Prevention of depression in at-risk adolescents: a randomized controlled trial

A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review

Background

Depression is a public health problem and common amongst adolescents. Cognitive behavioural therapy (CBT) is widely used to treat adolescent depression but existing research does not provide clear conclusions regarding the relative effectiveness of different delivery modalities.

Objectives

The primary aim is to estimate the relative efficacy of different modes of CBT delivery compared with each other and control conditions for reducing depressive symptoms in adolescents. The secondary aim is to compare the different modes of delivery with regard to intervention completion/attrition (a proxy for intervention acceptability).

Search Methods

The Cochrane Depression, Anxiety and Neurosis Clinical Trials Register was searched in April 2020. MEDLINE, PsycInfo, EMBASE, four other electronic databases, the CENTRAL trial registry, Google Scholar and Google were searched in November 2020, together with reference checking, citation searching and hand-searching of two databases.

Selection Criteria

Randomised controlled trials (RCTs) of CBT interventions (irrespective of delivery mode) to reduce symptoms of depression in young people aged 10-19 years with clinically relevant symptoms or diagnosis of depression were included.

Data Collection and Analysis

Screening and data extraction were completed by two authors independently, with discrepancies addressed by a third author. CBT interventions were categorised as follows: group CBT, individual CBT, remote CBT, guided self-help, and unguided self-help. Effect on depressive symptom score was estimated across validated self-report measures using Hedges' g standardised mean difference. Acceptability was estimated based on loss to follow-up as an odds ratio. Treatment rankings were developed using the surface under the cumulative ranking curve (SUCRA). Pairwise meta-analyses were conducted using random effects models where there were two or more head-to-head trials. Network analyses were conducted using random effects models.

Main Results

Sixty-eight studies were included in the review. The mean age of participants ranged from 10 to 19.5 years, and on average 60% of participants were female. The majority of studies were conducted in schools (28) or universities (6); other settings included primary care, clinical settings and the home. The number of CBT sessions ranged from 1 to 16, the frequency of delivery from once every 2 weeks to twice a week and the duration of each session from 20 min to 2 h. The risk of bias was low across all domains for 23 studies, 24 studies had some concerns and the remaining 21 were assessed to be at high risk of bias. Sixty-two RCTs (representing 6435 participants) were included in the pairwise and network meta-analyses for post-intervention depressive symptom score at post-intervention. All pre-specified treatment and control categories were represented by at least one RCT. Although most CBT approaches, except remote CBT, demonstrated superiority over no intervention, no approaches performed clearly better than or equivalent to another. The highest and lowest ranking interventions were guided self-help (SUCRA 83%) and unguided self-help (SUCRA 51%), respectively (very low certainty in treatment ranking). Nineteen RCTs (3260 participants) were included in the pairwise and network meta-analyses for 6 to 12 month follow-up depressive symptom score. Neither guided self-help nor remote CBT were evaluated in the RCTs for this time point. Effects were generally attenuated for 6- to 12-month outcomes compared to posttest. No interventions demonstrated superiority to no intervention, although unguided self-help and group CBT both demonstrated superiority compared to TAU. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking approaches were unguided self-help and individual CBT, respectively. Sixty-two RCTs (7347 participants) were included in the pairwise and network meta-analyses for intervention acceptability. All pre-specified treatment and control categories were represented by at least one RCT. Although point estimates tended to favour no intervention, no active treatments were clearly inferior. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking active interventions were individual CBT and group CBT respectively. Pairwise meta-analytic findings were similar to those of the network meta-analysis for all analyses. There may be age-based subgroup effects on post-intervention depressive symptoms. Using the no intervention control group as the reference, the magnitudes of effects appear to be larger for the oldest age categories compared to the other subgroups for each given comparison. However, they were generally less precise and formal testing only indicated a significant difference for group CBT. Findings were robust to pre-specified sensitivity analyses separating out the type of placebo and excluding cluster-RCTs, as well as an additional analysis excluding studies where we had imputed standard deviations.

Authors' Conclusions

At posttreatment, all active treatments (group CBT, individual CBT, guided self-help, and unguided self-help) except for remote CBT were more effective than no treatment. Guided self-help was the most highly ranked intervention but only evaluated in trials with the oldest adolescents (16-19 years). Moreover, the studies of guided self-help vary in the type and amount of therapist support provided and longer-term results are needed to determine whether effects persist. The magnitude of effects was generally attenuated for 6- to 12-month outcomes. Although unguided self-help was the lowest-ranked active intervention at post-intervention, it was the highest ranked at follow-up. This suggests the need for further research into whether interventions with self-directed elements enable young people to maintain effects by continuing or revisiting the intervention independently, and whether therapist support would improve long-term outcomes. There was no clear evidence that any active treatments were more acceptable to participants than any others. The relative effectiveness of intervention delivery modes must be taken into account in the context of the needs and preferences of individual young people, particularly as the differences between effect sizes were relatively small. Further research into the type and amount of therapist support that is most acceptable to young people and most cost-effective would be particularly useful.

Feasibility, acceptability, and depression outcomes of a randomized controlled trial of Mindful Self-Compassion for Teens (MSC-T) for adolescents with subsyndromal depression

INTRODUCTION

Adolescents are experiencing high rates of depressive symptoms, with negative consequences to their long-term health. Group-based, mindful self-compassion programs show promise in mitigating the development of more significant depression in at-risk adolescents. However, the lack of well-designed, active control conditions has limited the ability to examine the efficacy of such interventions.

METHODS

Fifty-nine adolescents (Mage  = 15.81, 70% female) with subsyndromal depressive symptoms from the Southeastern US were randomized to group-based Mindful Self-Compassion for Teens (N = 30) or a newly developed active control Healthy Lifestyles group (N = 29) during 2018 and 2019. Participants attended 8 weekly "main" sessions followed by 6 monthly continuation sessions. The feasibility and acceptability of participation in both groups were measured using attrition, attendance, credibility, and satisfaction data. Depression scores were collected weekly, and self-compassion scores were collected five times across 36 weeks.

RESULTS

Both groups were equally feasible and acceptable during the 8-week program period; however, monthly continuation sessions were poorly attended in both groups. The risk of developing clinically significant depression was 2.6 times higher in the control group compared with the self-compassion group (p = .037) across 36 weeks. Depression significantly decreased in the self-compassion group, while it significantly increased in the control group. Both groups increased significantly in reports of self-compassion. These findings are on par with results noting the efficacy of cognitive-based interventions for high-risk adolescents; follow-up studies with larger sample sizes should be conducted to confirm these findings.

CONCLUSIONS

Initial examination suggests Mindful Self-Compassion for Teens programming is feasible, acceptable, and efficacious in preventing the development of clinically significant depression in adolescents with subsyndromal depression. Future studies may benefit from refinements to the self-compassion measurement and/or the attention control condition; moreover, larger sample sizes are needed to confirm results.

PATHway: Intervention optimization of a prevention program for adolescents at-risk for depression in the primary care setting

With as many as 13% of adolescents diagnosed with depressive disorders each year, prevention of depressive disorders has become a key priority for the National Institute of Mental Health (NIMH). Currently, we have no widely available interventions to prevent these disorders. To address this need, we developed a multi-health system collaboration to develop and evaluate the primary care based technology "behavioral vaccine," Competent Adulthood Transition with Cognitive-Behavioral Humanistic and Interpersonal Therapy (CATCH-IT). The full CATCH-IT program demonstrated evidence of efficacy in prevention of depressive episodes in clinical trials. However, CATCH-IT became larger and more complex across trials, creating issues with adherence and scalability. We will use a multiphase optimization strategy approach to optimize CATCH-IT. The theoretically grounded components of CATCH-IT include: behavioral activation, cognitive-behavioral therapy, interpersonal psychotherapy, and parent program. We will use a 4-factor (2x2x2x2) fully crossed factorial design with N = 16 cells (25 per cell, after allowing 15% dropout) to evaluate the contribution of each component. Eligible at-risk youth will be high school students 13 through 18 years old, with subsyndromal symptoms of depression. The study design will enable us to eliminate non-contributing components while preserving efficacy and to optimize CATCH-IT by strengthening tolerability and scalability by reducing resource use. By reducing resource use, we anticipate satisfaction and acceptability will also increase, preparing the way for an implementation trial.

Primary care-based screening and recruitment for an adolescent depression prevention trial: Contextual considerations during a youth mental health crisis

Background

Rising rates of adolescent depression in the wake of COVID-19 and a youth mental health crisis highlight the urgent need for accessible mental healthcare and prevention within primary care. Digital mental health interventions (DMHIs) may increase access for underserved populations. However, these interventions are not well studied in adolescents, nor healthcare settings. The purpose of this study was to identify barriers and facilitators to screening and recruitment activities for PATH 2 Purpose (P2P): Primary Care and Community-Based Prevention of Mental Disorders in Adolescents, a multi-site adolescent depression prevention trial comparing two digital prevention programs within four diverse health systems in two U.S. states.

