Interpersonal Psychotherapy for Depressed Adolescents (IPT- A): Extending the Reach from Academic to Community Settings1

Depression Part 2: Treatment

Depression treatment strategies are within the scope of pediatric practice and among the competencies recommended by the Academy of Pediatrics and The American Board of Pediatrics. Treatments that may be provided through collaborative care include nonpharmacologic therapies such as psychosocial treatments and evidence-based psychotherapies, and pharmacotherapy and monitoring processes for depression. Abundant support and guidance are available to pediatricians in depression care, including mental health consultation and online materials.

Depression Part 1: Evaluation

By young adulthood, 1 in 5 teens will experience an episode of major depression. The second leading cause of death among youths aged 15 to 24 years is suicide, most of which will have been caused by untreated or undiagnosed depression. Depression is a highly heritable condition: depressed children often have depressed parents. Support to caregivers is important because depressed parents can have negative effects on children's development and future mental health. Groups more vulnerable to mental health disorders such as depression include Black, Indigenous, and persons of color and lesbian, gay, bisexual, transgender, or queer/questioning, who in recent years have the highest rate of suicide attempts (Black teens, sexual minority youth), the highest increases in suicide rates (Black children and youths), and the highest suicide rates (American Indian/Alaskan native). They frequently experience more adverse childhood events, which increases the risk of depression and suicide attempts. Pediatricians are most likely to care for these vulnerable youths, who often are less engaged in specialty mental health care for a variety of reasons, including stigma and barriers to access. By offering behavioral and mental health care to vulnerable populations in primary care, mental health equity may be achieved. Screening for depression and assessment for suicide are within the scope of pediatric practice and among the competencies recommended by the American Academy of Pediatrics and The American Board of Pediatrics.

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.

Interpersonal Counseling in the Treatment of Adolescent Depression: A Randomized Controlled Effectiveness and Feasibility Study in School Health and Welfare Services

In order to offer early and accessible treatment for adolescents with depression, brief and effective treatments in adolescents’ everyday surroundings are needed. This randomized controlled trial studied the preliminary effectiveness, feasibility, and acceptability of interpersonal counseling (IPC) and brief psychosocial support (BPS) in school health and welfare services. The study was conducted in the 28 lower secondary schools of a large city in Southern Finland, randomized to provide either IPC or BPS. Help-seeking 12–16-year-old adolescents with mild-to-moderate depression, with and without comorbid anxiety, were included in the study. Fifty-five adolescents received either 6 weekly sessions of IPC or BPS and two follow-up sessions. Outcome measures included self- and clinician-rated measures of depression, global functioning, and psychological distress/well-being. To assess feasibility and acceptability of the treatments, adolescents’ and counselors’ treatment compliance and satisfaction with treatment were assessed. Both treatments were effective in reducing depressive disorders and improving adolescents’ overall functioning and well-being. At post-treatment, in both groups, over 50% of adolescents achieved recovery based on self-report and over 70% based on observer report. Effect sizes for change were medium or large in both groups at post-treatment and increased at 6-month follow-up. A trend indicating greater baseline symptom severity among adolescents treated in the IPC-providing schools was observed. Adolescents and counselors in both groups were satisfied with the treatment, and 89% of the adolescents completed the treatments and follow-ups. This trial suggests that both IPC and BPS are feasible, acceptable, and effective treatments for mild-to-moderate depression in the school setting. In addition, IPC seems effective even if comorbid anxiety exists. Our study shows that brief, structured interventions, such as IPC and BPS, are beneficial in treating mild-to-moderate depression in school settings and can be administered by professionals working at school.

Trial registrationhttp://www.clinicaltrials.gov. Unique identifier: NCT03001245.

Lessons Learned About Barriers to Implementing School-Based Interventions for Adolescents: Ideas for Enhancing Future Research and Clinical Projects

The majority of youth with mental health problems do not receive treatment, highlighting the critical need to transport evidence-based interventions into community settings, such as schools. Despite being able to reach a large number of adolescents and minority youth, the process of implementing evidence-based interventions to schools is challenging. This paper discusses some expected and unexpected challenges experienced during the implementation of an open trial and a pilot randomized controlled trial examining the acceptability and effectiveness of a school-based preventive intervention for adolescents at risk for internalizing disorders. First, we highlight key programs and findings on preventive interventions for adolescents at risk for depression and anxiety. Next, we provide a brief overview of the preventive intervention we implemented in schools. This provides a context for the section that describes implementation issues and highlights specific challenges and potential solutions for intervention implementation. Finally, the paper offers recommendations for researchers and clinicians interested in implementing school-based mental health services for adolescents.

