Interpersonal Psychotherapy-Adolescent Skills Training: Effects on School and Social Functioning

Implementation Feasibility and Hidden Costs of Statewide Scaling of Evidence-Based Therapies for Children and Adolescents

OBJECTIVE

State mental health systems are retraining their workforces to deliver services supported by research. Knowledge about evidence-based therapies (EBTs) for child and adolescent disorders is robust, but the feasibility of their statewide scaling has not been examined. The authors reviewed implementation feasibility for 12 commonly used EBTs, defining feasibility for statewide scaling as an EBT having at least one study documenting acceptability, facilitators and barriers, or fidelity; at least one study with a racially and ethnically diverse sample; an entity for training, certification, or licensing; and fiscal data reflecting the costs of implementation.

METHODS

The authors reviewed materials for 12 EBTs being scaled in New York State and conducted a literature review with search terms relevant to their implementation. Costs and certification information were supplemented by discussions with treatment developers and implementers.

RESULTS

All 12 EBTs had been examined for implementation feasibility, but only three had been examined for statewide scaling. Eleven had been studied in populations reflecting racial-ethnic diversity, but few had sufficient power for subgroup analyses to demonstrate effectiveness with these samples. All had certifying or licensing entities. The per-clinician costs of implementation ranged from $500 to $3,500, with overall ongoing costs ranging from $100 to $6,000. A fiscal analysis of three EBTs revealed hidden costs ranging from $5,000 to $24,000 per clinician, potentially limiting sustainability.

CONCLUSIONS

The evidence necessary for embedding EBTs in state systems has notable gaps that may hinder sustainability. Research-funding agencies should prioritize studies that focus on the practical aspects of scaling to assist states as they retrain their workforces.

Trial protocol for the Building Resilience through Socio-Emotional Training (ReSET) programme: a cluster randomised controlled trial of a new transdiagnostic preventative intervention for adolescents

BACKGROUND

Adolescence is a period of heightened vulnerability to developing mental health problems, and rates of mental health disorder in this age group have increased in the last decade. Preventing mental health problems developing before they become entrenched, particularly in adolescents who are at high risk, is an important research and clinical target. Here, we report the protocol for the trial of the 'Building Resilience through Socioemotional Training' (ReSET) intervention. ReSET is a new, preventative intervention that incorporates individual-based emotional training techniques and group-based social and communication skills training. We take a transdiagnostic approach, focusing on emotion processing and social mechanisms implicated in the onset and maintenance of various forms of psychopathology.

METHODS

A cluster randomised allocation design is adopted with randomisation at the school year level. Five-hundred and forty adolescents (aged 12-14) will be randomised to either receive the intervention or not (passive control). The intervention is comprised of weekly sessions over an 8-week period, supplemented by two individual sessions. The primary outcomes, psychopathology symptoms and mental wellbeing, will be assessed pre- and post-intervention, and at a 1-year follow-up. Secondary outcomes are task-based assessments of emotion processing, social network data based on peer nominations, and subjective ratings of social relationships. These measures will be taken at baseline, post-intervention and 1-year follow-up. A subgroup of participants and stakeholders will be invited to take part in focus groups to assess the acceptability of the intervention.

DISCUSSION

This project adopts a theory-based approach to the development of a new intervention designed to target the close connections between young people's emotions and their interpersonal relationships. By embedding the intervention within a school setting and using a cluster-randomised design, we aim to develop and test a feasible, scalable intervention to prevent the onset of psychopathology in adolescence.

TRIAL REGISTRATION

ISRCTN88585916. Trial registration date: 20/04/2023.

Effect of interpersonal psychotherapy on social functioning, overall functioning and negative emotions for depression: A meta-analysis

BACKGROUND

Interpersonal psychotherapy (IPT) has been widely used for depression. However, current studies of IPT have been restricted to depressive symptoms, and the results for improving social functioning were controversial.

METHODS

A comprehensive literature search of randomized controlled trials (RCTs) was conducted through eleven databases. Data analysis was performed by RevMan5.3, and effects were summarized by using a random effects model of mean differences with 95 % confidence intervals.

RESULTS

From 2443 records, eleven studies met inclusion and exclusion criteria were used for meta-analysis. The results showed that IPT had significant effects on improving social functioning (SMD: -0.53, 95 % CI: -0.80 to -0.26), reducing depression (SMD: -0.49, 95 % CI: -0.80 to -0.19) and anxiety (SMD: -0.90, 95 % CI: -1.28 to -0.52), but the effect on the overall functioning (SMD: -0.37, 95 % CI: -0.73 to -0.01) is not obvious. Moreover, subgroup analysis showed that IPT was effective in improving social functioning in adolescent depression (SMD: -0.35, 95 % CI: -0.58 to -0.13) and perinatal depression (SMD: -1.01, 95 % CI: -1.35 to -0.67), while there was no significant difference in the adult depression group (SMD: -0.39, 95 % CI: -1.05 to 0.27).

