A Longitudinal Follow-up Study Examining Adolescent Depressive Symptoms as a Function of Prior Anxiety Treatment

Anxiety Symptom Trajectories Predict Depression Symptom Trajectories up to Four Years After CBT for Youth Anxiety Disorders

Long-term data on depression symptoms after cognitive behavioral therapy (CBT) for youth anxiety disorders are scant. We examined depression symptoms up to four years post CBT for anxiety addressing youth age and gender, family social class, and parent mental health as predictors. The sample comprised 179 youth (M age at pre-treatment = 11.5 years; SD = 2.1) in a randomized controlled trial. Clinically assessed anxiety diagnoses and youth and parent-reported anxiety and depression symptoms were measured before, after, and one and four years after CBT. Parent self-reported mental health was measured before CBT. We used regression analyses to determine whether full diagnostic recovery at post-CBT predicted depression trajectories across the four-year assessment period. We used growth curve models to determine whether anxiety trajectories predicted depression trajectories across the four-year assessment period. Youth who lost their anxiety diagnoses after CBT had significantly lower parent-reported depression levels over time, but not lower youth self-reported depression levels. The anxiety symptom trajectory predicted the depression symptom trajectory up to four years post-treatment. There was more explained variance for within-informant (youth-youth; parent-parent) than cross-informants. Being older, female, having lower socio-economic status and parents with poorer mental health were associated with more youth-rated depression over time. However, these demographic predictors were not significant when anxiety symptoms trajectories were added to the models. Successful CBT for anxiety in children is associated with less depression symptoms for as long as four years. Anxiety symptom improvement appears to be a stronger predictor that demographic variables and parent mental health.

The relationship between anxiety and depression in adolescent depression patients: The mediating effect of hope level and coping modes

Background

Adolescents diagnosed with depression are particularly susceptible to anxiety and depressive symptoms, this vulnerability often diminishes their future expectations and overall outlook on life. The objective of this research was to scrutinize the associated risk factors of adolescent depression and delineated the interplay between anxiety and depressive symptoms. Concurrently, it sought to ascertain the latent mediating effects of hope levels and coping strategies within this framework.

Methods

A mixed-methods research approach was employed. For the qualitative component, 18 adolescents with depression were interviewed following a semi-structured interview guide, with sessions audio-recorded. The data were subsequently transcribed and subjected to thematic content analysis. In the quantitative phase, a cross-sectional online survey was administered to 210 adolescents diagnosed with depression using Questionnaire Star, with data analysis performed using SPSS25.0 and AMOS 24.0.

Results

The qualitative analysis identified three major themes and nine categories as key risk factors influencing the onset of adolescent depression. Three major themes were generated: school factors, family factors, and other factors. Nine categories were generated: heavy academic load, strained peer, and teacher-student relationships; unstable family structures, internal familial conflicts, and high parental expectations; a strong sense of social isolation, insufficient sexual education, and prevalent suicidal ideation or attempts. A nurturing and supportive school environment significantly bolsters adolescents' sense of hope and coping abilities, while a warm and encouraging family setting effectively mitigates psychological stress. Conversely, heightened loneliness and the onset of suicidal ideation are frequently linked to diminished hope and the adoption of maladaptive coping strategies. Hence, to comprehensively understand the intricate interplay of these factors, this study concentrated on the levels of hope and coping mechanisms, investigating their potential mediating role in adolescent anxiety and depression. Quantitative analysis revealed a positive correlation between anxiety and depression (r = 0.767, p＜0.01). Additionally, it was found that hope levels and coping strategies mediated the relationship between anxiety and depressive symptoms (β = -0.24-0.84 = 0.20, p < 0.001; β = 0.19-0.51 = -0.10, p < 0.01), with the mediating influence of hope levels being more significant than that of coping strategies.

Conclusion

Enhancing hope levels and fostering positive coping strategies are instrumental in aiding adolescents with depression to alleviate their anxiety and depressive symptoms. Moreover, this study underscored the importance of focusing on adolescents' mental health and providing them with emotional support, thereby increasing their hope levels and encouraging the adoption of positive coping mechanisms to effectively address their challenges.

