma. Two publications reported a priori hypotheses and adjustment for multiple comparisons, both finding that baseline depression severity and family conflict were associated with poorer outcomes.

Conclusions and Relevance

This review identified commonly researched variables requiring more scrutiny as well as underresearched variables to inform future study designs. Further efforts to discover predictors, moderators, and mediators associated with treatment response have great potential to optimize care for adolescents with depression.

Review of family-based treatments from 2010 to 2019 for suicidal ideation and behavior

Suicide ideation and behavior are pervasive public health issues. Given that positive interpersonal relationships can be a protective factor against suicide risk, we conducted a systematic review to examine peer-reviewed publications from 2010 to 2019 that included empirical data, tested an intervention with at least some family component, and included a suicide-related outcome measure. We reviewed and synthesized findings from 22 articles covering 7 intervention categories with 12 interventions to examine the treatment components and the quality of evidence to support them. Using Southam-Gerow and Prinstein's (Child Adolesc Psychol 43:16, 2014) guidelines, we identified two well-established intervention categories that met the highest standards for interventions and three probably efficacious intervention categories. All interventions found focused solely on suicide risk in adolescent populations. More studies are needed for adult populations and to explore the role of family moderators and mediators to test whether suicide outcomes are reduced by improvement in the family environment.

Preference, Knowledge, and Attitudes of Parents Toward Cognitive Behavioral Therapy for Their Children in Riyadh, Saudi Arabia

Introduction: Cognitive behavioral therapy (CBT) for children and adolescents has shown efficacy in treating different psychiatric disorders. It has been added to multiple clinical guidelines as the first-line treatment. However, despite more studies of its efficacy, CBT is underutilized in clinical settings due to a lack of rigorous training programs and qualified CBT therapists. The limited knowledge of parents in this intervention and their negative attitudes toward it have been considered as possible reasons. Methods: This is a cross-sectional survey-based study among 464 Saudi parents living in Riyadh city. We aimed to evaluate the preference, knowledge, and attitudes of Saudi parents toward CBT for their children. We compared the difference in the level of knowledge and attitudes toward CBT in relation to the characteristics of parents. An online questionnaire that included 39 questions was carefully reconstructed from four validated scales, approved by an expert panel, and piloted. Participants were recruited to participate through online social media. Results: Saudi parents had average knowledge about CBT; however, they had positive attitudes toward the therapy itself and its role in treating the behavioral issues of children. Male participants showed better knowledge than female participants. Participants with higher education and those with high income had more favorable attitudes toward CBT than others. Conclusion: The knowledge of parents is considered inadequate and indicated the need for more awareness and perhaps mass education. In contrast, they maintained positive attitudes and were interested in evidence-based treatment, with more preference toward non-psychopharmacological interventions.

Forks in the road: Definitions of response, remission, recovery, and other dichotomized outcomes in randomized controlled trials for adolescent depression. A scoping review

BACKGROUND

Definitions of dichotomous outcome terms, such as "response," "remission," and "recovery" are central to the design, interpretation, and clinical application of randomized controlled trials of adolescent depression interventions. Accordingly, this scoping review was conducted to document how these terms have been defined and justified in clinical trials.

METHOD

Bibliographic databases MEDLINE, Embase, APA PsycInfo, and CINAHL were searched from inception to February 2020 for randomized controlled trials evaluating treatments for adolescent depression. Ninety-eight trials were included for data extraction and analysis.

RESULTS

Assessment of outcome measurement instruments, metric strategies, methods of aggregation, and measurement timing, yielded 53 unique outcome definitions of "response" across 45 trials that assessed response, 47 unique definitions of "remission" in 29 trials that assessed remission, and 19 unique definitions of "recovery" across 11 trials that assessed recovery. A minority of trials (N = 35) provided a rationale for dichotomous outcomes definitions, often by citing other studies that used a similar definition (N = 11). No rationale included input from youth or families with lived experience.

CONCLUSION

Our review revealed that definitions of "response," "remission," "recovery," and related terms are highly variable, lack clear rationales, and are not informed by key stakeholder input. These limitations impair pooling of trial results and the incorporation of trial findings into pragmatic treatment decisions in clinical practice. Systematic approaches to establishing outcome definitions are needed to enhance the impact of trials examining adolescent depression treatment.

Behavioral Activation as an 'active ingredient' of interventions addressing depression and anxiety among young people: a systematic review and evidence synthesis

BACKGROUND

Psychological interventions such as behavioral activation (BA) that focus on overt behaviors rather than complex cognitive skills may be developmentally well-suited to address youth mental health problems. The current systematic review synthesized evidence on the characteristics, effectiveness and acceptability of behavioral activation (BA) to examine its role as a potential 'active ingredient' for alleviating depression and anxiety among young people aged 14 to 24 years.

METHODS

Evidence across the following sources were synthesized: (i) randomized control trials (RCT) evaluating interventions where BA has been used as a standalone intervention or as part of a multicomponent intervention, (ii) qualitative studies examining the acceptability of BA as an intervention or as a coping strategy among young people with lived experiences. Consultations with a youth advisory group (YAG) from India were used to draw inferences from existing evidence and identify future research priorities.