LIMITATION

The blind method cannot be carried out in most studies due to the particularity of psychotherapy, heterogeneity in some results.

CONCLUSION

IPT has a significant effect on improving social functioning and reducing depression and anxiety, while the effect on overall functioning requires further research. Overall, IPT is one of the effective nonpharmacological treatments for depression.

The Depression Prevention Initiative: Trauma as a Moderator of Prevention Outcomes

Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST) is an evidence-based indicated depression prevention program that has been shown to reduce depression symptoms. Research is needed to identify moderators of IPT-AST's effects. Although trauma history has emerged as a moderator of depression treatment outcomes, the impact of trauma on short- and long-term outcomes in the context of preventive interventions for adolescent depression is unknown. This study examines the impact of trauma on prevention outcomes in a school-based randomized controlled trial (RCT) in which 186 adolescents (mean age = 14.01 years, SD = 1.22; 67% female) were randomly assigned to IPT-AST delivered by research staff or group counseling (GC) provided by school counselors. Trauma history significantly moderated intervention outcomes during the active phase of the intervention, but not during long-term follow-up. During the active phase, youth in IPT-AST with low or no trauma exposure experienced significantly greater reductions in depression symptoms than youth in GC with low or no trauma exposure, but there were no significant differences in rates of change between the two interventions for youth with high or any trauma exposure. These findings highlight the importance of assessing trauma and investigating whether these interventions can be tailored or supplemented to enhance the effects for youth with trauma exposure.

An Evaluation of the Acceptability, Appropriateness, and Utility of a Bibliotherapy for Children of Parents With a Mental Illness

BACKGROUND

Children of parents with a mental illness are at higher risk for various psychiatric problems and adaptive difficulties compared to those of parents without mental health problems. Certain preventive psychoeducational interventions target these children to promote their well-being and resilience and prevent the emergence of adaptive difficulties. However, few such interventions have been developed and evaluated specifically for elementary school-aged children of parents with a mental illness.

OBJECTIVES

This study aims to evaluate an interpersonal psychotherapy-based book targeting children living with a parent with a mental illness.

METHODS

The study examines children, parents and psychosocial workers' perception of the acceptability, appropriateness and utility of the book. In total, 22 participants answered online open-ended questions after reading the book.

RESULTS

The book was highly appreciated and positively perceived by the families and psychosocial workers. Results suggest that children, parents and psychosocial workers viewed it as an appropriate and useful tool for supporting children with a parent with a mental illness. The present study reveals that the bibliotherapy appears well adapted to the developmental level of school-age children.

DISCUSSION

This study presents a book that shows promise for supporting the resilience of elementary school-aged children having a parent with a mental illness. Results highlight the importance of tailoring the content and modalities of interventions to the developmental level, needs and preferences of elementary school-aged children. The relevance of a collaborative method is also discussed, thus providing knowledge regarding this type of approach for the development of interventions targeting children.

Interpersonal Psychotherapy-Adolescent Skills Training With Youth From Asian American and Immigrant Families: Cultural Considerations and Intervention Process

Although research has identified effective evidence-based depression prevention interventions for diverse youth, little is known about how the intervention process unfolds with immigrant family youth. This study utilized a qualitative approach to explore cultural and clinical differences in the implementation of Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST) in two schools, one serving youth from primarily immigrant, Asian American families and the second, youth from mostly nonimmigrant, non-Hispanic White families. A total of 131 IPT-AST sessions were audio recorded, transcribed, and coded for presence and patterns of cultural and clinical constructs. Results revealed that sessions with immigrant family youth were more likely to contain discussions of interpersonal problems characterized by estrangement, goals of spending time together with important others, mentions of emotion suppression and academic achievement expectations, conversations about acculturation, differences in value orientation, and discomfort with implementing new intervention skills. Dialogue from interventionist and youth exchanges is presented to illustrate how these themes emerged and were addressed by interventionists in a culturally responsive manner. The study highlights how IPT-AST with immigrant family and Asian American youth may unfold differently compared to youth from nonimmigrant families. Implications of findings for providers are discussed.

Sleep problems, internalizing and externalizing symptoms, and domains of health-related quality of life: bidirectional associations from early childhood to early adolescence

STUDY OBJECTIVES

To examine longitudinal, bidirectional associations among behavioral sleep problems, internalizing and externalizing symptoms, and domains of health-related quality of life (HRQoL) from early childhood to adolescence in a population sample of Australian children.

