Depression Change Profiles in Adolescents Treated for Comorbid Depression/Substance Abuse and Profile Membership Predictors

Juvenile Justice-Based Interdisciplinary Collective Care: An Innovative Approach

Mental health concerns among juvenile-justice-involved youth (JJIY) continue to be a major health crisis in the United States (US). While scholarship has explored mental health concerns among JJIY, and the link to negative life outcomes, there are gaps in the existing research, particularly in effective interventions and models aimed at addressing both the mental health concerns and criminogenic risk contributing to recidivism and other negative life outcomes of this population. In this paper, we present Justice-Based Interdisciplinary Collective Care (JBICC), an innovative framework to address both the mental health needs and delinquent behavior of youth offenders. The model bridges community partners, with the purpose of informing future interventions, implementations, and research in this area. Increased justice-based interdisciplinary collective collaboration between the juvenile justice system and community programs/organizations would be a major benefit to youth offenders and their families. We also focus on the need for cultural responsiveness to be interwoven throughout all aspects of treatment. JBICC offers an opportunity to expanded services outside traditional settings and methods to ensure that youth offenders and their families receive validating and culturally responsive access to services.

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.

Functional Family Therapy for families of youth (age 11-18) with behaviour problems: A systematic review and meta-analysis

Background

Functional Family Therapy (FFT) is a short-term family-based intervention for youth with behaviour problems. FFT has been widely implemented in the USA and other high-income countries. It is often described as an evidence-based program with consistent, positive effects.

Objectives

We aimed to synthesise the best available data to assess the effectiveness of FFT for families of youth with behaviour problems.

Search Methods

Searches were performed in 2013-2014 and August 2020. We searched 22 bibliographic databases (including PsycINFO, ERIC, MEDLINE, Science Direct, Sociological Abstracts, Social Services Abstracts, World CAT dissertations and theses, and the Web of Science Core Collection), as well as government policy databanks and professional websites. Reference lists of articles were examined, and experts were contacted to search for missing information.

Selection Criteria

We included randomised controlled trials (RCTs) and quasi-experimental designs (QEDs) with parallel cohorts and statistical controls for between-group differences at baseline. Participants were families of young people aged 11-18 with behaviour problems. FFT programmes were compared with usual services, alternative treatment, and no treatment. There were no publication, geographic, or language restrictions.

Data Collection and Analysis

Two reviewers independently screened 1039 titles and abstracts, read all available study reports, assessed study eligibility, and extracted data onto structured electronic forms. We assessed risks of bias (ROB) using modified versions of the Cochrane ROB tool and the What Works Clearinghouse standards. Where possible, we used random effects models with inverse variance weights to pool results across studies. We used odds ratios for dichotomous outcomes and standardised mean differences for continuous outcomes. We used Hedges g to adjust for small sample sizes. We assessed the heterogeneity of effects with χ 2 and I 2. We produced separate forest plots for conceptually distinct outcomes and for different endpoints (<9, 9-14, 15-23, and 24-42 months after referral). We grouped studies by study design (RCT or QED), and then assessed differences between these two subgroups of studies with χ 2 tests. We generated robust variance estimates, using correlated effects (CE) models with small sample corrections to synthesise all available outcome data. Exploratory CE analyses assessed potential moderators of effects within these domains. We used GRADE guidelines to assess the certainty of evidence on six primary outcomes at 1 year after referral.

Main Results

Twenty studies (14 RCTs and 6 QEDs) met our inclusion criteria. Fifteen of these studies provided some valid data for meta-analysis; these studies included 10,980 families in relevant FFT and comparison groups. All included studies had high risks of bias on at least one indicator. Half of the studies had high risks of bias on baseline equivalence, support for intent-to-treat analysis, selective reporting, and conflicts of interest. Fifteen studies had incomplete reporting of outcomes and endpoints. Using the GRADE rubric, we found that the certainty of evidence for FFT was very low for all of our primary outcomes. Using pairwise meta-analysis, we found no evidence of effects of FFT compared with other active treatments on any primary or secondary outcomes. Primary outcomes were: recidivism, out-of-home placement, internalising behaviour problems, external behaviour problems, self-reported delinquency, and drug or alcohol use. Secondary outcomes were: peer relations and prosocial behaviour, youth self esteem, parent symptoms and behaviour, family functioning, school attendance, and school performance. There were few studies in the pairwise meta-analysis (k < 7) and little heterogeneity of effects across studies in most of these analyses. There were few differences between effect estimates obtained in RCTs versus QEDs. More comprehensive CE models showed positive results of FFT in some domains and negative results in others, but these effects were small (standardised mean difference [SMD] <|0.20|) and not significantly different from no effect with one exception: Two studies found positive effects of FFT on youth substance abuse and two studies found null results in this domain, and the overall effect estimate for this outcome was statistically different from zero. Over all outcomes (15 studies and 293 effect sizes), small positive effects were detected (SMD = 0.19, SE = 0.09), but these were not significantly different from zero effect. Prediction intervals showed that future FFT evaluations are likely to produce a wide range of results, including moderate negative effects and strong positive results (-0.37 to 0.75).