Method

This qualitative study is a component of a larger Hybrid Type I trial. We conducted semi-structured key informant interviews with clinical and non-clinical implementers involved with screening and recruitment for the P2P trial. Informed by the Consolidated Framework for Implementation Research (CFIR), interviews were conducted at the midpoint of the trial to identify barriers, facilitators, and needed adaptations, and to gather information on determinants that may affect future implementation.

Findings

Respondents perceived the P2P trial as valuable, well aligned with the mission of their health systems. However, several barriers were identified, many of which stemmed from influences outside of the healthcare settings. Universal and site-specific outer setting influences (COVID-19 pandemic, youth mental health crisis, local community conditions) interacted with Inner Setting and Innovation domains to create numerous challenges to the implementation of screening and recruitment.

Conclusion

Our findings emphasize the need for ongoing, comprehensive assessment of dynamic inner and outer setting contexts prior to and during implementation of clinical trials, as well as flexibility for adaptation to unique clinical contexts. The CFIR is useful for assessing determinants during times of rapid inner and outer setting change, such as those brought on by the COVID-19 pandemic, youth mental health crisis, and the corresponding exacerbation of resource strain within healthcare settings.

Clinical trial registration

PATH 2 Purpose: Primary Care and Community-Based Prevention of Mental Disorders in Adolescents https://www.clinicaltrials.gov/study/NCT04290754.

BEhavioral Health Stratified Treatment (B.E.S.T.) to optimize transition to adulthood for youth with intellectual and/or developmental disabilities

Youth with intellectual and/or developmental disabilities (IDD) often struggle with depression and anxiety, which adversely impacts transition to adulthood. Integrated behavioral health care coordination, wherein care coordinators and behavioral health specialists collaborate to provide systematic, cost-effective, patient-centered care, is a promising strategy to improve access to behavioral health services and address factors that impact transition to adulthood, including depression/anxiety symptoms. Current care coordination models (e.g., Title V Maternal and Child Health Bureau [MCHB]) do not include behavioral health services. The CHECK (Coordinated HealthCarE for Complex Kids) mental health model, hereby refined and renamed BEhavioral Health Stratified Treatment (B.E.S.T.), is a behavioral health intervention delivery program designed for integration into care coordination programs. This study aims to determine whether an integrated behavioral health care coordination strategy (i.e., MCHB care coordination plus B.E.S.T.) would be more acceptable and lead to better youth health and transition outcomes, relative to standard care coordination (i.e., MCHB care coordination alone). Results would guide future investment in improving outcomes for youth with IDD. This study is a two-arm randomized clinical trial of 780 transition-aged youth with IDD (13-20 years) to evaluate the comparable efficacy of MCHB Care Coordination alone vs. MCHB Care Coordination plus B.E.S.T. on the following outcomes: 1) decreased symptoms and episodes of depression and anxiety over time; 2) improved health behaviors, adaptive functioning and health related quality of life; 3) increased health care transition (HCT) readiness; and 4) improved engagement and satisfaction with care coordination among stakeholders.

Following the children of depressed parents from childhood to adult life: A focus on mood and anxiety disorders

Background

Parental depression increases risk for anxiety and depression in offspring. The transition from adolescence to adulthood is a common risk period for onset of such disorders. However, relatively few studies have considered development of these disorders from childhood to adulthood including multiple assessments during this transition period.

Method

Offspring of depressed parents aged 9-17 years at baseline were followed prospectively for 13 years (n = 337). Average length of follow-up was 16 months between the first and second waves, 13 months between the second and third, and 8 years between the third and fourth. Current (3-month) psychopathology was assessed at each wave using diagnostic interviews. We derived estimates of 3-month prevalence, age at first diagnosis, course and comorbidity of disorders. Social functioning in adult life was assessed at the final wave and we assessed how prior and current disorder impacted adult functioning.

Results

A quarter of young people met criteria for a mood disorder and a third for anxiety disorder at least once. Mood and anxiety disorder prevalence increased from 4.5% and 15.8% respectively in childhood (9-11 years) to 22.3% and 20.9% respectively by age 23-28. Increased prevalence across the transition from adolescence to adulthood was particularly marked in males, while prevalence increased earlier in adolescence in females. Age at first diagnosis varied widely (mood disorder mean = 16.5 years (range 9-26); anxiety disorder mean = 14.5 years (range 9-28)). Over half (52%) reported functional impairment in early adulthood, 31% harmful alcohol use, and 10% self-harm or a suicide attempt. Both previous and current mood or anxiety disorder were associated with functional impairment in early adulthood.

Conclusions

There is a prolonged risk period for mood and anxiety disorders in this group, with prevalence peaking in early adulthood. This highlights the need for prolonged vigilance and effective targeted interventions in the offspring of depressed parents.

Transdiagnostic risk of mental disorders in offspring of affected parents: a meta-analysis of family high-risk and registry studies

The offspring of parents with mental disorders are at increased risk for developing mental disorders themselves. The risk to offspring may extend transdiagnostically to disorders other than those present in the parents. The literature on this topic is vast but mixed. To inform targeted prevention and genetic counseling, we performed a comprehensive, PRISMA 2020-compliant meta-analysis. We systematically searched the literature published up to September 2022 to retrieve original family high-risk and registry studies reporting on the risk of mental disorders in offspring of parents with any type of mental disorder. We performed random-effects meta-analyses of the relative risk (risk ratio, RR) and absolute risk (lifetime, up to the age at assessment) of mental disorders, defined according to the ICD or DSM. Cumulative incidence by offspring age was determined using meta-analytic Kaplan-Meier curves. We measured heterogeneity with the I2 statistic, and risk of bias with the Quality In Prognosis Studies (QUIPS) tool. Sensitivity analyses addressed the impact of study design (family high-risk vs. registry) and specific vs. transdiagnostic risks. Transdiagnosticity was appraised with the TRANSD criteria. We identified 211 independent studies that reported data on 3,172,115 offspring of parents with psychotic, bipolar, depressive, disruptive, attention-deficit/hyperactivity, anxiety, substance use, eating, obsessive-compulsive, and borderline personality disorders, and 20,428,575 control offspring. The RR and lifetime risk of developing any mental disorder were 3.0 and 55% in offspring of parents with anxiety disorders; 2.6 and 17% in offspring of those with psychosis; 2.1 and 55% in offspring of those with bipolar disorder; 1.9 and 51% in offspring of those with depressive disorders; and 1.5 and 38% in offspring of those with substance use disorders. The offspring's RR and lifetime risk of developing the same mental disorder diagnosed in their parent were 8.4 and 32% for attention-deficit/hyperactivity disorder; 5.8 and 8% for psychosis; 5.1 and 5% for bipolar disorder; 2.8 and 9% for substance use disorders; 2.3 and 14% for depressive disorders; 2.3 and 1% for eating disorders; and 2.2 and 31% for anxiety disorders. There were 37 significant transdiagnostic associations between parental mental disorders and the RR of developing a different mental disorder in the offspring. In offspring of parents with psychosis, bipolar and depressive disorder, the risk of the same disorder onset emerged at 16, 5 and 6 years, and cumulated to 3%, 19% and 24% by age 18; and to 8%, 36% and 46% by age 28. Heterogeneity ranged from 0 to 0.98, and 96% of studies were at high risk of bias. Sensitivity analyses restricted to prospective family high-risk studies confirmed the pattern of findings with similar RR, but with greater absolute risks compared to analyses of all study types. This study demonstrates at a global, meta-analytic level that offspring of affected parents have strongly elevated RR and lifetime risk of developing any mental disorder as well as the same mental disorder diagnosed in the parent. The transdiagnostic risks suggest that offspring of parents with a range of mental disorders should be considered as candidates for targeted primary prevention.

A Randomized Clinical Trial of Technology-Enhanced Family-Focused Therapy for Youth in the Early Stages of Mood Disorders

Objective

Family-focused therapy (FFT) is associated with enhanced outcomes in youth with bipolar and depressive disorders, but has not been evaluated in conjunction with mobile health tools. In symptomatic adolescents whose parents had histories of mood disorders, we examined whether the effects of telehealth-based FFT were augmented by mobile health apps that emphasized mood tracking and family coping skills.

Method

Participants (aged 13-19 years) had active mood symptoms and a parent with major depressive or bipolar disorder. Participants received 12 sessions in 18 weeks of telehealth FFT, with random assignment to (1) a mobile app (MyCoachConnect, MCC) that enabled mood tracking, reviews of session content, and text reminders to practice mood management and family communication skills (FFT-MCC); or (2) a mobile app that enabled mood tracking only (FFT-Track). Independent evaluators assessed youth every 9 weeks over 6 months on depressive symptoms (primary outcome), anxiety, and psychosocial functioning.

Results

Participants (N = 65; mean age 15.8 ± 1.6 years) significantly improved in depressive symptoms over 6 months (F1,170 = 45.02, p < .0001; ή2 = 0.21, 95% CI = 0.11-0.31), but there were no effects of treatment condition or treatment by time interactions on depression scores. When secondary outcome measures were considered, the subgroup of youth with bipolar spectrum disorders showed greater improvements in anxiety and global functioning in FFT-MCC compared with FFT-Track.