Treating Emotional Disorders in Spanish Children: A Controlled Randomized Trial in a Clinical Setting

Super Skills for Life (SSL) is a CBT-transdiagnostic group intervention currently being translated and validated in multiple countries. In Spanish children, it has shown a positive impact on anxious and depressive symptoms, as well as other variables such as self-concept, prosocial behaviors, or behavioral problems. However, the effectiveness of the program to treat internalizing symptoms in children with a mental disorder in a clinical setting has not been examined so far. The aim of this study was to evaluate the effectiveness of SSL in a Spanish sample of children with a major internalizing disorder. Participants aged 8-12 years (71.6% boys) were randomly allocated to the SSL group (n = 43) or the waiting list control (WLC) group (n = 43). All children and their parents completed a series of measures before the first session and after the last session or at about the same time in the WLC group. The effectiveness of the intervention was assessed using generalized estimating equations. Significant reductions from pretest to posttest across multiple outcomes were found in children who participated in SSL group compared to those in the WLC group, including anxiety symptoms (SCAS, p = .02), anxiety interference (CALIS, p = .002), depressive symptoms (CDI, p = .033) and remission from diagnosis (K-SADS, p < .001). This study provides initial support for SSL as an effective treatment for children with emotional disorders in clinical settings. Future studies are needed to analyze long-term effects and broader benefits of the program in clinical contexts.

Subgenual Anterior Cingulate Cortex Reactivity to Rejection Vs. Acceptance Predicts Depressive Symptoms among Adolescents with an Anxiety History

OBJECTIVE

The goal of this study was to examine whether neural sensitivity to negative peer evaluation conveys risk for depression among youth with a history of anxiety. We hypothesized that brain activation in regions that process affective salience in response to rejection, relative to acceptance, from virtual peers would predict depressive symptoms 1 year later and would be associated with ecological momentary assessment (EMA) reports of peer connectedness.

METHOD

Participants were 38 adolescents ages 11-16 (50% female) with a history of anxiety, recruited from a previous clinical trial. The study was a prospective naturalistic follow-up of depressive symptoms assessed 2 years (Wave 2) and 3 years (Wave 3) following treatment. At Wave 2, participants completed the Chatroom Interact Task during neuroimaging and 16 days of EMA.

RESULTS

Controlling for depressive and anxiety symptoms at Wave 2, subgenual anterior cingulate (sgACC; β = .39, p = .010) activation to peer rejection (vs. acceptance) predicted depressive symptoms at Wave 3. SgACC activation to rejection (vs. acceptance) was highly negatively correlated with EMA reports of connectedness with peers in daily life (r = - .71, p < .001).

CONCLUSION

Findings suggest that elevated sgACC activation to negative, relative to positive, peer evaluation may serve as a risk factor for depressive symptoms among youth with a history of anxiety, perhaps by promoting vigilance or reactivity to social evaluative threats. SgACC activation to simulated peer evaluation appears to have implications for understanding how adolescents experience their daily social environments in ways that could contribute to depressive symptoms.

An explanatory model of depressive symptoms from anxiety, post-traumatic stress, somatic symptoms, and symptom perception: the potential role of inflammatory markers in hospitalized COVID-19 patients

BACKGROUND

The context of the COVID-19 pandemic has harmed the mental health of the population, increasing the incidence of mental health problems such as depression, especially in those who have had COVID-19. Our study puts forward an explanatory model of depressive symptoms based on subjective psychological factors in those hospitalized for COVID-19 with and without biological markers (i.e., inflammatory markers). Therefore, we aim to evaluate the hypotheses proposed in the model to predict the presence of depressive symptoms.

METHOD

We conducted a cross-sectional study, using a simple random sampling. Data from 277 hospitalized patients with COVID-19 in Lima-Peru, were collected to assess mental health variables (i.e., depressive, anxiety, post-traumatic stress, and somatic symptoms), self-perception of COVID-19 related symptoms, and neutrophil/lymphocyte ratio (NLR) such as inflammatory marker. We performed a structural equation modeling analysis to evaluate a predictive model of depressive symptoms.