METHOD

Data were drawn from the Longitudinal Study of Australian Children, a national prospective cohort study with 4983 children participating in the Kindergarten cohort. Data were collected when children were aged 4-5, 6-7, 8-9, 10-11, and 12-13 years. At each study wave, the primary parent (97% mothers) reported on behavioral child sleep problems, internalizing and externalizing symptoms, and HRQoL domains (psychosocial and physical). Cross-lagged structural equation models were used to evaluate bidirectional associations.

RESULTS

At nearly every age, behavioral sleep problems were associated with worse subsequent psychosocial and physical HRQoL. Despite bidirectional associations between mental health and HRQoL at many waves, HRQoL domains more strongly predicted later internalizing symptoms, while externalizing symptoms more strongly predicted later HRQoL. Many of the bidirectional associations among sleep, mental health, and HRQoL were found earlier in childhood.

CONCLUSIONS

Behavioral sleep problems may forecast later HRQoL psychosocial and physical impairments. Attending to both sleep problems and HRQoL could prevent the progression of internalizing conditions, while a focus on externalizing concerns could prevent the worsening of these symptoms, sleep problems, and HRQoL, particularly during the transition to school.

The Depression Prevention Initiative: Mediators of Interpersonal Psychotherapy-Adolescent Skills Training

Several adolescent depression prevention programs have demonstrated effects on depressive symptoms and overall functioning. Yet, despite an increasing emphasis on elucidating mechanisms of change in interventions, few studies have identified mediators of these preventive interventions. In this study, we examined interpersonal mediators of Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST), an evidence-based depression prevention program. The Depression Prevention Initiative is a school-based randomized controlled trial in which 186 adolescents (M age = 14.01, SD = 1.22; 66.7% female; 32.2% racial minority) were assigned to receive either IPT-AST (n = 95) or Group Counseling (GC) (n = 91). We examined whether change in interpersonal conflict, social support, or social functioning from baseline to midintervention mediated the effects of IPT-AST on depressive symptoms and overall functioning at postintervention. At postintervention, youth in IPT-AST had lower depressive symptoms (d = -.31) and higher overall functioning scores (d = .32) than youth in GC. Improvements in adolescent romantic functioning, reductions in peer conflict, and improvements in a factor score reflecting mother-adolescent conflict and difficulties in family functioning emerged as significant mediators. However, the effects of the intervention on change in the mediators were not statistically significant. These findings add to the sparse literature on mediators of psychosocial interventions, provide partial support for the theoretical mechanisms underlying change in IPT-AST, and highlight important directions for future prevention and intervention research.

Featured Article: Interpersonal Stressors and Resources as Predictors of Adolescent Adjustment Following Traumatic Brain Injury

Objective

The present study sought to examine adolescents' perceptions of their interpersonal stressors and resources across parent, sibling, friend, and school relationships, and the longitudinal associations with self-reported adjustment after traumatic brain injury (TBI) over a 12-month period.

Methods

We examined the main effects of stressors and resources on internalizing and externalizing symptoms in 152 adolescents who had sustained complicated mild-to-severe TBI. We also investigated the conjoint effects of stressors and resources and the moderating effects of TBI severity with stressors and resources on outcomes.

Results

High stressors consistently predicted worse adjustment. High resources were generally only associated with fewer internalizing symptoms. Main effects were qualified by interactions between school stressors and resources in predicting externalizing symptoms and between friend stressors and resources in predicting internalizing and externalizing symptoms. For school stressors, the effects of resources on externalizing symptoms functioned as a buffer. In comparison, the buffering effects of friend resources on internalizing and externalizing symptoms disappeared at moderate-to-high levels of friend stress. Moderating effects of TBI severity were also observed, such that as family resources increased, only adolescents with complicated mild-to-moderate TBI, but not those with severe TBI, experienced decreases in internalizing and eternalizing symptoms.

Conclusion

Interpersonal stressors and social support have important implications for adolescent adjustment after TBI. Adolescents with low levels of school resources, with high levels of friend stress, and who sustain severe TBI are at greatest risk for difficulties with adjustment.