Conclusion

Youth in the early stages of mood disorder may benefit from FFT enhanced by mobile health apps. Collaborations between researchers and information technologists on mobile app design and user experience may lead to increases in engagement among adolescents.

Clinical trial registration information

Technology Enhanced Family Treatment; https://clinicaltrials.gov/; NCT03913013.

Epidemiology of depressive disorders among youth during Gaokao to college in China: results from Hunan Normal University mental health survey

BACKGROUND

Given the serious consequences of depression and the lack of information about it during the crucially developmental period from the National College Entrance Exam (CEE, i.e., Chinese gaokao) to college, this study aimed to estimate the cumulative incidence, prevalence, age of onset, correlates, and service use of depressive disorders (DDs) among youth who passed the CEE and were enrolled at Hunan Normal University in China.

METHODS

A two-stage cross-sectional epidemiological survey of DDs was conducted from October to December, 2017 among 6,922 incoming college students (98.5% effective response, N = 6,818, 71.4% female, age range: 16-25 years, mean age = 18.6). Using a stratified sampling method based on the risk of depression, 926 participants (mean age = 18.5, 75.2% female) were selected and subsequently interviewed with the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and lifetime version (K-SADS-PL).

RESULTS

The sex-adjusted 9-month (i.e., 3 months pre-CEE, 3 months after CEE, and 3 months post-matriculation) incidence of new-onset DDs was 2.3% (standard error [S.E.] 0.3%), and the sex-adjusted 1-month, 6-month and lifetime prevalence were 0.7 (S.E. 0.3%), 1.7 (S.E. 0.2%) and 7.5% (S.E. 1.3%), respectively. The median age of onset was 17 (interquartile range: 16-18) years. Critically, over one-third (36.5%, S.E. 0.6) of depressed youth had their new onset during the 9-month period. The risk factors for depression included having mothers with higher education, experiencing major life events, being female, and experiencing parental divorce or death. The adjusted lifetime treatment rate was 8.7%.

CONCLUSION

The 9-month incidence of new-onset depression from gaokao to college among the youth sample in China is similar to the global annual incidence (3.0%), but the 1-month and lifetime prevalence are significantly lower than the global point (7.2%) and lifetime prevalence (19%). These findings suggest a high proportion of new-onset depression during the CEE to college among the sample youth in China. The risk of depression is associated with familial and stress correlates. Low treatment is a serious concern. Emphasis on early prevention and available treatment for adolescent and young adult depression is a critical need in China.

A randomized controlled trial of a preventive intervention for the children of parents with depression: mid-term effects, mediators and moderators

BACKGROUND

In a parallel randomized controlled trial the effectiveness of the family- and group-based cognitive-behavioural "Gug-Auf" intervention in preventing depression in children of depressed parents was evaluated. We hypothesized that the intervention would be associated with reduced incidence of depression at 15 months as well as with reduced symptom severity at 6, 9, and 15 months. We also explored the role of a number of mediators and moderators.

METHODS

Families were included if a parent (n = 100, mean age = 46.06, 61% female) had experienced depression and children (n = 135, aged 8-17 years, 53% female) had no mental illness. Families (91.5% German) were randomly allocated (50:50 block-wise; stratified by child age and parental depression) to the 12-session "GuG-Auf" intervention or no intervention. Outcomes were assessed (on an intention-to-treat basis) at 0-(T1), 6-(T2), 9-(T3) and 15-months (T4) after baseline. Primary outcome (onset of depression; T4) was assessed with standardized (blinded) clinical interviews. Secondary (unblinded) outcome was risk of depression (at T2-T4) indicated by self- and parent-reported symptoms of internalizing, externalizing and depressive disorder. Potential mediators were emotion regulation, attributional style, knowledge of depression and parenting style. Potential moderators were parental depression severity and negative life events.

RESULTS

None of the children who received the intervention developed depression, whereas two of those in the control group did. The intervention significantly reduced depression risk (indicated by severity of self-reported internalizing symptoms) at T3 (p = .027, d = -0.45) and T4 (p = .035, d = -0.44). Both groups showed reduced depressive symptoms (p = .029, d = -0.44). Cognitive problem-solving and negative parenting emerged as mediators. There was no evidence that the intervention was associated with parent-reported internalizing symptoms or externalizing symptoms. No adverse events were observed.

CONCLUSIONS

Children of parents with depression showed an increase in self-reported (but not parent-reported) internalizing symptoms over time. This increase was not present in children who received the GuG-Auf intervention. The intervention was not associated with changes in externalizing symptoms. Conclusions regarding prevention of the onset of depression were not possible. Despite some limitations in the generalizability, these findings contribute to reducing the burden of youth depression.

REGISTRATION

The trial was registered on 16/04/2014 at ClinicalTrials.gov ( NCT02115880 ) and study protocol published in BMC Psychiatry ( https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-014-0263-2 ).

Evaluating Effect Moderators in Cognitive Versus Behavioral Based CBT-Modules and Sequences Towards Preventing Adolescent Depression

OBJECTIVE

The aim of this study was to investigate age group, gender, and baseline depressive symptom severity as possible effect moderators in (1) cognitive versus behavioral based CBT-modules and (2) sequences of modules that started either with cognitive or behavioral modules in indicated depression prevention in adolescents.

METHOD

We conducted a pragmatic cluster-randomized trial under four parallel conditions. Each condition consisted of four CBT-modules of three sessions (cognitive restructuring, problem solving, behavioral activation, relaxation), but the sequencing of modules differed. The CBT-modules and sequences were clustered into more cognitive versus more behavioral based approaches. The sample involved 282 Dutch adolescents with elevated depressive symptoms (Mage = 13.8; 55.7% girls, 92.9% Dutch). Assessments were conducted at baseline, after three sessions, at post-intervention and 6-month follow-up with self-reported depressive symptoms as the primary outcome.

RESULTS

We found no evidence for substantial moderation effects. Age group, gender, and depressive symptom severity level at baseline did not moderate the effects of cognitive versus behavioral modules after three sessions. No evidence was also found that these characteristics moderated the effectiveness of sequences of modules that started either with cognitive or behavioral modules at post-intervention and 6-month follow-up.

CONCLUSION

Cognitive and behavioral based modules and sequences in the prevention of depression in adolescents might apply to a relatively wide range of adolescents in terms of age group, gender, and severity levels of depressive symptoms.Abbreviation: CDI-2:F: Children's Depression Inventory-2 Full-length version; CDI-2:S: Children's Depression Inventory-2 Short version; STARr: Solve, Think, Act, Relax, and repeat.

eHealth Familias Unidas Mental Health: Protocol for an effectiveness-implementation hybrid Type 1 trial to scale a mental health preventive intervention for Hispanic youth in primary care settings

This article focuses on the rationale, design and methods of an effectiveness-implementation hybrid type I randomized trial of eHealth Familias Unidas Mental Health, a family-based, online delivered intervention for Hispanic families to prevent/reduce depressive and anxious symptoms, suicide ideation/behaviors, and drug use in Hispanic youth. Utilizing a rollout design with 18 pediatric primary care clinics and 468 families, this study addresses intervention effectiveness, implementation research questions, and intervention sustainment, to begin bridging the gap between research and practice in eliminating mental health and drug use disparities among Hispanic youth. Further, we will examine whether intervention effects are partially mediated by improved family communication and reduced externalizing behaviors, including drug use, and moderated by parental depression. Finally, we will explore whether the intervention's impact on mental health and drug use, as well as sustainment of the intervention in clinics, varies by quality of implementation at clinic and clinician levels. Trail registration: ClinicalTrials.gov Identifier: NCT05426057, First posted June 21, 2022.

Personalized Depression Prevention Reduces Dependent Stressors Among Adolescents: Results from a Randomized Controlled Trial

OBJECTIVE

Depression and stressors both increase during adolescence. The stress generation model posits that depression symptoms and associated impairment contribute to the generation of dependent stressors. Adolescent depression prevention programs have been shown to reduce the risk of depression. Recently, risk-informed personalization approaches have been adopted to enhance the efficacy of depression prevention, and preliminary evidence supports the beneficial effects of personalized prevention on depression symptoms. Given the close association between depression and stress, we examined the hypothesis that personalized depression prevention programs would reduce adolescents' experience of dependent stressors (interpersonal and non-interpersonal) over longitudinal follow-up.

METHOD

The present study included 204 adolescents (56% girls, 29% racial minority) who were randomized to receive either a cognitive-behavioral or an interpersonal prevention program. Youth were categorized as high or low on cognitive and interpersonal risk using a previously established risk classification system. Half of the adolescents received a prevention program that matched their risk profile (e.g., high cognitive risk randomized to cognitive-behavioral prevention); half received a mismatched program (e.g., high interpersonal risk randomized to cognitive-behavioral prevention). Exposure to dependent and independent stressors was assessed repeatedly over an 18-month follow-up period.

RESULTS

Matched adolescents reported fewer dependent stressors during the post-intervention follow-up period (d = .46, p = .002) and from baseline through 18-months post-intervention (d = .35, p = .02) compared to mismatched youth. As expected, there were no differences between matched and mismatched youth on the experience of independent stressors.