Authors’ Conclusions

Results of 10 RCTs and five QEDs show that FFT does not produce consistent benefits or harms for youth with behavioural problems and their families. The positive or negative direction of results is inconsistent within and across studies. Most outcomes are not fully reported, the quality of available evidence is suboptimal, and the certainty of this evidence is very low. Overall estimates of effects of FFT may be inflated, due to selective reporting and publication biases.

Improvement in psychological wellbeing among adolescents with a substance use disorder attending an outpatient treatment programme

OBJECTIVES

Adolescents with substance use disorders (SUDs) exhibit high rates of comorbid psychological problems. This study aimed to examine the impact of an outpatient substance use treatment programme upon the psychological wellbeing of adolescents.

METHODS

A prospective study was carried out examining psychological symptoms in a group of adolescents attending the Youth Drug and Alcohol (YoDA) Addiction Service in Dublin. Participants were treated with evidenced based psychological models such as cognitive behavioural therapy, motivational interviewing and systemic family therapy. The Becks Youth Inventory was utilised to assess psychological symptoms at treatment entry and repeated three months later at follow up.

RESULTS

Among 36 adolescents who were included in this study, poly-substance misuse was the norm. Almost three-quarter had a cannabis use disorder (CUD). There were significant reductions in mean subscale scores of depression (56.0 to 50.8, p = 0.003), anger (55.2 to 49.5, p < 0.001) and disruptive behaviour (61.6 to 56.5, p = 0.002) at follow up. Although there wasn't a statistically significant reduction in mean scores for anxiety, we observed a significant proportion of participants (p = 0.008) improving and moving out of a moderate to severe symptom range when examined by category. This was also the case for self-concept (p = 0.04). Furthermore this study revealed a positive correlation between the reduction in days of cannabis use and reduction in depressive scores (Pearson correlation 0.49, p = 0.01) among those with a CUD.

CONCLUSION

The findings indicate that substance use treatment for adolescents is associated with important psychological and behavioural improvements.

Social Support and Parental Conflict as Predictors of Outcomes of Group Cognitive Behavioral Therapy for Adolescent Depression

Group cognitive behavioral therapy (CBT) is an effective treatment for adolescent depression, but outcomes vary. Our goal was to examine interpersonal factors that predict response to group CBT for adolescent depression using a broad range of outcomes, including depressive symptoms, session attendance, treatment completion, engagement, and improvement. Seventy adolescents (age 14-18) with depression completed self-report measures of social support and parental conflict and were offered an established 16-session group CBT program. Correlation and regression analyses were conducted for interpersonal predictors and CBT outcomes. Accounting for pre-treatment depressive symptoms, fewer social supports predicted lower likelihood of finishing treatment and less clinician-rated improvement. Greater pre-treatment parental conflict predicted fewer sessions attended, lower clinician-rated engagement, and less clinician-rated improvement. Results highlight the need to consider interpersonal difficulties in CBT, as they may present a barrier to treatment attendance, engagement, and improvement.

Predictors of treatment non-response for depression in a sample of female adolescents with risk-taking and self-injurious behavior - A one year follow-up

OBJECTIVE

Depressive disorders (DD) are highly prevalent among adolescents. While up to 60 % do not respond to treatment, evidence on predictors of treatment non-response in this age group is mixed, impeding meaningful clinical implications. Drawing on a consecutive clinical cohort of adolescents with risk taking and self-injurious behavior, the present study aimed to identify predictors of treatment non-response for female DD in a naturalistic one year follow-up.

METHODS

The sample comprised female adolescents with verified DD (n = 152). Patients underwent assessments at baseline (T0) and follow-up (T1). Sociodemographic factors (e.g., age), clinical measures (e.g., symptom severity, trauma), and treatment variables (e.g. number of psychotherapy sessions), were analyzed as potential predictors of treatment non-response in unadjusted analyses and analyses adjusting for treatment intensity and age at baseline. Treatment response was defined based on not fulfilling formal diagnosis for DD at follow-up (52.3 %; n = 80) or the 50 % decrease in self-reported depressive symptoms (21.1 %; n = 32) from T0 to T1.

RESULTS

Greater depressive and overall symptom severity, greater frequency of self-injuries, history of suicide attempts and history of childhood trauma at T0 were robustly associated with treatment non-response based on diagnostic interviews. Only a lower number of siblings was robustly associated with treatment non-response based on self-reports.