RESULTS

The results showed a prevalence of depressive symptoms (11.2%), anxiety symptoms (7.9%), somatic symptoms (2.2%), and symptoms of post-traumatic stress (6.1%) in the overall sample. No association was found between the prevalence of these mental health problems among individuals with and without severe inflammatory response. The mental health indicators with the highest prevalence were sleep problems (48%), low energy (47.7%), nervousness (48.77%), worry (47.7%), irritability (43.7%) and back pain (52%) in the overall sample. The model proposed to explain depressive symptoms was able to explain more than 83.7% of the variance and presented good goodness-of-fit indices. Also, a different performance between the proposed model was found between those with and without severe inflammatory response. This difference was mainly found in the relationship between anxiety and post-traumatic stress symptoms, and between the perception of COVID-19 related symptoms and somatic symptoms.

CONCLUSIONS

Results demonstrated that our model of mental health variables may explain depressive symptoms in hospitalized patients of COVID-19 from a third-level hospital in Peru. In the model, perception of symptoms influences somatic symptoms, which impact both anxiety symptoms and symptoms of post-traumatic stress. Thus, anxiety symptoms could directly influence depressive symptoms or through symptoms of post-traumatic stress. Our findings could be useful to decision-makers for the prevention of depression, used to inform the creation of screening tools (i.e., perception of symptoms, somatic and anxiety symptoms) to identify vulnerable patients to depression.

Parents still matter! Parental warmth predicts adolescent brain function and anxiety and depressive symptoms 2 years later

Anxiety is the most prevalent psychological disorder among youth, and even following treatment, it confers risk for anxiety relapse and the development of depression. Anxiety disorders are associated with heightened response to negative affective stimuli in the brain networks that underlie emotion processing. One factor that can attenuate the symptoms of anxiety and depression in high-risk youth is parental warmth. The current study investigates whether parental warmth helps to protect against future anxiety and depressive symptoms in adolescents with histories of anxiety and whether neural functioning in the brain regions that are implicated in emotion processing and regulation can account for this link. Following treatment for anxiety disorder (Time 1), 30 adolescents (M age = 11.58, SD = 1.26) reported on maternal warmth, and 2 years later (Time 2) they participated in a functional neuroimaging task where they listened to prerecorded criticism and neutral statements from a parent. Higher maternal warmth predicted lower neural activation during criticism, compared with the response during neutral statements, in the left amygdala, bilateral insula, subgenual anterior cingulate (sgACC), right ventrolateral prefrontal cortex, and anterior cingulate cortex. Maternal warmth was associated with adolescents' anxiety and depressive symptoms due to the indirect effects of sgACC activation, suggesting that parenting may attenuate risk for internalizing through its effects on brain function.

Association of Neural Reward Circuitry Function With Response to Psychotherapy in Youths With Anxiety Disorders

OBJECTIVE

Identifying neural correlates of response to psychological treatment may inform targets for interventions designed to treat psychiatric disorders. This study examined the extent to which baseline functioning in reward circuitry is associated with response to psychotherapy in youths with anxiety disorders.

METHODS

A randomized clinical trial of cognitive-behavioral therapy compared with supportive therapy was conducted in youths with anxiety disorders. Before treatment, 72 youths (9-14 years old) with anxiety disorders and 37 group-matched healthy comparison youths completed a monetary reward functional MRI task. Treatment response was defined categorically as at least a 35% reduction in diagnostician-rated anxiety severity from pre- to posttreatment assessment. Pretreatment neural activation in the striatum and medial prefrontal cortex (mPFC) during monetary wins relative to losses was examined in relation to treatment response.

RESULTS

Responders, nonresponders, and healthy youths differed significantly in mPFC activation to rewards versus losses at baseline. Youths with anxiety exhibited higher mPFC activity relative to healthy youths, although this may have been driven by differences in depressive symptoms. Planned comparisons between treatment responders (N=48) and nonresponders (N=24) also revealed greater pretreatment neural activation in a cluster encompassing the subgenual anterior cingulate cortex and nucleus accumbens among responders.

CONCLUSIONS

Striatal activation to reward receipt may not differentiate youths with anxiety from healthy youths. However, higher striatal responsivity to rewards may allow youths with anxiety to improve during treatment, potentially through greater engagement in therapy. Function in reward circuitry may guide development of treatments for youths with anxiety.