RESULTS

As part of the review, 23 RCTs were identified; three studies examined BA as a standalone intervention, and the remaining studies examined multicomponent intervention where BA was a constituent element. The intervention protocols varied in composition, with the number of intervention elements ranging between 5 to 18. There was promising but limited evidence in standalone interventions for thse effectiveness of BA for depression. The impact of BA in multicomponent interventions was difficult to evaluate in the absence of focal assessment of activation outcomes. Evidence from 37 additional qualitative studies of youth lived experience literature, corroborated by the YAG inputs, indicated that young people preferred using behavioral strategies similar to BA to cope with depression in their own life. Themes indicated that the activities that are important to an individual and their socio-contextual factors need to be considered in the planning and implementing BA intervention. Evidence for the use of BA in anxiety was limited across data sources.

CONCLUSIONS

Overall, there was preliminary empirical evidence for the effectiveness and acceptability of BA for youth depression. Further research is needed to examine the components and mechanisms that contribute to its effectiveness as an active intervention ingredient for depression and anxiety.

Supporting the parents of children and young people with anxiety and depressive disorders is an opportunity not to be missed: a scoping review

Guidance is scarce on whether and how to involve parents in treatment for anxiety and depressive disorders in children and young people. We did a scoping review of randomised controlled trials of psychological interventions for anxiety and depressive disorders in children and young people, in which parents were involved in treatment, to identify how parents and carers have been involved in such treatments, how this relates to both child and broader outcomes, and where research should focus. We identified 73 trials: 62 focused on anxiety and 11 on depressive disorders. How parents were involved in treatments varied greatly, with at least 13 different combinations of ways of involving parents in the anxiety trials and seven different combinations in the depression trials. Including parents in treatment did not impair children's and young people's outcomes, but the wide variability in how they were involved prevents clarity about why some trials favoured parent involvement and others did not. Studies must consider the long-term and wider benefits beyond children's and young people's mental health, such as enhanced engagement, family wellbeing, and economic gains.

Implementing Attachment-Based Family Therapy for Depressed and Suicidal Adolescents and Young Adults in LGBTQ+ Services

Background: Suicide is a serious public health problem for LGBTQ+ adolescents and young adults. Attachment-based family therapy (ABFT) is one of the few suicide treatment models that has been tested with this population. The challenge remains in how to implement ABFT into the ecology of LGBTQ+ service settings. Aims: In this study, we tested the feasibility, acceptability, and preliminary effectiveness of ABFT in LGBTQ+ community settings. Method: Ten participants were enrolled in 16 weeks of ABFT across three LGBTQ+ organizations. Feasibility (treatment completion) and acceptability (Working Alliance Inventory [WAI]; opinions about treatment [OAT]) were measured for youth and caregivers. Depression and suicide outcomes were assessed for nine participants. Results: ABFT was demonstrated to be both feasible and acceptable. All participants completed treatment, and there were no dropouts. Adolescents/young adults and their caregivers reported high WAI and adequate OAT scores throughout treatment. There was a significant decrease in suicidal ideation (β = -12.16, t(10) = -3.14, p < .01). Decreases in depression, however, were not significant (β = -1.83, t(9.11) = -0.88, p = .40). Limitations: The small sample limits our ability to estimate treatment effectiveness. A larger effectiveness trial is warranted. Conclusion: ABFT is a promising treatment for LGBTQ+ service settings.

Inside the Clockwork of the ECHO Factorial Trial: A Conceptual Model With Proposed Mediators for Prevention of Emotional Problems in Children

Having interventions that are not only evidence-based and effective but also cost-effective and efficient is important for the prevention and treatment of child and adolescent emotional problems. A randomized clinical trial (RCT) tests the total interventions effect but does not address specific components of the intervention. In this article the hypothesis and a conceptual model of the ECHO study are presented and discussed. The ECHO intervention consists of three different components each containing two levels of intervention. By using a cluster randomized factorial design, children aged 8-12 at 40 schools across Norway will be randomized to eight different experimental conditions investigating the optimal balance between effect, cost-effectiveness, and efficiency. The article presents the design and the different components being tested and discusses how optimalization can be reached through this innovative design. The article also discusses how interventions can be improved by investigating and understanding the mechanisms of change within psychological interventions. For each of the three components in the study we consider the mediators that could be active within the intervention and how the study investigates such mediation. The results will contribute to a better understanding of how psychological interventions work and how we intend to optimize the EMOTION intervention.

Moderators and Predictors of Response After 36 Weeks of Treatment in the Treatment for Adolescents with Depression Study (TADS)

This study investigated pretreatment variables associated with depression severity in adolescents following maintenance treatment for major depressive disorder (MDD). Data was derived from the Treatment for Adolescents with Depression Study (TADS). Participants received one of three treatments: cognitive behavioral therapy (CBT), fluoxetine (FLX), or combined CBT and fluoxetine (COMB). Participants received 12 weeks of acute treatment, 6 weeks of consolidation treatment, and 18 weeks of maintenance treatment (N = 327, M age = 14.62 yrs). Outcome was measured by the Children's Depression Rating Scale-Revised. Results showed adolescents with shorter depressive episodes, better global functioning, less suicidal ideation, better health/social functioning, and greater expectancy of positive treatment response were more likely to have lower depression severity following 36 weeks of treatment, regardless of modality. Adolescents with lower initial depression demonstrated lower depression severity if treated with CBT. FLX was more effective in reducing depression severity in adolescents with severe baseline depression than for those with mild or moderate depression. Adolescents with higher family incomes were more likely to have lower depression severity if they received CBT only. In conclusion, adolescents with shorter depressive episodes, better health, social, and global functioning, less suicidal ideation, and greater expectancy for treatment at baseline respond equally well to CBT, fluoxetine, and combined treatment. Adolescents who are more severely depressed at baseline may have a better treatment response if they are treated with FLX; whereas adolescents of higher income are more likely to have a better response if they receive CBT only.

