Moderators of Treatment for Adolescent Depression

What CBT Modules Work Best for Whom? Identifying Subgroups of Depressed Youths by Their Differential Response to Specific Modules

Prior research suggests that the effects of specific cognitive-behavioral therapy (CBT) modules on symptom outcomes can be estimated. We conducted a study utilizing idiographic and nomothetic methods to clarify which CBT modules are most effective for youth depression, and for whom they are most effective. Thirty-five youths received modular CBT for depression. Interrupted time series models estimated whether the introduction of each module was associated with changes in internalizing symptoms, whereby significant symptom reduction would suggest a therapeutic response to the module. Regression models were used to explore whether participant characteristics predicted subgroups of youths based on their estimated response to certain types (e.g., cognitive) of modules, and whether group membership was associated with posttreatment outcomes. Thirty youths (86%) had at least one module associated with a significant change in internalizing symptoms from premodule delivery to postmodule delivery. The specific modules associated with these changes varied across youths. Behavioral activation was most frequently associated with symptom decreases (34% of youths). No participant characteristics predicted estimated response to module type, and group membership was not significantly associated with posttreatment outcomes. Youths display highly heterogeneous responses to treatment modules, indicating multiple pathways to symptom improvement for depressed youths.

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.

Understanding treatment non-responders: A qualitative study of depressed adolescents' experiences of 'unsuccessful' psychotherapy

OBJECTIVES

This paper aimed to explore the experiences of depressed adolescents who completed but did not 'respond' to standard psychotherapy, based on a lack of improvement in pre-post symptoms scores.

DESIGN

This was a qualitative study employing interpretative phenomenological analysis (IPA).

METHOD

Seventy-seven adolescents with moderate to severe depression were interviewed as part of a qualitative arm of a randomised controlled trial. Five adolescents' post-treatment interviews were purposively sampled, based on lack of improvement on pre-post symptom scores, and adolescents still scoring above the clinical threshold for depression. The interviews were analysed using IPA.

RESULTS

Adolescents made sense of their depression as part of their identity and held negative expectations of therapy. Some aspects of therapy brought up intolerable feelings that contributed to disengagement in the therapeutic process and culminated in disappointing and hopeless endings. On the other hand, where a stronger therapeutic relationship was developed, some participants experienced certain improvements.

CONCLUSIONS

Findings highlight how actively exploring the adolescent's therapy expectations, developing a strong early therapeutic relationship and being mindful of the potential impact of endings are important in therapeutic work with adolescents with depression, especially where they may have a strong sense of hopelessness and self-criticism. Moreover, the finding that adolescents experienced improvements in other domains despite a lack of symptom reduction highlights the need to review how treatment outcomes are currently defined. Integrating individual perspectives of therapy with quantitative outcome measures can provide a more nuanced insight of treatment effects.

Embracing Scientific Humility and Complexity: Learning "What Works for Whom" in Youth Psychotherapy Research

Clinical psychological scientists have spent decades attempting to understand "what works for whom" in the context of youth psychotherapy, toward the longstanding goal of personalizing psychosocial interventions to fit individual needs and characteristics. However, as the articles in this Special Issue jointly underscore, more than 50 years of psychotherapy research has yet to help us realize this goal. In this introduction to the special issue, we outline how and why "aspiration-method mismatches" have hampered progress toward identifying moderators of youth psychotherapy; emphasize the need to embrace etiological complexity and scientific humility in pursuing new methodological solutions and propose individual and structural strategies for better-aligning clinical research methods with the goal of personalizing mental health care for youth with diverse identities and treatment needs.

Psychiatric comorbidity of developmental trauma disorder and posttraumatic Stress disorder: findings from the DTD field trial replication (DTDFT-R)

Background: Developmental Trauma Disorder (DTD) has extensive comorbidity with internalizing and externalizing disorders distinct from posttraumatic stress disorder (PTSD). Objective: To replicate findings of DTD comorbidity and to determine whether this comorbidity is distinct from, and extends beyond, comorbidities of PTSD. Method: DTD was assessed by structured interview, and probable DSM-IV psychiatric disorders were identified with KSADS-PL screening modules, in a multi-site sample of 271 children (ages 8-18 years old; 47% female) in outpatient or residential mental health treatment for multiple (M = 3.5 [SD = 2.4]) psychiatric diagnoses other than PTSD or DTD. Results: DTD (N = 74, 27%) and PTSD (N = 107, 39%) were highly comorbid and shared several DSM-IV internalizing and externalizing disorder comorbidities. Children with DTD with or without PTSD had more comorbid diagnoses (M = 5.7 and 5.2 [SD = 2.4 and 1.7], respectively) than children with PTSD but not DTD (M = 3.8[SD = 2.1]) or neither PTSD nor DTD (M = 2.1[SD = 1.9]), F[3,267] = 55.49, p < .001. Further, on a multivariate basis controlling for demographics and including all potential comorbid disorders, DTD was associated with separation anxiety disorder, depression, and oppositional defiant disorder after controlling for PTSD, while PTSD was associated only with separation anxiety disorder after controlling for DTD. Both DTD and PTSD were associated with suicidality. Conclusions: DTD is associated with psychiatric comorbidity beyond that of PTSD, and DTD warrants assessment for treatment planning with children in intensive psychiatric services.