Protective Factors Associated with Daily Affective Reactivity and Instability During Adolescence

The daily emotional experiences of adolescents are dynamic, vary significantly across individuals, and are crucial to their psychological adjustment, warranting a need to identify factors that promote adaptive affective responses to stressors and attenuated affective instability. The objective of this study, therefore, was to examine protective factors linked to individual differences in daily affective reactivity and instability utilizing a daily diary design in a national sample of 100 U.S. adolescents (13-17 years; 40% girls; 79% White). Adolescents completed a baseline survey and then 14 daily online surveys. Better mother-adolescent communication predicted lower negative affect reactivity, whereas greater use of problem-focused coping strategies predicted higher positive affect reactivity. Greater trait resilience and instrumental support seeking predicted lower negative affect instability. Conversely, more emotional support seeking predicted higher negative affect instability. No factors were associated with positive affect instability, and father-adolescent communication was unrelated to daily affective reactivity and instability. The findings implicate specific protective factors associated with distinct aspects of affective reactivity and instability.

SCHOOL-RELATED OUTCOMES FROM A RANDOMIZED CONTROLLED TRIAL OF ADOLESCENT DEPRESSION PREVENTION PROGRAMS

Previous research has demonstrated the effectiveness of school-based depression prevention programs in reducing depressive symptoms and improving functioning. This study examined whether these programs have positive effects on school-related outcomes. Students at 10 middle and high schools in New Jersey were randomized to weekly sessions of Interpersonal Psychotherapy - Adolescent Skills Training (IPT-AST) or group counseling (GC). Analyses examined whether there were intervention effects on participants' grades, attendance rates, and disciplinary outcomes over approximately one year post-intervention. Although there were no significant main effects of intervention condition, moderation analyses indicated more favorable effects of IPT-AST among certain higher-risk subgroups (e.g., those from low-income families). Participants who experienced meaningful improvement in their depressive symptoms had significantly more positive outcomes on overall grades than those who did not experience meaningful improvement, regardless of intervention condition. Further research is needed to clarify the effects of depression prevention programs on these school-related outcomes.

Programs for the Prevention of Youth Depression: Evaluation of Efficacy, Effectiveness, and Readiness for Dissemination

The objective of this study was to evaluate the current state of evidence of the effectiveness of depression prevention programs for youth, assess the degree to which current evidence supports broad implementation, and outline additional steps needed to close the gap between effectiveness and dissemination. We used the Society for Prevention Research's Standards of Evidence (Flay et al., 2005 ) to evaluate the degree to which existing depression prevention programs have established intervention efficacy, effectiveness, and readiness for dissemination. We reviewed all depression prevention programs for youth that have been evaluated in at least two published, randomized controlled trials in which the intervention was compared to a no-intervention control group. A total of 37 studies evaluating 11 different programs were reviewed with regard to depressive symptoms and diagnoses at postintervention and follow-up (at least 6 months). Eight programs demonstrated significant main effects on depressive symptoms relative to controls in multiple randomized controlled trials; 5 programs had at least 1 trial with significant main effects present at least 1 year postintervention. Two programs demonstrated efficacy for both depressive symptoms and depressive episodes across multiple independent trials. Regarding effectiveness, 6 programs had at least 1 study showing significant effects when delivered by endogenous service providers; 4 programs had significant effects in studies conducted independently of the program developers. Several programs have demonstrated promise in terms of efficacy, but no depression prevention program for children or adolescents as yet has garnered sufficient evidence of effectiveness under real-world conditions to warrant widespread dissemination at this time.

Treatment and Prevention of Depression and Anxiety in Youth: Test of Cross-Over Effects

Anxiety and depression are highly comorbid and share several common etiological processes. Therefore, it may be more efficient to develop interventions that treat or prevent these problems together rather than as separate entities. The present meta-analytic review examined whether interventions for children and adolescents that explicitly targeted either anxiety or depression showed treatment specificity or also impacted the other outcome (i.e. cross-over effects). We addressed this question both within the same type of study (i.e. treatment, prevention) and across study types. Only randomized controlled trials (RCTs) that assessed both constructs with dimensional measures were included in this review. For treatment studies, RCTs targeting anxiety (n = 18) showed significant effects on both anxious and depressive symptoms, although more strongly on anxiety than depression; similarly, RCTs treating depression (n = 9) yielded significant effects on both depressive and anxious symptoms, but stronger effects on depression than anxiety. Thus, there were cross-over effects in treatments purportedly targeting either anxiety or depression, and also treatment specificity, such that larger effects were seen for the target problem at which the treatment was aimed. Anxiety prevention studies (n = 14) significantly affected anxious, but not depressive symptoms, indicating no cross-over effect of anxiety prevention trials on depression. For depression prevention studies (n = 15), the effects were not significant for either depressive or anxiety symptoms, although the effect was significantly larger for depressive than for anxious symptoms. Post-hoc analyses revealed that the effect on depressive symptoms was significant in depression preventions trials of targeted but not universal samples. Implications for transdiagnostic interventions are discussed.