Psychological Treatments for Depression in Adolescents: More Than Three Decades Later

Depression is a common and impairing disorder which is a serious public health problem. For some individuals, depression has a chronic course and is recurrent, particularly when its onset is during adolescence. The purpose of the current paper was to review the clinical trials conducted between 1980 and 2020 in adolescents with a primary diagnosis of a depressive disorder, excluding indicated prevention trials for depressive symptomatology. Cognitive behavioral therapy (CBT) is the pre-eminent treatment and is well established from an evidence-based treatment perspective. The body of research on the remaining treatments is smaller and the status of these treatments is varied: interpersonal therapy (IPT) is well established; family therapy (FT) is possibly effective; and short-term psychoanalytic therapy (PT) is experimental treatment. Implementation of the two treatments that work well-CBT and IPT-has more support when provided individually as compared to in groups. Research on depression treatments has been expanding through using transdiagnostic and modular protocols, implementation through information and communication technologies, and indicated prevention programs. Despite significant progress, however, questions remain regarding the rate of non-response to treatment, the fading of specific treatment effects over time, and the contribution of parental involvement in therapy.

Visual memory improvement in adolescents at high risk for suicide who are receiving psychotherapy at a community clinic

The current study aims to: 1) investigate cognitive differences among adolescents at risk for suicide versus healthy controls (HC) and 2) identify cognitive changes associated with response to psychotherapy among adolescents at high risk for suicide. Thirty-five adolescents at high risk for suicide (HR), and 14 HC adolescents were recruited. Clinical and cognitive assessments were conducted in both groups at baseline and 16 weeks later (after the patients completed psychotherapy). HR and HC adolescents were compared at baseline and at completion of the study. We also conducted further analysis by separating into two groups the HR adolescents who responded to psychotherapy (n=17) and those who did not (n=11). At baseline, the HR group had significantly lower performance on verbal memory and processing speed than the HC group. At week 16, HR adolescents performed as well as HC adolescents in all cognitive domains. Among patients, better performance on visual memory was observed in those who responded to psychotherapy compared to those who did not. We concluded that lower performance on verbal memory and processing speed may be associated with a high risk for suicide among adolescents. Improvement in visual memory might be related to a lower risk for suicide in adolescents.

Effectiveness of attachment-based family therapy compared to treatment as usual for depressed adolescents in community mental health clinics

BACKGROUND

Major Depressive Disorder (MDD) is a disabling mood disorder, profoundly affecting a large number of adolescent's quality of life. To date, no obvious treatment of choice for MDD in adolescents is available and progress in the treatment of depressed adolescents will have important public health implications. Attachment-Based Family Therapy (ABFT), as the only empirically supported family therapy model designed to treat adolescent depression, aims to repair interpersonal ruptures and rebuild an emotionally protective parent-child relationship.

OBJECTIVE

To study the effectiveness of ABFT compared with treatment as usual (TAU) delivered within child- and adolescent mental health services (CAMHS) to adolescents with MDD.

METHOD

Sixty adolescents (86.7% girls), aged 13-18 years (M = 14.9, SD = 1.35), with MDD referred to two CAMHS were randomized to 16 weeks of ABFT or TAU. ABFT consisted of weekly therapy sessions (family/individual or both) according to the treatment manual. TAU was not monitored. Primary outcomes were assessed by blinded evaluators at baseline and post-treatment with the Hamilton Depression Scale (HAMD). Self-reported (Beck Depression Inventory-II, BDI-II) depressive symptoms were assessed at baseline, and after 4, 6, 8, 10,12, 14, and 16 weeks. Analyses were performed according to intent-to-treat principles.

RESULTS

At post-treatment, clinician-rated remission rates on the HAMD (5% in ABFT and 3.33% in TAU, p = 1, OR = 1.54, Fisher's exact test) and self-reported symptoms of depression on the BDI-II did not differ significantly between groups (X²[2, N = 60] = 0.06, p = 0.97). In both treatment groups participants reported significantly reduced depressive symptoms, but the majority (63.3%) of adolescents were still in the clinical range after 16 weeks of treatment.

CONCLUSION

ABFT was not superior to TAU. Remission and response rates were low in both groups, suggesting none of the treatments were effective in treating MDD in adolescents. Findings must be viewed in the context of the study's small sample size, missing data, and implementation challenges. Continued efforts to improve treatment for MDD in outpatient clinics are warranted. Future research should examine moderators of and mechanisms for individual differences to treatment response, as well as the feasibility and cost-effectiveness of implementing treatment models which may require extensive training and expertise to yield clinically meaningful improvements in non-research settings. Trial registration Clinicaltrials.gov identifier: NCT01830088 https://clinicaltrials.gov/ct2/show/NCT01830088?term=Villab%C3%B8&draw=2&rank=1 Date of registration: April 12, 2013.