CONCLUSIONS

These findings further highlight the potential of personalized approaches to depression prevention and demonstrate benefits that go beyond depression symptom reduction.

Reduced parenting stress following a prevention program decreases internalizing and externalizing symptoms in the offspring of parents with bipolar disorder

BACKGROUND

Offspring of parents with bipolar disorder (OBD) are at risk for developing mental disorders, and the literature suggests that parenting stress may represent an important risk factor linking parental psychopathology to offspring psychopathology. We aimed to investigate whether improvements in parenting stress mediated the relationship between participation in a prevention program and offspring internalizing and externalizing symptoms at follow-up.

METHODS

Families having a parent with BD (N = 25) underwent a 12-week prevention program. Assessments were conducted at pre-intervention, post-intervention, and at 3- and 6-month follow-ups. Families of parents with no affective disorders (i.e., control families) served as a comparison sample (N = 28). The Reducing Unwanted Stress in the Home (RUSH) program aimed to teach communication, problem-solving, and organization skills to improve the rearing environment. Measures included the Parenting Stress Index-4th Edition, the Behaviour Assessment Scales for Children-2nd Edition, and the UCLA Life Stress Interview.

RESULTS

Families having a parent with BD reported more parenting stress at pre-intervention, and more change across time, than control families. Improvements in parenting stress mediated the relationship between participation in the intervention and reduced offspring internalizing and externalizing symptoms. While families having a parent with BD reported more chronic interpersonal stress at pre-intervention, no intervention effects were found.

CONCLUSIONS

The findings demonstrate that a preventative intervention targeting parenting stress in families may serve to prevent the development of mental disorders in at-risk children.

Examining the impact of randomized control intervention on depressive symptoms in schoolchildren with atypical behaviors

BACKGROUND

The need to investigate depression among disadvantaged groups motivated this study. This study investigated the impacts of rational emotive behavior therapy (REBT) on depressive symptoms in schoolchildren with atypical behaviors in Enugu State Nigeria.

METHOD

A group randomized controlled design was used to assign 37 schoolchildren to the intervention group and 37 schoolchildren to the waitlisted control group. These people were evaluated at three times (pretest, post-test, and later test) using a dependent measure. The outcome demonstrated that there was no discernible difference between the participants in the treatment group and those in the waitlisted control group at the time of the pretest. The post-treatment test results revealed a considerable improvement among participants as a result of REBT therapy.

RESULTS

The later test result revealed that the treatment's significant improvement was maintained in favor of the REBT group. The outcome of REBT treatment was not moderated due to location. The data showed a significant interaction impact on participants' depression levels in relation to the interaction between groups and gender during therapy.

CONCLUSION

Following the outcomes, we concluded that REBT is a long-term efficacious intervention for treating depressive symptoms in schoolchildren with atypical behaviors in Enugu State Nigeria regardless of location and gender.

Examining Patterns of Psychotherapy Service Utilization Among Medicaid-Enrolled Adolescents

OBJECTIVE

Adolescents with behavioral health disorders (i.e., mental health disorders and substance use) often experience frequent recurrence of symptoms, suggesting a need for an ongoing behavioral health intervention, rather than a single course of treatment. However, little is known about mental health care service use among adolescents over longer periods. The authors examined longitudinal patterns of outpatient behavioral health service utilization in a large sample of adolescents.

METHODS

Medicaid claims for 8,197 adolescents (ages 10.0-13.9 years, mean±SD=11.5±1.2; 61% male) from one Indiana county between 2006 and 2017 were examined, with a focus on outpatient psychotherapy visits. Latent class analysis (LCA) was used to detect clusters of longitudinal patterns of outpatient psychotherapy visits across 5 years, beginning with an adolescent's first behavioral health visit.

RESULTS

A five-class LCA model emerged with unique classes of service use based on duration and level of engagement (frequency) of monthly outpatient psychotherapy visits. Most adolescents fell in the nonuse class (38.7% of the sample). Additional classes were defined as late-onset low engagement (17.1%), early-onset high engagement (15.5%), early-onset moderate engagement (16.7%), and continuously high engagement (11.9%). Statistically significant differences were found across the classes in average duration and frequency of involvement (p<0.001), as well as in demographic characteristics (race, age, gender, and ethnicity) and behavioral health diagnoses (p<0.001).

CONCLUSIONS

These findings confirm that adolescents with behavioral health diagnoses do not follow a uniform pattern of psychotherapy utilization. The distinct patterns of service use point toward the need to identify appropriate long-term service recommendations for adolescents.

Personalised app-based relapse prevention of depressive and anxiety disorders in remitted adolescents and young adults: a protocol of the StayFine RCT

INTRODUCTION

Youth in remission of depression or anxiety have high risks of relapse. Relapse prevention interventions may prevent chronicity. Aim of the study is therefore to (1) examine efficacy of the personalised StayFine app for remitted youth and (2) identify high-risk groups for relapse and resilience.

METHOD AND ANALYSIS

In this Dutch single-blind parallel-group randomised controlled trial, efficacy of app-based monitoring combined with guided app-based personalised StayFine intervention modules is assessed compared with monitoring only. In both conditions, care as usual is allowed. StayFine modules plus monitoring is hypothesised to be superior to monitoring only in preventing relapse over 36 months. Participants (N=254) are 13-21 years and in remission of depression or anxiety for >2 months. Randomisation (1:1) is stratified by previous treatment (no treatment vs treatment) and previous episodes (1, 2 or >3 episodes). Assessments include diagnostic interviews, online questionnaires and monitoring (ecological momentary assessment with optional wearable) after 0, 4, 12, 24 and 36 months. The StayFine modules are guided by certified experts by experience and based on preventive cognitive therapy and ingredients of cognitive behavioural therapy. Personalisation is based on shared decision-making informed by baseline assessments and individual symptom networks. Time to relapse (primary outcome) is assessed by the Kiddie Schedule for Affective Disorders and Schizophrenia-lifetime version diagnostic interview. Intention-to-treat survival analyses will be used to examine the data. Secondary outcomes are symptoms of depression and anxiety, number and duration of relapses, global functioning, and quality of life. Mediators and moderators will be explored. Exploratory endpoints are monitoring and wearable outcomes.

ETHICS, FUNDING AND DISSEMINATION

The study was approved by METC Utrecht and is funded by the Netherlands Organisation for Health Research and Development (636310007). Results will be submitted to peer-reviewed scientific journals and presented at (inter)national conferences.

TRIAL REGISTRATION NUMBER

NCT05551468; NL8237.

Secondary Analysis to Inform the Development of Adaptive Preventive Interventions

For the past 30 years, scholars across the fields of epidemiology, education, psychology, and numerous other fields have worked to develop interventions designed to reduce risk and enhance protection to prevent mental, emotional, and behavioral problems across the lifespan. This article presents a series of next steps that leverage this foundational science to inform the development of adaptive preventive interventions. Adaptive preventive interventions (APIs) tailor the intervention to fit the diverse, sometimes changing, needs of participants with the goal of better prevention outcomes for more individuals. Secondary analyses of data from preventive intervention trials to identify moderators, mediators, and antecedents of attrition and intervention failure can be useful for designing effective APIs. Moderators that identify intervention effect heterogeneity can be used within an API to tailor the intervention to meet the unique needs of important participant subgroups. Mediators and predictors of disengagement and attrition can be helpful tailoring variables in an API to trigger change to the intervention. Preventive intervention trials that incorporate frequent assessment of potential mediators, moderators, and antecedents of attrition during the intervention period are needed. Secondary analyses of data from preventive intervention trials provide an important foundation for next-generation APIs.

Adaptation of the Coping With Stress Course for Black Adolescents in Low-Income Communities: Examples of Surface Structure and Deep Structure Cultural Adaptations

Black adolescents in low-income communities are at increased risk of developing mental health problems due to the impact of cumulative poverty-related stressors and racial discrimination, yet Black youth have relatively low rates of mental health service utilization, resulting in significant unmet need. The Coping With Stress (CWS) Course is an evidence-based, cognitive behavioral intervention that has been shown to reduce the incidence of anxiety, mood, and conduct problems among predominantly White samples, as well as Asian and Latinx youth. In the past 25 years since the CWS Course was introduced, Black adolescents have either been severely underrepresented or conspicuously absent from program evaluation research on the CWS Course, with few exceptions. The purpose of this article is threefold: (1) to justify the need for cultural adaptations to the CWS Course for Black adolescents from low-income communities, (2) to describe the scientific basis for the specific surface structure and deep structure modifications made to the culturally adapted version of the CWS Course, known as Resilient In spite of Stressful Events or RISE, and (3) to illustrate the deep structure adaptations with a vignette drawn from implementation of the RISE program with Black adolescents in a low-income, urban community.