Cognitive behavioural therapy (CBT), third-wave CBT and interpersonal therapy (IPT) based interventions for preventing depression in children and adolescents

BACKGROUND

Depression is common in young people. It has a marked negative impact and is associated with self-harm and suicide. Preventing its onset would be an important advance in public health. This is an update of a Cochrane review that was last updated in 2011.

OBJECTIVES

To determine whether evidence-based psychological interventions (including cognitive behavioural therapy (CBT), interpersonal therapy (IPT) and third wave CBT)) are effective in preventing the onset of depressive disorder in children and adolescents.

SEARCH METHODS

We searched the specialised register of the Cochrane Common Mental Disorders Group (CCMDCTR to 11 September 2015), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We searched conference abstracts and reference lists of included trials and reviews, and contacted experts in the field.

SELECTION CRITERIA

We included randomised controlled trials of an evidence-based psychological prevention programme compared with any comparison control for young people aged 5 to 19 years, who did not currently meet diagnostic criteria for depression.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion and rated their risk of bias. We adjusted sample sizes to take account of cluster designs and multiple comparisons. We contacted trial authors for additional information where needed. We assessed the quality of evidence for the primary outcomes using GRADE.

MAIN RESULTS

We included 83 trials in this review. The majority of trials (67) were carried out in school settings with eight in colleges or universities, four in clinical settings, three in the community and four in mixed settings. Twenty-nine trials were carried out in unselected populations and 53 in targeted populations.For the primary outcome of depression diagnosis at medium-term follow-up (up to 12 months), there were 32 trials with 5965 participants and the risk of having a diagnosis of depression was reduced for participants receiving an intervention compared to those receiving no intervention (risk difference (RD) -0.03, 95% confidence interval (CI) -0.05 to -0.01; P value = 0.01). We rated this evidence as moderate quality according to the GRADE criteria. There were 70 trials (73 trial arms) with 13,829 participants that contributed to the analysis for the primary outcome of depression symptoms (self-rated) at the post-intervention time point, with results showing a small but statistically significant effect (standardised mean difference (SMD) -0.21, 95% CI -0.27 to -0.15; P value < 0.0001). This effect persisted to the short-term assessment point (up to three months) (SMD -0.31, 95% CI -0.45 to -0.17; P value < 0.0001; 16 studies; 1558 participants) and medium-term (4 to 12 months) assessment point (SMD -0.12, 95% CI -0.18 to -0.05; P value = 0.0002; 53 studies; 11,913 participants); however, the effect was no longer evident at the long-term follow-up. We rated this evidence as low to moderate quality according to the GRADE criteria.The evidence from this review is unclear with regard to whether the type of population modified the overall effects; there was statistically significant moderation of the overall effect for depression symptoms (P value = 0.0002), but not for depressive disorder (P value = 0.08). For trials implemented in universal populations there was no effect for depression diagnosis (RD -0.01, 95% CI -0.03 to 0.01) and a small effect for depression symptoms (SMD -0.11, 95% CI -0.17 to -0.05). For trials implemented in targeted populations there was a statistically significantly beneficial effect of intervention (depression diagnosis RD -0.04, 95% CI -0.07 to -0.01; depression symptoms SMD -0.32, 95% CI -0.42 to -0.23). Of note were the lack of attention placebo-controlled trials in targeted populations (none for depression diagnosis and four for depression symptoms). Among trials implemented in universal populations a number used an attention placebo comparison in which the intervention consistently showed no effect.

AUTHORS' CONCLUSIONS

Overall the results show small positive benefits of depression prevention, for both the primary outcomes of self-rated depressive symptoms post-intervention and depression diagnosis up to 12 months (but not beyond). Estimates of numbers needed to treat to benefit (NNTB = 11) compare well with other public health interventions. However, the evidence was of moderate to low quality using the GRADE framework and the results were heterogeneous. Prevention programmes delivered to universal populations showed a sobering lack of effect when compared with an attention placebo control. Interventions delivered to targeted populations, particularly those selected on the basis of depression symptoms, had larger effect sizes, but these seldom used an attention placebo comparison and there are practical difficulties inherent in the implementation of targeted programmes. We conclude that there is still not enough evidence to support the implementation of depression prevention programmes.Future research should focus on current gaps in our knowledge. Given the relative lack of evidence for universal interventions compared with attention placebo controls and the poor results from well-conducted effectiveness trials of universal interventions, in our opinion any future such trials should test a depression prevention programme in an indicated targeted population using a credible attention placebo comparison group. Depressive disorder as the primary outcome should be measured over the longer term, as well as clinician-rated depression. Such a trial should consider scalability as well as the potential for the intervention to do harm.