Incorporating family factors into treatment planning for adolescent depression: Perceived parental criticism predicts longitudinal symptom trajectory in the Youth Partners in Care trial

BACKGROUND

This study aimed to clarify the predictive significance of youth perceptions of parental criticism assessed using a brief measure designed to enhance clinical utility. We hypothesized that high perceived parental criticism would be associated with more severe depression over 18-months of follow-up.

METHODS

The study involved secondary analyses from the Youth Partners in Care trial, which demonstrated that a quality improvement intervention aimed at increasing access to evidence-based depression treatment in primary care led to improved depression outcomes at post-treatment compared to usual care enhanced by provider education regarding depression evaluation/management. Patients (N = 418; ages 13-21) were assessed at four time points: baseline; post-treatment (six-month follow-up); 12- and 18-month follow-ups. The primary analysis estimated the effect of perceived parental criticism on likelihood of severe depression (i.e., Center for Epidemiological Studies-Depression Scale ≥ 24) over post-intervention follow-ups using a repeated-measures logistic regression model. Secondarily, a linear mixed-effects growth model examined symptom trajectories from baseline through 18-months using the Mental Health Index-5, a measure of emotional distress available at all time-points.

RESULTS

High perceived parental criticism emerged as a robust predictor of clinically-elevated depression (OR=1.66, p=.02) and a more pernicious symptom trajectory over 18-months (β =-1.89, p<.0001).

LIMITATIONS

The association between the self-report perceived criticism and traditional expressed emotion measures derived from verbal and nonverbal parental behaviors was not evaluated.

CONCLUSIONS

Results support perceived parental criticism as a predictor of youth depression outcomes over 18-months. This brief measure can be feasibly integrated within clinical assessment to assist clinicians in optimizing treatment benefits.

Latent Profiles of Cognitive and Interpersonal Risk Factors for Adolescent Depression and Implications for Personalized Treatment

A personalized approach to treatment with patients being matched to the best-fit treatment has been proposed as one possible solution to the currently modest treatment response rates for adolescent depression. Personalized treatment involves identifying and characterizing subgroups likely to respond differently to different treatments. We investigated the feasibility of this approach, by focusing on two key risk factors that are the purported treatment targets of cognitive behavioral therapy (CBT) and interpersonal psychotherapy for depressed adolescents (IPT-A): negative unrealistic cognitions and interpersonal relationship difficulties, respectively. We sought to learn whether subgroups high and low on the two risk factors, respectively, might be identified in a large sample of depressed, treatment-seeking adolescents. Latent class analysis (LCA) was conducted on measures of the two risk factors among 431 adolescents (age 12-17) in the Treatment for Adolescents with Depression Study. LCA identified three classes: (1) adolescents with high levels of problems in both family relationships and cognitions (21.6% of sample), (2) adolescents with moderate levels of problems in both domains (52.4%), and (3) adolescents with low levels of problems in both domains (26.0%). These subgroups did not predict treatment outcome with CBT or CBT + fluoxetine (COMB). The results challenge a current assumption about how treatments could be personalized, and they support a multi-causal model of depression rather than a risk-factor-specific model. Strategies other than risk factor-based personalizing for case assignment to CBT vs. IPT-A are discussed.

Adapted Dialectical Behavior Therapy for Adolescents with a High Risk of Suicide in a Community Clinic: A Pragmatic Randomized Controlled Trial

OBJECTIVE

This study is a pragmatic randomized controlled trial, which compares the effectiveness of an adapted form of Dialectical Behavior Therapy for Adolescents (DBT-A) and treatment as usual plus group sessions (TAU + GS) to reduce suicidal risk for adolescents in a community health mental clinic.

METHOD

Thirty-five adolescents from a community outpatient clinic, with repetitive NSSI alone or with SA over the last 12 months and with current high suicide risk as assessed by the Columbia-Suicide Severity Rating Scale (C-SSRS), were enrolled. Participants were randomly assigned to undergo either DBT-A (n = 18) or TAU + GT (n = 17) treatments over a 16-week period. Primary outcomes were the difference between NSSI and SA recorded during the first 4 weeks and the final 4 weeks of treatment. Secondary outcomes included changes in Children's Global Assessment Scale (C-GAS), Suicidal Ideation Questionnaire (SIQ-JR), and Beck Depression Inventory-II (BDI-II).

RESULTS

Dialectical Behavior Therapy for Adolescents was more effective than TAU + GS at reducing NSSI, use of antipsychotics, and improving C-GAS. No SAs were reported in the two groups at the end of the treatment. Both treatments were equally effective in decreasing SIQ-JR and BDI-II scores.

CONCLUSIONS

These findings support the feasibility and effectiveness of DBT-A for adolescents at high risk of suicide in community settings.