Adolescent-onset depression is associated with altered social functioning into middle adulthood

Depression during sensitive periods of social development may have consequences that extend well beyond mental health, and far into adulthood. This study compared the social functioning of adults with adolescent-onset depression (ages 10-20) to those with adult-onset depression (ages 21+). Participants were 3,360 adults (67.2% female; ages 42 ± 15) who had experienced major depression. Adult functional outcomes were marital status, divorce, number of children, years of education, employment status, household income, dependency on welfare, and obesity. Participants with depression during adolescence were less likely to get married, have children, and more likely to have lower household incomes. Depression during adolescence may be associated with broader functional outcomes that impact individuals and society, and may be mitigated through intervention and effective policy.

Depression in young people

Depression rates in young people have risen sharply in the past decade, especially in females, which is of concern because adolescence is a period of rapid social, emotional, and cognitive development and key life transitions. Adverse outcomes associated with depression in young people include depression recurrence; the onset of other psychiatric disorders; and wider, protracted impairments in interpersonal, social, educational, and occupational functioning. Thus, prevention and early intervention for depression in young people are priorities. Preventive and early intervention strategies typically target predisposing factors, antecedents, and symptoms of depression. Young people who have a family history of depression, exposure to social stressors (eg, bullying, discordant relationships, or stressful life events), and belong to certain subgroups (eg, having a chronic physical health problem or being a sexual minority) are at especially high risk of depression. Clinical antecedents include depressive symptoms, anxiety, and irritability. Evidence favours indicated prevention and targeted prevention to universal prevention. Emerging school-based and community-based social interventions show some promise. Depression is highly heterogeneous; therefore, a stepwise treatment approach is recommended, starting with brief psychosocial interventions, then a specific psychological therapy, and then an antidepressant medication.

Adaptation of a school-based mental health program for adolescents in Vietnam

Introduction

Cultural adaptation of a school-based mental health intervention developed in a high-income country is a cost-effective method to address the mental health needs of adolescents in resource-constrained settings. The aim of this study was to translate and culturally adapt the Resourceful Adolescent Program for Adolescents (RAP-A) for adolescents attending high school in Vietnam.

Methods

The translation and adaptation were conducted using a five-step process including (1) initial stakeholder consultation, (2) forward translation, (3) backward translation, (4) adaptation, and (5) finalising the adapted version. An adaptation panel was established, including the RAP-A authors and mental health and public health experts from Australia, and psychology and public health experts from Vietnam. The panel collaborated closely with a group of stakeholders, including bilingual psychologists and psychiatrists, high school (grades 10–12) students and teachers throughout the adaptation process.

Results

The adapted version of RAP-A was named ‘Happy House’. Happy House was adapted to be delivered in larger groups and in longer sessions than the RAP-A. The 11 sessions in RAP-A were restructured to 6 sessions in Happy House. Major changes were not required for any of the materials. However, some content, illustrations and videos were adapted to be more feasible for the school context and to enhance the comprehensibility, acceptability and appropriateness.

Conclusion

Happy House has great potential to be relevant, comprehensible and acceptable for Vietnamese adolescents. Further research is warranted to examine the relevance, comprehensibility, acceptability, and effectiveness of this program on adolescents’ mental health before advocating for scaling up program delivery in high schools throughout Vietnam.

Intervention for Treating Depression in Parents of Children with Intellectual Disability of Down's Syndrome: A Sample of Nigerian Parents

A good number of parents of children with Down syndrome are prone to depressive disorders. The depressive feelings are attributed to negative perceptions of the situation, self, and the future. Given this, we explored the impact of the family health model of rational-emotive behavior therapy on depressive symptoms in parents of children with intellectual disability of Down syndrome in the COVID-19 pandemic era. This is a randomized pretest-posttest control group design that recruited 88 parents of children with intellectual disability of Down syndrome. We measured the depressive symptoms in parents at Time 1, Time 2, and Time 3 using the Beck depressive inventory and Hamilton depression rating scale. We adopted a family health model rational emotive behaviour therapy intervention in treating the depressive symptoms affecting the parents. The analysis of covariate results showed that at initial assessment there was no significant difference between the treatment group and comparison group at baseline evaluation of depressive symptoms in participants. At the posttest, it had a significant effect on the intervention on participants' depressive symptoms. Likewise, a follow-up result still shows that intervention had a significant effect on participants' depressive symptoms of participants. In conclusion, this study suggests that treatment variable accounted for the effect in decreasing depressive symptoms scores of participants.

Depression facilitators from the perspective of Iranian patients with major depressive disorder: a qualitative research

Background

Major depressive disorder is the most common psychological disorder and affects many people worldwide. Therefore, it is important to identify the factors that cause or facilitate this disorder.

Objectives

The aim of this qualitative study was to identify the facilitating factors of depression from the perspective of Iranian patients with major depressive disorder.

Methods

This qualitative study was conducted by content analysis method. Data were collected via purposeful sampling (maximum variation sampling) by conducting semi-structured interviews until reaching data saturation. In-depth interviews were conducted with 12 participants, including patients with major depressive disorder and their families in Razi Psychiatric Training and Treatment Center in Urmia (RPsTT) from November 2018 to February 2020. The process of data analysis was based on the Landman and Grenheim method. The accuracy and trustworthiness of the data were obtained through the Lincoln and Guba criteria.

Results

The analysis of interviews with the participants indicated four major categories: a. Environmental factors (approved by 8 participants), b. Attitudinal factors (approved by 12 participants), c. Economic factors (approved by 9 participants) and d. Situational factors (approved by 10 participants).

Conclusion

In order to prevent major depressive disorder or to reduce the signs of this disorder and improve these patients quality of life, paying attention to the facilitating factors from patient’s perspective based on their community culture can be effective. Among facilitating factors, attitudinal factors have the most impact on the incidence and exacerbation of this disorder from the perspective of patients.

A randomised controlled trial of a family-group cognitive-behavioural (FGCB) preventive intervention for the children of parents with depression: short-term effects on symptoms and possible mechanisms

OBJECTIVE

Parental depression is one of the biggest risk factors for youth depression. This parallel randomized controlled trial evaluates the effectiveness of the German version of the family-group-cognitive-behavioral (FGCB) preventive intervention for children of depressed parents.

METHODS

Families with (i) a parent who has experienced depression and (ii) a healthy child aged 8-17 years (mean = 11.63; 53% female) were randomly allocated (blockwise; stratified by child age and parental depression) to the 12-session intervention (EG; n = 50) or no intervention (CG; usual care; n = 50). Self-reported (unblinded) outcomes were assessed immediately after the intervention (6 months). We hypothesized that CG children would show a greater increase in self-reported symptoms of depression (DIKJ) and internalising/externalising disorder (YSR/CBCL) over time compared to the EG. Intervention effects on secondary outcome variables emotion regulation (FEEL-KJ), attributional style (ASF-KJ), knowledge of depression and parenting style (ESI) were also expected. Study protocol (Belinda Platt, Pietsch, Krick, Oort, & Schulte-Körne, 2014) and trial registration (NCT02115880) reported elsewhere.

RESULTS

We found significant intervention effects on self-reported internalising ([Formula: see text] = 0.05) and externalising ([Formula: see text] = 0.08) symptoms but did not detect depressive symptoms or parent-reported psychopathology. Parental depression severity did not modify these effects. Both groups showed equally improved knowledge of depression ([Formula: see text] = 0.06). There were no intervention effects on emotion regulation, attributional style or parenting style.

CONCLUSION

The German version of the FGCB intervention is effective in reducing symptoms of general psychopathology. There was no evidence that the mechanisms targeted in the intervention changed within the intervention period.

Personalized Depression Prevention: A Randomized Controlled Trial to Optimize Effects Through Risk-Informed Personalization

OBJECTIVE

To evaluate whether evidence-based depression prevention programs can be optimized by matching youths to interventions that address their psychosocial vulnerabilities.

METHOD

This randomized controlled trial included 204 adolescents (mean [SD] age = 14.26 [1.65] years; 56.4% female). Youths were categorized as high or low on cognitive and interpersonal risks for depression and randomly assigned to Coping With Stress (CWS), a cognitive-behavioral program, or Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST), an interpersonal program. Some participants received a match between risk and prevention (eg, high cognitive-low interpersonal risk teen in CWS, low cognitive-high interpersonal risk teen in IPT-AST), others received a mismatch (eg, low cognitive-high interpersonal risk teen in CWS). Outcomes were depression diagnoses and symptoms through 18 months postintervention (21 months total).

RESULTS

Matched adolescents showed significantly greater decreases in depressive symptoms than mismatched adolescents from postintervention through 18-month follow-up and across the entire 21-month study period (effect size [d] = 0.44, 95% CI = 0.02, 0.86). There was no significant difference in rates of depressive disorders among matched adolescents compared with mismatched adolescents (12.0% versus 18.3%, t₁₉₃ = .78, p = .44).

CONCLUSION

This study illustrates one approach to personalizing depression prevention as a form of precision mental health. Findings suggest that risk-informed personalization may enhance effects beyond a one-size-fits-all approach.

CLINICAL TRIAL REGISTRATION INFORMATION

Bending Adolescent Depression Trajectories Through Personalized Prevention; https://www.clinicaltrials.gov/; NCT01948167.