Stepped Care Interpersonal Psychotherapy Treatment for Depressed Adolescents: A Pilot Study in Pediatric Clinics

Adolescents with depression are at risk for negative long-term consequences and recurrence of depression. Many do not receive nor access treatment, especially Latino youth. New treatment approaches are needed. This study examined the feasibility and acceptability of a stepped collaborative care treatment model (SCIPT-A) for adolescents with depression utilizing interpersonal psychotherapy for adolescents (IPT-A) and antidepressant medication (if needed) compared to Enhanced Treatment as Usual (E-TAU) in urban pediatric primary care clinics serving primarily Latino youth. Results suggest the SCIPT-A model is feasible, acceptable and potentially beneficial for urban Latino adolescents. Clinicians delivered the SCIPT-A model with fidelity using supervision successfully implemented in a community setting.

Mother-Reported and Children's Perceived Social and Academic Competence in Clinic-Referred Youth: Unique Relations to Depression and/or Social Anxiety and the Role of Self-perceptions

Depression and social anxiety symptoms and disorders are highly comorbid, and are associated with low social acceptance and academic competence. Theoretical models of both depression and social anxiety highlight the saliency of negative self-perceptions. We examined whether children's self-perceptions of social acceptance and mother-reported youth social acceptance are independently and uniquely related to children's depression and social anxiety, both before and after controlling for comorbid symptoms. Similar questions were examined regarding academic competence. The sample was 110 clinic-referred youth aged 8-16 years (65 boys, 45 girls; M age = 11.15, SD = 2.57). In the social acceptance area, both youth self-perceptions and mother-perceptions had independent and unique relations to depression and social anxiety, before and after controlling for comorbid symptoms. In the academic domain, both youth self-perceptions and mother-perceptions had independent and unique relations to depression, before and after controlling for social anxiety; yet only youth self-perceptions were related to social anxiety, before, but not after controlling for depression. For depression, larger effect sizes were observed for children's perceived, versus mother-reported, social acceptance and academic competence. Bootstrapping and Sobel tests found youth self-perceptions of social acceptance mediated the relation between mothers' perceptions and each of youth depression and social anxiety; and perceived academic competence mediated the relation between mothers' perceptions and youth depression, both before and after controlling for social anxiety. We found similarities and differences in findings for depression and social anxiety. Theoretical and treatment implications are highlighted, and future research directions are discussed.

[Cognitive behavior therapy for depression in children and adolescents - procedure, effects, and developments]

Cognitive behavior therapy offers a theoretically and empirically valid therapeutic approach for children and adolescents suffering from depression. It can be recommended according to present guidelines and efficacy studies. Further research and conceptual development, however, is necessary especially regarding the small to moderate effect sizes as well as the lack of long-term efficacy and effect factors. This article gives a short overview of the basics and contents of cognitive behavior therapy for depressive children and adolescents. It furthermore presents the latest findings and an assessment of its efficacy and relevant developments and perspectives.

Integrating etiological models of social anxiety and depression in youth: evidence for a cumulative interpersonal risk model

Models of social anxiety and depression in youth have been developed separately, and they contain similar etiological influences. Given the high comorbidity of social anxiety and depression, we examine whether the posited etiological constructs are a correlate of, or a risk factor for, social anxiety and/or depression at the symptom level and the diagnostic level. We find core risk factors of temperament, genetics, and parent psychopathology (i.e., depression and anxiety) are neither necessary nor sufficient for the development of social anxiety and/or depression. Instead, aspects of children's relationships with parents and/or peers either mediates (i.e., explains) or moderates (i.e., interacts with) these core risks being related to social anxiety and/or depression. We then examine various parent- and peer-related constructs contained in the separate models of social anxiety and depression (i.e., parent-child attachment, parenting, social skill deficits, peer acceptance and rejection, peer victimization, friendships, and loneliness). Throughout our review, we report evidence for a Cumulative Interpersonal Risk model that incorporates both core risk factors and specific interpersonal risk factors. Most studies fail to consider comorbidity, thus little is known about the specificity of these various constructs to depression and/or social anxiety. However, we identify shared, differential, and cumulative risks, correlates, consequences, and protective factors. We then put forth demonstrated pathways for the development of depression, social anxiety, and their comorbidity. Implications for understanding comorbidity are highlighted throughout, as are theoretical and research directions for developing and refining models of social anxiety, depression, and their comorbidity. Prevention and treatment implications are also noted.

Cognitive-behavioral therapy for weight management and eating disorders in children and adolescents

Eating disorders and obesity in children and adolescents involve harmful behavior and attitude patterns that infiltrate daily functioning. Cognitive-behavioral therapy (CBT) is well suited to treating these conditions, given the emphasis on breaking negative behavior cycles. This article reviews the current empirically supported treatments and the considerations for youth with weight control issues. New therapeutic modalities (ie, enhanced CBT and the socioecologic model) are discussed. Rationale is provided for extending therapy beyond the individual treatment milieu to include the family, peer network, and community domains to promote behavior change, minimize relapse, and support healthy long-term behavior maintenance.