Smartteen- a computer assisted cognitive behavior therapy for Indian adolescents with depression- a pilot study

The prevalence of unipolar depression among adolescents in India is high. Cognitive behavior therapies (CBTs) are considered the current gold standard treatment for depression in adolescents; however, their access is limited in India. Given the ubiquity of technology including smartphones and computers, technology can be leveraged to improve access of CBT treatment in India. Our team developed smartteen- a computer application designed to augment in-person CBT for treatment of depression in adolescents. This paper will present results of the pilot evaluation of smartteen (a cCBT) for its feasibility, acceptability and effectiveness in reducing depressive symptoms. Twenty-one adolescents with unipolar depression seeking treatment at a tertiary care hospital were randomly assigned to smartteen (n = 11) and TAU (n = 10). Both groups received twelve weeks of treatment and were assessed at baseline, mid-treatment (6 weeks) and post-treatment (12 weeks) using four clinical measures including BDI-II, CDRS-R, CGI-S and CGAS. smartteen was shown to be feasible and acceptable treatment to adolescents. At 6 weeks, both treatments were effective in reducing depression. At 12 weeks, smartteen was significantly more effective than TAU in reducing depression symptoms and improving functioning on CGAS. Treatment compliance was better in smartteen group. smartten was shown to reduce the time spent by therapist to deliver 12 sessions of CBT treatment for depression. Results indicate that smartteen may be subjected to more rigorous evaluations with larger samples and considered for wider implementation if found effective.

The chronic pain skills study: Protocol for a randomized controlled trial comparing hypnosis, mindfulness meditation and pain education in Veterans

OBJECTIVES

To describe the protocol of a randomized controlled trial to evaluate the effectiveness and mechanisms of three behavioral interventions.

METHODS

Participants will include up to 343 Veterans with chronic pain due to a broad range of etiologies, randomly assigned to one of three 8-week manualized in-person group treatments: (1) Hypnosis (HYP), (2) Mindfulness Meditation (MM), or (3) Education Control (EDU).

PROJECTED OUTCOMES

The primary aim of the study is to compare the effectiveness of HYP and MM to EDU on average pain intensity measured pre- and post-treatment. Additional study aims will explore the effectiveness of HYP and MM compared to EDU on secondary outcomes (i.e., pain interference, sleep, depression, anxiety and PTSD), and the maintenance of effects at 3- and 6-months post-treatment. Participants will have electroencephalogram (EEG) assessments at pre- and post-treatment to determine if the power of specific brain oscillations moderate the effectiveness of HYP and MM (Study Aim 2) and examine brain oscillations as possible mediators of treatment effects (exploratory aim). Additional planned exploratory analyses will be performed to identify possible treatment mediators (i.e., pain acceptance, catastrophizing, mindfulness) and moderators (e.g., hypnotizability, treatment expectations, pain type, cognitive function).

SETTING

The study treatments will be administered at a large Veterans Affairs Medical Center in the northwest United States. The treatments will be integrated within clinical infrastructure and delivered by licensed and credentialed health care professionals.

Meta-Analysis: 13-Year Follow-up of Psychotherapy Effects on Youth Depression

OBJECTIVE

Youth depression is a debilitating condition that constitutes a major public health concern. A 2006 meta-analysis found modest benefits for psychotherapy versus control. Has 13 more years of research improved that picture? We sought to find out.

METHOD

We searched PubMed, PsychINFO, and Dissertation Abstracts International for 1960 to 2017, identifying 655 randomized, English-language psychotherapy trials for individuals aged 4 to 18 years. Of these, 55 assessed psychotherapy versus control for youth depression with outcome measures administered to both treatment and control conditions at post (κ = 53) and/or follow-up (κ = 32). Twelve study and outcome characteristics were extracted, and effect sizes were calculated for all psychotherapy versus control comparisons. Using a three-level random-effects model, we obtained an overall estimate of the psychotherapy versus control difference while accounting for the dependency among effect sizes. We then fitted a three-level mixed-effects model to identify moderators that might explain variation in effect size within and between studies.

RESULTS

The overall effect size (g) was 0.36 at posttreatment and 0.21 at follow-up (averaging 42 weeks after posttreatment). Three moderator effects were identified: effects were significantly larger for interpersonal therapy than for cognitive behavioral therapy, for youth self-reported outcomes than parent-reports, and for comparisons with inactive control conditions (eg, waitlist) than active controls (eg, usual care). Effects showed specificity, with significantly smaller effects for anxiety and externalizing behavior outcomes than for depression measures.

CONCLUSION

Youth depression psychotherapy effects are modest, with no significant change over the past 13 years. The findings highlight the need for treatment development and research to improve both immediate and longer-term benefits.

Can Cognitive-Behavioral Therapy Be Optimized With Parent Psychoeducation? A Randomized Effectiveness Trial of Adolescents With Major Depression in Puerto Rico

This is a longitudinal randomized control trial on the impact of adding a parent psychoeducation intervention (TEPSI) as part of cognitive-behavioral therapy (CBT) for adolescents with Major Depressive Disorder (MDD) in a Puerto Rican sample. We tested the efficacy of adding 8 group sessions of TEPSI to 12 sessions of individual CBT on reducing depressive symptoms, MDD diagnosis, and improving family functioning. Participants (n = 121) were randomized to individual CBT with or without TEPSI. No main group effects were found for most patient domains including depression symptoms, as well as presence of adolescent's MDD diagnosis at posttreatment. Results did show a main effect of CBT over time for depression symptoms, suicide ideation, family criticism, and the presence of MDD diagnosis decreasing from pre- to postintervention. A year post treatment, almost 70% of adolescents in both conditions (CBT and CBT + TEPSI) remained in remission. A main effect was obtained for treatment in the adolescent's perception of familism and family emotional involvement. The primary hypothesis that family psychoeducation would optimize CBT for depression in adolescents was not supported. Both conditions yielded similar clinical end points. The culturally adapted CBT was found effective with Latino/a adolescents showing clinically significant improvements from pretreatment to posttreatment and remained stable at a 1-year follow-up. Regarding family outcomes, adolescents in CBT + TEPSI remained stable from pretreatment to posttreatment on family emotional involvement, while adolescents in CBT-alone showed an increase. The implication of these findings is discussed.