A Systematic Review Focusing on Psychotherapeutic Interventions that Impact Parental Psychopathology, Child Psychopathology and Parenting Behavior

Given the high rates of co-occurrence of psychopathology within families, it is important to identify and characterize interventions that simultaneously reduce both parent and child symptoms, and improve parenting quality. This is needed as intervention development is increasingly moving toward integrated interventions that target some combination of parent and child mental health, and parenting behavior. Even so, much remains unknown regarding which treatment components provide maximum benefit for parent symptoms, child symptoms, and parenting behavior. This systematic review identified and characterized psychotherapeutic interventions that report improvements in each of three outcomes: parent symptoms, child symptoms and parenting behavior. Fifty-six unique interventions were eligible for review, of which 25 reported improvements in all three outcomes. All 25 of these interventions directly intervened on parenting behavior, often as the sole target of the intervention. Few interventions improved all three outcomes in samples in which parents, children or both met clinical-level thresholds of psychopathology. Additional research is needed to better understand the bi-directional and transactional influences of treatment on family members, and to better inform the development of interventions for dually disordered parent-child dyads across a range of diagnostic profiles.

Health-economic evaluation of psychological interventions for depression prevention: Systematic review

Psychological interventions have been proven to be effective to prevent depression, however, little is known on the cost-effectiveness of psychological interventions for the prevention of depression in various populations. A systematic review was conducted using PubMed, PsycINFO, Web of Science, Embase, Cochrane Central Register of Controlled Trials, Econlit, NHS Economic Evaluations Database, NHS Health Technology Assessment and OpenGrey up to January 2021. Only health-economic evaluations based on randomized controlled trials of psychological interventions to prevent depression were included. Independent evaluators selected studies, extracted data and assessed the quality using the Consensus on Health Economic Criteria and the Cochrane Risk of Bias Tool. Twelve trial-based economic evaluations including 5929 participants from six different countries met the inclusion criteria. Overall, the quality of most economic evaluations was considered good, but some studies have some risk of bias. Setting the willingness-to-pay upper limit to US$40,000 (2018 prices) for gaining one quality adjusted life year (QALY), eight psychological preventive interventions were likely to be cost-effective compared to care as usual. The likelihood of preventive psychological interventions being more cost-effective than care as usual looks promising, but more economic evaluations are needed to bridge the many gaps that remain in the evidence-base. ETHICS: As this systematic review is based on published data, approval from the local ethics committee was not required.

Prevalence of mental illness among parents of children receiving treatment within child and adolescent mental health services (CAMHS): a scoping review

People affected by mental illness often come from families with patterns of mental illness that span across generations. Hence, child and adolescent mental health services (CAMHS) likely provide treatment to many children with parents who also experience mental illness. The aim of this scoping review was to: (1) identify the prevalence of mental illness among parents of children in CAMHS; (2) identify and appraise the methodologies that have been implemented to assess the prevalence of parental mental illness in CAMHS; (3) identify additional circumstances associated with families where both parent and child experience mental illness; and (4) present recommendations that have been made for CAMHS practice based on these findings. English language, peer-reviewed studies (2010-2018) that had investigated the mental health of parents in CAMHS were included in the review. Literature searching yielded 18 studies which were found to have utilised diverse methodologies to assess parental mental health. Overall, reported prevalence of parental mental illness ranged from 16 to 79%; however, a single study that was deemed to be comprehensive reported prevalence rates of 36% for mothers and 33% for fathers. Across studies, parent and child mental illness was found to be associated with additional adversities impacting family functioning and wellbeing. For children who receive treatment for mental illness, having a parent who also experiences mental illness is a frequent family circumstance that has implications for their prospects for recovery. Accordingly, the mental health of parents should be an important consideration within the mental health care CAMHS provide to children.

Parent Traumatic Events and Adolescent Internalizing Symptoms: The Mediating Role of Parental Depression Among Youth with Persistent Post-concussive Symptoms

OBJECTIVE

Research has demonstrated associations between parental depression (PD) and negative psychological outcomes among their children. However, little is known about the pathways through which lifetime parent traumatic events (PTEs) influence their adolescents' internalizing symptoms. Our study examined whether PD mediates the association between PTE and adolescent depressive and anxious symptoms among youth with persistent postconcussive symptoms (PPCS).

METHODS

We used baseline data from a randomized effectiveness trial of collaborative care for treatment of persistent postconcussive symptoms among sports-injured adolescents aged 11-18 years. Parent-adolescent dyads were recruited from pediatric clinics throughout western Washington. Eligible adolescents had three or more PPCS that lasted for at least 1 month but <9 months and spoke English. Of 1,870 potentially eligible adolescents, 1,480 (79%) were excluded for not meeting the inclusion criteria. Of the eligible 390 adolescents, 189 (49%) declined to participate/consent. Participants included 200 parent-adolescent dyads (adolescent Mage = 14.7 years, SD = 1.7). Parent respondents were mostly female (83%) and mothers (81%). Adolescents reported on their depressive (Patient Health Questionnaire-9; PHQ-9) and anxious symptoms (Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]) and parents reported on their depressive symptoms (M = 3.7, SD = 3.7; PHQ-9).

RESULTS

Mediation analyses revealed two (out of four) significant indirect effects of PTE on both adolescent and parent report of depressive symptoms, but not anxiety.

CONCLUSIONS

This study elucidates one pathway (PD) through which PTE history influences adolescent depressive symptoms, supporting a two-generation approach to pediatric patient care for youth experiencing PPCS.

Combined Effects of Mother's, Father's and Teacher's Psychological Distress on Schoolchildren's Mental Health Symptoms

PURPOSE

Few studies have assessed the individual and joint effects of the mother's, father's and teacher's mental health symptoms on schoolchildren's behavior and emotional well-being simultaneously in the same study.

PATIENTS AND METHODS

A cross-sectional survey was conducted among 8488 Chinese schoolchildren aged 6-17 years in northeast China. The Strengths and Difficulties Questionnaire (SDQ) and General Health Questionnaire (GHQ) were used to measure the mental health of the students, their parents and the teacher in charge of the class, respectively. A total of 6173 students (72.73%) with full mental health information from all three caretakers were included in the final analysis.

RESULTS

We found a significantly elevated risk of mental health symptoms in children when their mothers (odds ratios (OR)=2.30, 95% CI=1.93-2.73), fathers (OR=2.08, 95% CI=1.73-2.50) and teachers (OR=1.18, 95% CI=1.01-1.39) reported poorer mental health, and the risk increased significantly with the number of the caretakers with mental symptoms. A father with poor mental health has both direct and indirect effects on a child's emotional health, by worsening the influence of a mother's poor mental health.

CONCLUSION

All three caretakers have a significant negative influence on schoolchildren's emotional well-being, in the order of mother > father > teacher. It is desirable to assess and manage students' mental health in the both the family and school contexts.

Psychological Treatments for Depression in Adolescents: More Than Three Decades Later

Depression is a common and impairing disorder which is a serious public health problem. For some individuals, depression has a chronic course and is recurrent, particularly when its onset is during adolescence. The purpose of the current paper was to review the clinical trials conducted between 1980 and 2020 in adolescents with a primary diagnosis of a depressive disorder, excluding indicated prevention trials for depressive symptomatology. Cognitive behavioral therapy (CBT) is the pre-eminent treatment and is well established from an evidence-based treatment perspective. The body of research on the remaining treatments is smaller and the status of these treatments is varied: interpersonal therapy (IPT) is well established; family therapy (FT) is possibly effective; and short-term psychoanalytic therapy (PT) is experimental treatment. Implementation of the two treatments that work well-CBT and IPT-has more support when provided individually as compared to in groups. Research on depression treatments has been expanding through using transdiagnostic and modular protocols, implementation through information and communication technologies, and indicated prevention programs. Despite significant progress, however, questions remain regarding the rate of non-response to treatment, the fading of specific treatment effects over time, and the contribution of parental involvement in therapy.

School-Based Approaches to Prevent Depression in Adolescents

Depression is one of the highest prevalent mental illnesses and is one of the common illnesses that can have its onset during childhood or adolescence. It is estimated that up to 20% of children experience mental illness worldwide. Preventing the onset of depression in children and adolescents should be a vital public health goal that will improve public health and decrease health care costs. We reviewed literature that described school-based interventions to prevent the onset of depression, reduce the severity of depressive symptoms, and enhance global functioning in adolescents. Our research also provides strategies for school-based intervention programs that are mainly categorized into three main subtypes. We also discussed each subtype and its advantages and limitations. The goal is to bring the readers an understanding of the importance of preventing depression on a community level, beginning at schools.

Development and Open Trial of a Technology-Enhanced Family Intervention for Adolescents at Risk for Mood Disorders

AIM

Integrating psychosocial interventions with mobile apps may increase treatment engagement among adolescents. We examined the user experience, uptake, and clinical effects of a mobile-enhanced family-focused therapy (FFT) among adolescents at risk for mood disorders.