Antidepressant Use in a 3- to 12-Year Follow-up of Anxious Youth: Results from the CAMELS Trial

The current study explored whether patient characteristics predicted patterns of antidepressant use (i.e., never used, single episode of use, or two or more episodes) in a naturalistic follow-up. Participants in the child/adolescent multimodal (CAMS) extended long-term study. (n = 318) indicated medication use over the course of eight follow-up visits, 3-12 years after receiving treatment in CAMS. 40.6% of participants reported never using an antidepressant during follow-up, 41.4% reported a single episode of antidepressant use, and 18.0% reported multiple episodes of antidepressant use. Greater baseline anxiety severity marginally predicted a single episode of antidepressant use; baseline depression severity predicted multiple episodes of use. Reasons for discontinuing antidepressants included perceived ineffectiveness (31.8%), side effects (25.5%), and improvement in symptoms (18.5%). Exploratory analyses examined predictors of medication use. Findings suggest that antidepressant use is common among anxious youth, as is discontinuation of antidepressant use. Clinical implications and future directions are discussed.

Editors' Best of 2019

There is, in the content of the Journal, an embarrassment of riches, and picking a "best" seems to demand a certain qualification: is the "best" the most interesting, most surprising, most educational, most important, most provocative, most enjoyable? How to choose? We are hardly unbiased and can admit to a special affection for the ones that we and the authors worked hardest on, hammering version after version into shape. Acknowledging these biases, here are the 2019 articles that we think deserve your attention or at least a second read.

But what will the results be?: Learning to tolerate uncertainty is associated with treatment-produced gains

The current study examined the association between changes in intolerance of uncertainty (IU) and treatment outcomes for anxious youth. Participants were youth ages 7 to 17 who received cognitive behavioral therapy for anxiety (N = 73). Youth and their primary caregivers completed a diagnostic interview and self- and parent-report measures at pre- and post-treatment, including the Intolerance of Uncertainty Scale for Children (IUS-C/P; Przeworski, 2006), the Coping Questionnaire (CQ-C/P; Kendall, 1994) and the Multidimensional Anxiety Scale for Children (MASC-C/P; March et al., 1997). Hierarchical regression analyses evaluated the role of change in IU (the IUS-C/P) in predicting changes in functional impairment, coping efficacy, and anxiety severity post-treatment, controlling for demographic variables (age and gender), and baseline levels of IU, anxiety severity, functional impairment, and coping efficacy. Results demonstrated that treatment was associated with improvements across child-, parent- and clinician-report, and decreased IU from pre- to post-treatment was associated with (a) decreased functional impairment, (b) increased coping efficacy and (c) decreased anxiety severity. The findings indicate that a greater reduction in IU over treatment is associated with better outcomes in children and adolescents with anxiety across informants, suggesting the possibility that an increased focus on IU during treatment for youth anxiety may improve treatment outcomes. Future research should assess the causality of this relationship.

Mood and suicidality outcomes 3-11 years following pediatric anxiety disorder treatment

BACKGROUND

Youth anxiety interventions have potential to reduce risk for depression and suicidality.

METHODS

This naturalistic follow-up of the multi-site, comparative treatment trial, inking and behavior, and depressive symptoms 3-11 years (mean 6.25 years) following 12-week evidence-based youth anxiety treatment. Participants (N = 319; 10-26 years, mean 17 years) completed semiannual questionnaires and annual diagnostic interviews for 4 years.

RESULTS

One-fifth (20.4%) of the sample met DSM-IV criteria for a mood disorder, 32.1% endorsed suicidal ideation, and 8.2% reported suicidal behavior. Latent class growth analysis yielded two linear trajectories of depressive symptoms, and 85% of the sample demonstrated a persistent low-symptom course over seven assessments. Child/Adolescent Anxiety Multimodal Study (CAMS) 12-week treatment outcome (positive response, remission) and treatment condition (cognitive behavior therapy [CBT], medication, CBT + medication, pill placebo) were not associated with subsequent mood disorder or suicidal thinking. CAMS remission predicted absence of suicidal behavior, and treatment response and remission predicted low depressive symptom trajectory. Greater baseline self-reported depressive symptoms predicted all long-term mood outcomes, and more negative life events predicted subsequent mood disorder, depressive symptom trajectory, and suicidal ideation.