A Randomized Controlled Trial: Attachment-Based Family and Nondirective Supportive Treatments for Youth Who Are Suicidal

OBJECTIVE

To evaluate the efficacy of attachment-based family therapy (ABFT) compared with a family-enhanced nondirective supportive therapy (FE-NST) for decreasing adolescents' suicide ideation and depressive symptoms.

METHOD

A randomized controlled trial of 129 adolescents who are suicidal ages 12- to 18-years-old (49% were African American) were randomized to ABFT (n = 66) or FE-NST (n = 63) for 16 weeks of treatment. Assessments occurred at baseline and 4, 8, 12, and 16 weeks. Trajectory of change and clinical recovery were calculated for suicidal ideation and depressive symptoms.

RESULTS

There was no significant between-group difference in the rate of change in self-reported ideation (Suicidal Ideation Questionnaire-Jr; F_1,127 = 181, p = .18). Similar results were found for depressive symptoms. However, adolescents receiving ABFT showed a significant decrease in suicide ideation (t₁₂₇ = 12.61, p < .0001; effect size, d = 2.24). Adolescents receiving FE-NST showed a similar significant decrease (t₁₂₇ = 10.88, p < .0001; effect size, d = 1.93). Response rates (ie, ≥50% decrease in suicide ideation symptoms from baseline) at post-treatment were 69.1% for ABFT versus 62.3% for FE-NST.

CONCLUSION

Contrary to expectations, ABFT did not perform better than FE-NST. The 2 treatments produced substantial decreases in suicidal ideation and depressive symptoms that were comparable to or better than those reported in other more intensive, multicomponent treatments. The equivalent outcomes could be attributed to common treatment elements, different active mechanisms, or regression to the mean. Future studies will explore long-term follow up, secondary outcomes, and potential moderators and mediators.

CLINICAL TRIAL REGISTRATION INFORMATION

Attachment-Based Family Therapy for Suicidal Adolescents; http://clinicaltrials.gov; NCT01537419.

The Family Check Up and Adolescent Depression: An Examination of Treatment Responders and Non-Responders

The Family Check Up (FCU) is a family-centered intervention for reducing children's problem behavior through improving parenting skills and family interactions. Although the FCU was designed to prevent conduct problems, we have also found the program to be effective in preventing escalating symptoms of depression in early adolescence. The current analyses examine heterogeneous patterns of response to treatment in an effort to identify factors associated with differential response to family intervention. We examined heterogeneity in trajectories of youth-reported depressive symptoms from grades 6 to 9, using a Latent Growth Mixture Modeling framework to identify patterns of treatment response and non-response. Three symptom trajectories were identified, including the following: (1) a large class exhibiting stable, low symptom levels, (2) a class exhibiting high and stable depressive symptoms, and (3) a class exhibiting low initial symptoms that increased over time. Significant intervention effects were identified only among the third class, as a preventive effect on depression from 7th to 9th grade for youth with low initial symptoms. No effect of intervention was observed in the other two classes. Comparisons of classes 2 and 3 suggested that class 3 members were more likely to be females with high baseline antisocial behavior, but lower initial levels of depression. The findings suggest the importance of exploring heterogeneity within a prevention design, as well as the importance of tailored approaches to the prevention of adolescent depression.

Intensive community treatment and support "Youth Wraparound" service in Western Australia: A case and feasibility study

BACKGROUND

Multiple services are often needed to address the needs of young people with complex emotional or behavioural needs. The Youth Wraparound model of service aims to provide all health and supportive services from one coordinating agency. While this has been researched overseas, there are currently few examples of this described in the Australian psychiatric context.

AIM

To document the implementation and evaluation of a Youth Wraparound service which was provided to a young person with exceptionally complex and challenging needs for 6 months. A single-case study design is presented with an evaluation of the clinical outcome and economic costs.

METHODS

We present a description of the service context, principles of the model of care, implementation process, and an evaluation of service utilization data from health and child protection services and mental health records. A single-case longitudinal design compared service utilization data obtained up to 3 years prior to treatment with data collected one and a half years since treatment commenced.

RESULTS

There were significant reductions in the number of admissions to emergency departments, mental health wards and secure units, and improvements in mental health and well-being. Yearly average time in institutional settings reduced from 69% to 7%. Cost savings in health utilization were estimated at $2 326 790.

CONCLUSIONS

The Youth Wraparound model has the potential to offer improved clinical outcomes, significant cost savings over time, improved coordination between care providers, and an alternative to detention or incarceration.