METHOD

We created a mobile app containing 12 lesson plans corresponding to content of weekly FFT sessions, with modules concerning mood management, family communication and problem-solving. We pilot tested the app in an open trial of FFT (12 sessions in 18 weeks) for adolescents who had active depressive or hypomanic symptoms, a parent with mood disorder, and at least one parent who expressed high levels of criticism. Teens and parents made daily and weekly ratings of youths' moods, amount of parent/offspring criticism, and practice of FFT psychoeducational, communication or problem-solving skills. Independent evaluators interviewed adolescents at baseline and every 9 weeks over 27 weeks to measure symptom trajectories.

RESULTS

Participants were adolescents (n=22; mean age 15.4 ± 1.8 years; 45.5% female) and their 34 parents. Completion of requested app assessment and skill practices averaged 46%-65% among adolescents and parents over 18 weeks of treatment. Adolescents showed significant improvement in clinician-rated depression scores over 27 weeks (Cohen's d=1.58, 95% CI, 0.83 to 2.32) and reported reductions in the amount of perceived criticism expressed by parents.

LIMITATIONS

The uncontrolled design limits inferences about whether the mobile app augmented the effects of FFT on moods or family relationships.

CONCLUSIONS

Mobile applications may enhance users' responses to family therapy and provide clinicians with information regarding clinical status. Clinicaltrials.gov NCT03913013.

Improved Parent-Child Interactions Predict Reduced Internalizing Symptoms Among the Offspring of Parents with Bipolar Disorder Undergoing a Prevention Program: A Proof-of-Concept Study

The offspring of parents with bipolar disorder (OBD) exhibit elevated rates of psychopathology. However, preventative interventions are lacking. Using a quasi-experimental design with an assessment-only control group, we examined if a 12-week program (entitled Reducing Unwanted Stress in the Home, RUSH) decreases internalizing and externalizing symptoms in the OBD (aged 6-11 years) via intervention-related gains in parent-child interaction quality. Participants consisted of 55 offspring (26 OBD; 29 controls) and their parents. Assessments were conducted at four time points up to six months following the end of the RUSH program, during which parent and teacher ratings of child symptoms, and parent-child interaction quality (parental positivity and negativity, and dyadic mutuality) were measured. Multilevel modelling showed improved parental positivity and negativity, and dyadic mutuality among target dyads immediately and six months post-intervention. For the bootstrapping mediation analyses, intervention-related change in parental negativity fully mediated the relations between having participated in the RUSH program and lower parent-reported internalizing problems among the OBD six months later. These data provide evidence of the efficacy of the RUSH program for OBD who exhibited improved interactions with their parents post-intervention. Further investigation via a randomized controlled trial is warranted.

Profiles of Depressive Symptoms and Diabetes Distress in Preadolescents With Type 1 Diabetes

OBJECTIVES

Diabetes distress and depressive symptoms are common psychosocial concerns for people with diabetes. These are related, yet distinct, mood states, which have each been related to diabetes management and glycated hemoglobin (A1C) among adolescents and adults with diabetes. However, they have not been examined concurrently in preadolescents with type 1 diabetes. Understanding the overlaps and distinctions between diabetes distress and depressive symptoms in youth would help guide decisions about psychosocial screening in diabetes clinical practice. In this study, we aimed to categorize preadolescents based on clinical cutoffs of concurrently administered measures of depressive symptoms and diabetes distress, and identify clinical and demographic characteristics of each group.

METHODS

One hundred eighty youth (age range, 9 to 13 years; age [mean ± standard deviation], 11.3±1.3 years; 55% female; 56% Caucasian; mean A1C, 8.4±1.6% [68 mmol/mol]) completed measures of diabetes distress, depressive symptoms and quality of life. Daily blood glucose monitoring frequency was calculated from meter download. A1C values were obtained from electronic medical records.

RESULTS

Depressive symptoms and diabetes distress each significantly correlated with A1C and quality of life. Although most (69%) participants had no clinically significant elevations in either diabetes distress or depressive symptoms, 14% had elevated depressive symptoms only and 17% had elevated distress without concurrent elevated depressive symptoms. Groups differed based on A1C, quality of life and insurance status.

CONCLUSIONS

Routine assessment of both depressive symptoms and diabetes distress may help to identify preadolescents with type 1 diabetes who require psychosocial support.

Optimal approaches for preventing depressive symptoms in children and adolescents based on the psychosocial interventions: A Bayesian Network Meta-Analysis

BACKGROUND

It is necessary to develop effective preventive interventions before depression established to alleviate depressive symptoms or delay the onset of depression. In this study, we employed Bayesian network meta-analysis to identify the optimal psychosocial intervention approach for preventing depressive symptoms in children and adolescents.

METHODS

We searched publication databases and conference abstracts, from time of their inception through April 2019 without language restriction, for randomized controlled trials that compared the efficacy of various psychosocial intervention approaches. We extracted the mean and standard deviation values between baseline and the last observation, and calculated the change score in depression. We also assessed ranking probability by surface under the cumulative ranking curve using a 95% credible interval.

RESULTS

A total of 27 randomized controlled trials, involving 5,976 participants aged between 7 to 18 years, were included in our analyses. Analysis of various valid assessment instruments indicated that computer cognitive-behavioral therapy [standard mean difference (SMD = -1.82)], cognitive-behavioral therapy (SMD = -1.54) and interpersonal psychotherapy (SMD = -1.29) were statistically superior to wait-list group. Among the approaches, computer cognitive-behavioral therapy had the highest probability of being the best intervention, based on improvement from baseline to the end of the intervention (SUCRA = 90.47%, CrI: 0.55, 1.00).

LIMITATIONS

The results herein may not apply to other cultures and ethnic minorities because about half of the studies included in our analysis were conducted in the United States.

CONCLUSIONS

Computer cognitive-behavioral therapy was the most recommended intervention to accompany the depression among children and adolescents according to our Bayesian network meta-analysis results.

Is the Thoughts and Health programme feasible in the context of Swedish schools? A quasi-experimental controlled trial study protocol

INTRODUCTION

Clinical depression is a substantial problem among adolescents, increasing significantly at about age 15 years. It causes impairment in social, academic and familial relationships, as well as ongoing cognitive and emotional difficulties for the individual. A study in Iceland demonstrated that a cognitive-behavioural, developmentally based intervention programme, 'Thoughts and Health', prevented initial episodes of depression and/or dysthymia (DYS) (major depressive disorder/DYS) in adolescents for up to 12 months following completion of the programme. We would like to test the feasibility of implementing the Icelandic method in a Swedish context and to evaluate the long-term effects of such a programme.

METHODS AND ANALYSIS

A quasi-experimental controlled design, combined with qualitative and quantitative methods, will be used to address the research questions.In this study, 617 children aged ~14 years will be screened for depression, and those "at risk" for development of clinical depression will be offered a 12 week course, 'Thoughts and Health'. This course aims to prevent first depression in adolescents. A comparable group of children will function as controls.Depending on the type of variable, baseline comparisons between the two groups of relevant initial measures will be evaluated with t-tests or χ² analyses. The effects of the programme on the development of clinical levels of depression will be evaluated using the follow-up data of 6, 12 and 18 months. Index parental depression at baseline will be tested as a moderator in the evaluation of the effects of the prevention programme.

ETHICS AND DISSEMINATION

This study is approved by the Swedish Ethical Review Board (reference number 2019-03347) in Gothenburg.We plan to disseminate the knowledge gained from this study by publishing our results in peer-reviewed scientific journals and other scholarly outlets.

TRIAL REGISTRATION NUMBER

NCT04128644; Pre-results.

Prevention programmes for children of parents with a mood/anxiety disorder: Systematic review of existing programmes and meta-analysis of their efficacy

Objectives

To systematically describe the characteristics and techniques of prevention programmes for children of parents with mood/anxiety disorders. In addition, recruitment approaches and difficulties were identified and a meta‐analysis was conducted to examine the efficacy of these prevention programmes.

Methods

Randomized controlled trials assessing the efficacy of a prevention programme for children (6–25 years) of parents with mood and/or anxiety disorders were included. A systematic literature search was conducted in PubMed, PsychINFO, and CENTRAL from the earliest record to March 2019. In addition, programme manuals of identified prevention programmes were requested for a content analysis.

Results

Twenty‐two articles containing eight unique prevention programmes involving 1,325 subjects were identified. Programmes varied in the number and types of techniques, but all provided psychoeducation. Results suggested that recruitment via clinicians was more successful than recruitment via health maintenance organization databases. In a meta‐analysis, a significant risk difference was found in favour of prevention programmes on the risk of developing a depressive/anxiety disorder in offspring at short‐term (9–18 months follow‐up; RR = 0.37, 95% CI [0.21; 0.66]) and long‐term follow‐up (24 months or longer follow‐up; RR = 0.71, 95% CI [0.57; 0.87] and on symptom levels in offspring at post‐intervention (SMD = −0.19, 95% CI [−0.36; −0.02]) and at 12‐months follow‐up (SMD = −0.31, 95% CI [−0.57; −0.06]).

Conclusions

The prevention programmes combined psychoeducational elements with skills training and/or cognitive‐behavioural therapy elements. The recruitment process and the content of these programmes are sometimes insufficiently described. Nevertheless, they appear to be effective, indicating a need to further examine how these programmes exactly work and for whom.