CONCLUSIONS

Effective early treatment of youth anxiety, including CBT, medication, or CBT + medication, reduces risk for subsequent chronic depressive symptoms and suicidal behavior. Attention to (sub)clinical depressive symptoms and management of negative life events may reduce odds of developing a mood disorder, chronic depressive symptoms, and suicidality. Findings contribute to evidence that early intervention for a primary disorder can serve as secondary prevention.

Neural Activation to Parental Praise Interacts With Social Context to Predict Adolescent Depressive Symptoms

Negative relationships with parents and peers are considered risk factors for depression in adolescence, yet not all adolescents perceiving negative social relationships develop depression. In line with neurobiological susceptibility to social context models, we examined how individual differences in neural processing of parental praise, a unique form of social reward, might explain variability in susceptibility to perceived maternal acceptance and peer victimization. During neuroimaging, 38 11- to 17-year-olds with a history of anxiety listened to audio clips of a parent (predominately mothers) providing personalized praise and neutral statements. Average activation during parental praise clips relative to neutral clips was extracted from several anatomically-defined reward-related regions-of-interest (ROIs): the subgenual anterior cingulate cortex, caudate nucleus, amygdala, nucleus accumbens, and insula. Moderation models included direct effects and interactions between neural activation to social reward, peer victimization, and maternal acceptance at the time of scanning on depressive symptoms 1 year later. Results showed a significant three-way interaction for the bilateral caudate such that peer victimization was associated with depressive symptoms only for individuals with higher caudate response to praise who perceived maternal acceptance as low. Consistent with neurobiological susceptibility to social context models, caudate activation to social reward could represent a neural marker that helps explain variability in adolescent sensitivity to social contexts. High caudate activation to praise could reflect a history of negative experiences with parents and/or peers that places youth at greater risk for depressive symptoms. Findings suggest that interactions between neural response to reward and salient social contexts may help us understand changes in depressive symptoms during a period of development marked by significant biopsychosocial change.

Reduced Reward Responsiveness Predicts Change in Depressive Symptoms in Anxious Children and Adolescents Following Treatment

Objectives: Reduced reward responsiveness, as measured by the event-related potential (ERP) component, the reward positivity (RewP), has been shown to play a role in the development of internalizing disorders, but implications for treatment remain unclear. In adult patients with anxiety and/or depression, reduced RewP has emerged as a predictor of greater change in symptoms following cognitive behavior therapy (CBT) or selective serotonin reuptake inhibitor (SSRI) treatment. The objectives of this preliminary study were to extend these findings to children and adolescents with anxiety disorders by evaluating RewP to reward as a predictor of change in anxiety severity or depressive symptoms following treatment with CBT or SSRI and to explore whether RewP differentially predicts response to one type of treatment. Methods: Patients (7-19 years old) with social and/or generalized anxiety disorder (N = 27) completed baseline measures of anxiety severity and depressive symptoms, as well as an ERP monetary reward anticipation and feedback task. RewP was measured in response to reward and breaking even feedback. Patients were then randomly assigned to CBT or SSRI treatment, and completed measures of anxiety and depressive symptom severity at the last treatment session. Results: Reduced reward responsiveness, as measured by RewP to rewards, predicted greater change in depressive symptoms following treatment, adjusting for baseline symptoms, age, and RewP to breaking even. RewP was not a significant predictor of change in anxiety symptoms. Although preliminary, exploratory analyses suggested that among anxious youth, RewP specifically predicted change in depressive symptoms following CBT, rather than SSRI. Conclusion: Results provide preliminary support for the utility of ERP measures of reward responsiveness in predicting treatment response in youth. With further research and standardization, ERP assessments could potentially be implemented in clinical settings to inform prognosis and treatment planning for youth with internalizing disorders.

Editorial: Could a Treatment for Youth Anxiety Specifically Prevent the Emergence of Depression 2 Years Later?

The comorbidity of depression and anxiety is a major global health problem. A 2015 report examining response patterns of 74,000 adults across 27 World Mental Health surveys in 24 countries showed a very high comorbidity between a diagnosis of lifetime DSM-IV¹ major depressive disorder and a diagnosis of any anxiety disorder in the past 12 months or lifetime anxiety disorder at similar rates in high-income and mid- to low-income countries. In addition, the report highlighted that almost 70% of people with lifetime depression and anxiety first developed anxiety and that the course and burden of lifetime depression comorbid with anxiety was usually more impairing than depression without anxiety.².