Parental Validation and Invalidation Predict Adolescent Self-Harm

This study was designed to evaluate family processes theoretically implicated in the onset and maintenance of adolescent self-harm. In the present study, we focus on understanding parental validation and invalidation in response to their adolescent in order to estimate the association between parental responses and self-harm in a high risk group of adolescents. We also sought to determine the influence of psychotherapy on parental validation and invalidation over time during participation in a randomized clinical trial of psychotherapy designed to reduce self-harm. Thirty-eight teens (M age= 14.85; 94.1% female, 55.3% Caucasian, and 17.5% Latino) and their parents participated in three assessments over a six month period corresponding to pretreatment, midtreatment and end of treatment in the trial. Results indicate a robust association between parental validation, invalidation and adolescent self-harm. There were no significant associations observed between parental validation, invalidation, and adolescent suicidal ideation. Observed levels of parental validation and invalidation were not changed during the six-month course of psychotherapy.

Recent developments in the treatment of major depressive disorder in children and adolescents

Major depressive disorder in adolescents is an important public health concern. It is common, a risk factor for suicide and is associated with adverse psychosocial consequences. The UK National Institute for Health and Care Excellence guidelines recommend that children and young people with moderate-to-severe depression should be seen within Child and Adolescent Mental Health Services and receive specific psychological interventions, possibly in combination with antidepressant medication. Cognitive behavioural therapy (in some studies) and interpersonal psychotherapy have been demonstrated to be more effective than active control treatments for depressed adolescents. For children with depression, there is some evidence that family focused approaches are more effective than individual therapy. Fluoxetine is the antidepressant with the greatest evidence for effectiveness compared with placebo. Treatment with antidepressants and/or psychological therapy is likely to reduce suicidality, although in some young people, selective serotonin reuptake inhibitors lead to increased suicidality. There is limited evidence that combination of specific psychological therapy and antidepressant medication is better than treatment with monotherapy. There are methodological limitations in the published literature that make it difficult to relate study findings to the more severely ill clinical population in Child and Adolescent Mental Health Services. Young people should have access to both evidence-based psychological interventions and antidepressants for paediatric depression. Collaborative decisions on treatment should be made jointly by young people, their carers and clinicians, taking into account individual circumstances and potential benefits, risks and availability of treatment.

Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial

Importance

Suicide is a leading cause of death among 10- to 24-year-old individuals in the United States; evidence on effective treatment for adolescents who engage in suicidal and self-harm behaviors is limited.

Objective

To evaluate the efficacy of dialectical behavior therapy (DBT) compared with individual and group supportive therapy (IGST) for reducing suicide attempts, nonsuicidal self-injury, and overall self-harm among high-risk youths.

Design, Setting, and Participants

This randomized clinical trial was conducted from January 1, 2012, through August 31, 2014, at 4 academic medical centers. A total of 173 participants (pool of 195; 22 withdrew or were excluded) 12 to 18 years of age with a prior lifetime suicide attempt (≥3 prior self-harm episodes, suicidal ideation, or emotional dysregulation) were studied. Adaptive randomization balanced participants across conditions within sites based on age, number of prior suicide attempts, and psychotropic medication use. Participants were followed up for 1 year.

Interventions

Study participants were randomly assigned to DBT or IGST. Treatment duration was 6 months. Both groups had weekly individual and group psychotherapy, therapist consultation meetings, and parent contact as needed.

Main Outcomes and Measures

A priori planned outcomes were suicide attempts, nonsuicidal self-injury, and total self-harm assessed using the Suicide Attempt Self-Injury Interview.

Results

A total of 173 adolescents (163 [94.8%] female and 97 [56.4%] white; mean [SD] age, 14.89 [1.47] years) were studied. Significant advantages were found for DBT on all primary outcomes after treatment: suicide attempts (65 [90.3%] of 72 receiving DBT vs 51 [78.9%] of 65 receiving IGST with no suicide attempts; odds ratio [OR], 0.30; 95% CI, 0.10-0.91), nonsuicidal self-injury (41 [56.9%] of 72 receiving DBT vs 26 [40.0%] of 65 receiving IGST with no self-injury; OR, 0.32; 95% CI, 0.13-0.70), and self-harm (39 [54.2%] of 72 receiving DBT vs 24 [36.9%] of 65 receiving IGST with no self-harm; OR, 0.33; 95% CI, 0.14-0.78). Rates of self-harm decreased through 1-year follow-up. The advantage of DBT decreased, with no statistically significant between-group differences from 6 to 12 months (OR, 0.65; 95% CI, 0.12-3.36; P = .61). Treatment completion rates were higher for DBT (75.6%) than for IGST (55.2%), but pattern-mixture models indicated that this difference did not informatively affect outcomes.

Conclusions and Relevance

The results of this trial support the efficacy of DBT for reducing self-harm and suicide attempts in highly suicidal self-harming adolescents. On the basis of the criteria of 2 independent trials supporting efficacy, results support DBT as the first well-established, empirically supported treatment for decreasing repeated suicide attempts and self-harm in youths.

Trial Registration

ClinicalTrials.gov Identifier: NCT01528020.