Practitioner points

Preventive interventions for children of parents with mood/anxiety disorders appear to be effective in preventing these disorders in offspring.

Available preventive intervention programmes focus mostly on psychoeducation, cognitive‐behavioural therapy, and family processes.

More effort should be made into describing preventive interventions so that they can be easily implemented by practitioners.

Studies should further examine why and for whom preventive interventions for children of parents with mood/anxiety disorders are effective.

Associations of parental depression during adolescence with cognitive development in later life in China: A population-based cohort study

BACKGROUND

Prior research has underscored negative impacts of perinatal parental depression on offspring cognitive performance in early childhood. However, little is known about the effects of parental depression during adolescence on offspring cognitive development.

METHODS AND FINDINGS

This study used longitudinal data from the nationally representative China Family Panel Studies (CFPS). The sample included 2,281 adolescents aged 10-15 years (the median age was 13 years with an interquartile range between 11 and 14 years) in 2012 when their parents were surveyed for depression symptoms with the 20-item Center for Epidemiologic Studies Depression Scale (CES-D). The sample was approximately balanced by sex, with 1,088 females (47.7%). We examined the associations of parental depression in 2012 with offspring cognitive performance (measured by mathematics, vocabulary, immediate word recall, delayed word recall, and number series tests) in subsequent years (i.e., 2014, 2016, and 2018) using linear regression models, adjusting for various offspring (i.e., age, sex, and birth order), parent (i.e., parents' education level, age, whether living with the offspring, and employment status), and household characteristics (i.e., place of residence, household income, and the number of offspring). We found parental depression during adolescence to be significantly associated with worse cognitive performance in subsequent years, in both crude and adjusted models. For example, in the crude models, adolescents whose mothers had depression symptoms in 2012 scored 1.0 point lower (95% confidence interval [CI]: -1.2 to -0.8, p < 0.001) in mathematics in 2014 compared to those whose mothers did not have depression symptoms; after covariate adjustment, this difference marginally reduced to 0.8 points (95% CI: -1.0 to -0.5, p < 0.001); the associations remained robust after further adjusting for offspring earlier cognitive ability in toddlerhood (-1.2, 95% CI: -1.6, -0.9, p < 0.001), offspring cognitive ability in 2012 (-0.6, 95% CI: -0.8, -0.3, p < 0.001), offspring depression status (-0.7, 95% CI: -1.0, -0.5, p < 0.001), and parents' cognitive ability (-0.8, 95% CI: -1.2, -0.3, p < 0.001). In line with the neuroplasticity theory, we observed stronger associations between maternal depression and mathematical/vocabulary scores among the younger adolescents (i.e., 10-11 years) than the older ones (i.e., 12-15 years). For example, the association between maternal depression and 2014 vocabulary scores was estimated to be -2.1 (95% CI: -2.6, -1.6, p < 0.001) in those aged 10-11 years, compared to -1.2 (95% CI: -1.6, -0.8, p < 0.001) in those aged 12-15 years with a difference of 0.9 (95% CI: 0.2, 1.6, p = 0.010). We also observed a stronger association of greater depression severity with worse mathematical scores. The primary limitations of this study were the relatively high attrition rate and residual confounding.

CONCLUSIONS

In this study, we observed that parental depression during adolescence was associated with adverse offspring cognitive development assessed up to 6 years later. These findings highlight the intergenerational association between depression in parents and cognitive development across the early life course into adolescence.

[Preventive and therapeutic interventions for children of mentally ill parents]

Preventive and therapeutic interventions for children of mentally ill parents Abstract. The risk of developing mental disorders increases markedly in children of mentally ill parents. Several risk factors have been identified and become possible targets of preventive and therapeutic interventions. Numerous studies investigated the efficacy of these interventions, which are very heterogeneous regarding content and methodology. One part of these studies focuses on infants of depressed and substance-addicted mothers; the other part focuses on children and adolescents of parents suffering from various mental disorders. Today, we have several meta-analyses at our disposal which yielded small effect sizes concerning the development of psychological symptoms or disorders in these affected children. The current review reveals a lack of high-quality studies, and analyses on cost-effectiveness are also needed. The preventive and therapeutic interventions now available show inadequate efficacy to effectively improve the situation of these children and adolescents. Future research is needed to develop and implement cost-effective interventions as well as high-quality studies to investigate the efficacy of these interventions.

Effects of an adolescent depression prevention program on maternal criticisms and positive remarks

This study examined effects of an adolescent depression prevention program on maternal criticisms and positive remarks, whether the extent of adolescents' depression accounted for effects, and whether effects of the program on maternal criticisms and positive remarks differed by adolescents' gender. Participants were 298 adolescent (M_age = 14.79, SD = 1.36; 59% female) offspring of mothers with histories of depression; youth were randomized to either a cognitive-behavioral prevention (CBP) program or usual care (UC). At baseline and 9-month postintervention evaluations, mothers were administered the Five-Minute Speech Sample to measure number of criticisms and positive remarks made during an open-ended description of their child and their relationship. Adolescents' depression from pre- through postintervention was assessed with interviews. A hierarchical generalized linear model showed a significant condition-by-gender interaction, indicating that, controlling for baseline criticism, at postintervention mothers of girls in CBP made significantly more criticisms than did mothers of girls in UC, whereas mothers of boys in CBP made fewer criticisms than did mothers of boys in UC. The extent of adolescents' depression from pre- through postintervention partially mediated the relation between intervention condition and mothers' criticisms, for boys but not for girls. Second, controlling for preintervention positive remarks, at postintervention, mothers of youth in CBP made significantly more positive remarks about their child than did mothers of youth in UC, regardless of gender; this relation was not mediated by adolescent depression from pre- through postintervention. We suggest possible explanations for the observed effects of CBP on mothers' criticisms and positive remarks. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

24-Month Outcomes of Primary Care Web-Based Depression Prevention Intervention in Adolescents: Randomized Clinical Trial

Background

Adolescent depression carries a high burden of disease worldwide, but access to care for this population is limited. Prevention is one solution to curtail the negative consequences of adolescent depression. Internet interventions to prevent adolescent depression can overcome barriers to access, but few studies examine long-term outcomes.

Objective

This study compares CATCH-IT (Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training), an internet-based intervention, to a general health education active control for depression onset at 12 and 24 months in adolescents presenting to primary care settings.

Methods

A 2-site randomized trial, blinded to the principal investigators and assessors, was conducted comparing Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training to health education to prevent depressive episodes in 369 adolescents (193 youths were randomly assigned to Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training and 176 to health education) with subthreshold depressive symptoms or prior depressive episodes. Participants were recruited from primary care settings in the United States. The primary outcome was the occurrence of a depressive episode, determined by the Depression Symptom Rating. The secondary outcome was functioning, measured by the Global Assessment Scale.

Results

In intention-to-treat analyses, the adjusted hazard ratio favoring Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training for first depressive episode was not statistically significant at 12 months (hazard ratio 0.77, 95% CI 0.42-1.40, P=.39) and 24 months (hazard ratio 0.87, 95% CI 0.52-1.47, P=.61). Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training provided preventive benefit for first depressive episode for those with mild hopelessness or at least moderate paternal monitoring at baseline. Global Assessment Scale scores improved comparably in both groups (intention-to-treat).

Conclusions

A technology-based intervention for adolescent depression prevention implemented in primary care did not have additional benefit at 12 or 24 months. Further research is necessary to determine whether internet interventions have long-term benefit.

Trial Registration

ClinicalTrials.gov NCT01893749; http://clinicaltrials.gov/ct2/show/NCT01893749.

Resemblance and clustering of mother's and father's psychopathology levels among Chinese parents of schoolchildren with psychiatric disorders

Background

Few studies have assessed the characteristics of spousal psychopathologies among parents of schoolchildren with and without psychological disorders (PD) in China.

Methods

Parental symptoms were measured using the General Health Questionnaire (GHQ) in 275 mothers and 278 fathers of 298 schoolchildren with PDs diagnosed in a population survey and in 825 mothers and 834 fathers of 894 schoolchildren without PDs as a 1:3 matched comparison group. Spousal GHQ scores were compared. Childhood PD type, presence of childhood comorbidities, and multiple parental and family characteristics were examined as predictors for parental GHQ scores by multiple linear regression analyses.

Results

The GHQ scores were significantly higher among mothers and fathers of children with any PD. Maternal GHQ scores were higher than paternal scores and significantly correlated with paternal GHQ scores in both groups. Spousal GHQ, personal PD history, and childhood PD comorbidity were significant independent predictors of both parents’ GHQ scores. There were also significant associations among parental chronic disease, low family income, and paternal and maternal GHQ score, as well as among low maternal education, less common disorder (LCD) prevalence in children and maternal GHQ score. The rate of GHQ score ≥3 for both parents was significantly higher in the study group than the control group (15.1 vs.7.0%).

Conclusions

Parents of children with any PD type demonstrate significantly elevated psychopathologies, and psychopathology tends to occur concomitantly and resemble that of the other spouse. Screening and treatment of parental psychiatric symptoms will benefit all family members.