LIMITATIONS

Findings may not generalize to other treatment settings.

CONCLUSION

Collectively, our results highlight overall symptom severity as significant predictor of treatment non-response in female adolescents with depression. Methodological differences (interviews versus self-reports) and potential implications from these findings for clinical practice are discussed.

Adaptive Treatment for Youth With Substance Use and Depression: Early Depression Response and Short-term Outcomes

OBJECTIVE

To investigate prevalence and predictors of early depression response (EDR) in adolescents with substance use and depression receiving cognitive-behavioral therapy (CBT) for substance use and to test the efficacy of supplemental CBT targeting depression (CBT-D) for non-EDR adolescents in an adaptive treatment approach.

METHOD

At 2 sites, 95 youths (ages 14-21, mean [SD] = 17.4 [1.8]) with alcohol or cannabis use and depressive symptoms received up to 12 sessions of CBT for substance use over 14 weeks. Assessments were at baseline and weeks 4, 9, and 14. The Children's Depression Rating Scale-Revised was the primary depression measure, with a reduction of 50% or more on this scale at week 4 defining EDR. The primary substance use outcomes of alcohol use, heavy alcohol use, and cannabis use frequency were assessed via interview report on the Alcohol Consumption Questionnaire and the Drug Checklist. Urinalysis provided a secondary measure of cannabis use. Non-EDR adolescents were randomly assigned to supplemental CBT-D or enhanced treatment as usual (ETAU).

RESULTS

Thirty-five adolescents (37%; 95% CI, 27%-47%) demonstrated EDR. Fewer days of cannabis use (odds ratio 0.977; 95% CI, 0.961-0.992) and absence of conduct disorder (odds ratio 0.149; 95% CI, 0.031-0.716) predicted EDR. Frequency of drinking (F_1,82 = 11.09, η² = 0.119, p = .001), heavy drinking (F_1,82 = 19.91, η² = 0.195, p < .0001), and cannabis use (F_1,220 = 35.01, η² = 0.137, p < .001) decreased over time for EDR, CBT-D, and ETAU adolescents, with EDR adolescents evidencing earlier lower cannabis use (F_2,220 = 4.16, η² = 0.036, p = .0169). Negative (clean) urine screens increased over time (F_1,219 = 5.10, η² = 0.023, p = .0249). Comparison of CBT-D and ETAU indicated that depression significantly decreased over time in both groups (F_1,48 = 64.20, η² = 0.572, p < .001), with no advantage for CBT-D.

CONCLUSION

Approximately one-third of adolescents with substance use and depression attain EDR during substance use treatment. Less frequent cannabis use facilitates depression response. The relatively small sample may have precluded identification of additional EDR predictors.

CLINICAL TRIAL REGISTRATION INFORMATION

Treatment for Teens With Alcohol Abuse and Depression; https://clinicaltrials.gov/; NCT02227589.

Parental Monitoring Predicts Depressive Symptom and Suicidal Ideation Outcomes in Adolescents Being Treated for Co-Occurring Substance Use and Psychiatric Disorders

BACKGROUND

Comorbidity of substance use disorders (SUDs) with mood disorders and other psychiatric conditions is common. Parenting processes and family functioning are impaired in adolescents with SUDs and mood disorders, and parent/family factors predict intervention response. However, limited research has examined the relationship between parent/family factors and mood symptom treatment response in adolescents with comorbid SUDs and psychiatric conditions.

METHOD

This study examined the predictive effects of parenting processes and family functioning on depressive symptoms and suicidal ideation (SI) in a randomized controlled trial of integrated cognitive-behavioral therapy vs. treatment as usual for 111 adolescents with comorbid SUDs and psychiatric disorders. Measures of parenting processes, family functioning, depressive symptoms, and SI were completed at baseline and 3-, 6-, and 12-month follow-ups. Exploratory analyses involved mixed-effects regression models.

RESULTS

Across treatment conditions, depressive symptoms and SI improved over 12 months. Family functioning domains of family roles (d=0.47) and affective involvement (d=0.39) significantly improved across treatment conditions over 12 months. Higher baseline parental monitoring predicted improved trajectory of depressive symptoms (d=0.44) and SI (d=0.46). There were no significant predictive effects for baseline family functioning or other parenting processes (listening, limit setting).

LIMITATIONS

Limitations include the modest sample, attrition over follow-up, and generalizability to samples with higher rates of mood disorders and/or uncomplicated mood disorders.

CONCLUSIONS

Parental monitoring may be an important prognostic indicator of depressive symptoms and SI in adolescents with co-occurring SUDs and psychiatric conditions, and therefore may be useful to assess and target in treatment, in addition to family functioning.