Parental involvement in adolescent depression interventions: A systematic review of randomized clinical trials

Despite the widespread research recommendations for psychiatric nurses and other mental health professionals to include parents in adolescent depression treatment, no systematic reviews have yet synthesized the findings from intervention studies that included parents in the treatment and/or prevention of adolescent depression. Therefore, this systematic review was conducted to (i) identify and describe clinical trials that included parents as an integral component of adolescent depression interventions, (ii) examine the effectiveness of these trials in reducing depressive symptoms, and (iii) evaluate their methodological quality. We systematically searched the databases PubMed and PsycINFO. The search strategy adhered to the PRISMA statement to guide identification and selection of articles. Further, a structured evaluation form was adapted from the CONSORT statement and methodological literature to evaluate the elicited clinical trials. A total of 288 unique articles met criteria for abstract level screening, 45 articles were selected for full-text review, and 16 articles were included in the final analysis. We found that (i) available approaches to include parents in adolescent depression interventions vary in their theoretical stance, purpose, sample characteristics, and measured outcomes, (ii) the health outcomes of these approaches seemed to be contingent upon the nature of parental involvement, and (iii) effective translation of these approaches into practice needs to be considered in the light of their methodological rigour. Our review revealed a variety of promising approaches to utilize the parental and family contexts as a means of preventing or treating adolescent depression. However, more research is needed to determine which interventions, within what contexts, and using what resources will facilitate the best health outcomes for adolescents with depression and their parents.

Delineating the trajectories of social and occupational functioning of young people attending early intervention mental health services in Australia: a longitudinal study

OBJECTIVES

Mental disorders typically emerge during adolescence and young adulthood and put young people at risk for prolonged socioeconomic difficulties. This study describes the longitudinal course of social and occupational functioning of young people attending primary care-based, early intervention services.

DESIGN

A longitudinal study of young people receiving mental healthcare.

SETTING

Data were collected between January 2005 and August 2017 from a designated primary care-based mental health service.

PARTICIPANTS

554 young people (54% women) aged 12-32 years.

MEASURES

A systematic medical file audit collected clinical and functional information at predetermined time intervals (ie, 3 months to 5+ years) using a clinical pro forma. Group-based trajectory modelling (GBTM) was used to identify distinct trajectories of social and occupational functioning over time (median number of observations per person=4; median follow-up time=23 months).

RESULTS

Between first clinical contact and time last seen, 15% of young people had reliably deteriorated, 23% improved and 62% did not demonstrate substantive change in function. Of the whole cohort, 69% had functional scores less than 70 at time last seen, indicative of ongoing and substantive impairment. GBTM identified six distinct functional trajectories whereby over 60% had moderate-to-serious functional impairment at entry and remained chronically impaired over time; 7% entered with serious impairment and deteriorated further; a quarter were mildly impaired at entry and functionally recovered and only a small minority (4%) presented with serious impairments and functionally improved over time. Not being in education, employment or training, previous hospitalisation and a younger age at baseline emerged as significant predictors of these functional trajectories.

CONCLUSION

Young people with emerging mental disorders have significant functional impairment at presentation for care, and for the majority, it persists over the course of clinical care. In addition to providing clinical care earlier in the course of illness, these data suggest that more sophisticated and more intensive individual-level and organisational strategies may be required to achieve significant and sustained functional improvements.

Antidepressants in paediatric depression: do not look back in anger but around in awareness

In this paper, we summarise and critique a network meta-analysis (NMA) of antidepressant efficacy and tolerability for paediatric depression and an accompanying editorial. Although we agree that many of the extant studies are flawed, this meta-analysis showed clear efficacy of fluoxetine in the NMA, and for sertraline and escitalopram in pairwise analyses. Consequently, these papers underestimate the benefits of antidepressants for paediatric depression, and provide support for current practice guideline, which recommends the use of an antidepressant if the patient does not respond to psychotherapy. In these circumstances, fluoxetine should be the first choice, with escitalopram and sertraline as alternatives. Declaration of interest D.A.B. receives royalties from Guilford Press, has or will receive royalties from the electronic self-rated version of the C-SSRS from eResearch Technology, Inc., is on the editorial board of UpToDate, and is a reviewer for Healthwise. R.D.G. serves as an expert witness for the US Department of Justice, Pfizer, Wyeth and GSK; and is the founder of Adaptive Testing Technologies. P.W. receives personal fees from Lundbeck and Takeda. B.D. reports a licensing agreement with Lundbeck for a psychosocial treatment manual for depression. No other disclosures were reported.

Two-Year Impact of Prevention Programs on Adolescent Depression: an Integrative Data Analysis Approach

This paper presents the first findings of an integrative data analysis of individual-level data from 19 adolescent depression prevention trials (n = 5210) involving nine distinct interventions across 2 years post-randomization. In separate papers, several interventions have been found to decrease the risk of depressive disorders or elevated depressive/internalizing symptoms among youth. One type of intervention specifically targets youth without a depressive disorder who are at risk due to elevated depressive symptoms and/or having a parent with a depressive disorder. A second type of intervention targets two broad domains: prevention of problem behaviors, which we define as drug use/abuse, sexual risk behaviors, conduct disorder, or other externalizing problems, and general mental health. Most of these latter interventions improve parenting or family factors. We examined the shared and unique effects of these interventions by level of baseline youth depressive symptoms, sociodemographic characteristics of the youth (age, sex, parent education, and family income), type of intervention, and mode of intervention delivery to the youth, parent(s), or both. We harmonized eight different measures of depression utilized across these trials and used growth models to evaluate intervention impact over 2 years. We found a significant overall effect of these interventions on reducing depressive symptoms over 2 years and a stronger impact among those interventions that targeted depression specifically rather than problem behaviors or general mental health, especially when baseline symptoms were high. Implications for improving population-level impact are discussed.