Effect of a Cognitive-Behavioral Prevention Program on Depression 6 Years After Implementation Among At-Risk Adolescents: A Randomized Clinical 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.

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.

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 ).

Developing and validating a prediction model of adolescent major depressive disorder in the offspring of depressed parents

BACKGROUND

Parental depression is common and is a major risk factor for depression in adolescents. Early identification of adolescents at elevated risk of developing major depressive disorder (MDD) in this group could improve early access to preventive interventions.

METHODS

Using longitudinal data from 337 adolescents at high familial risk of depression, we developed a risk prediction model for adolescent MDD. The model was externally validated in an independent cohort of 1,384 adolescents at high familial risk. We assessed predictors at baseline and MDD at follow-up (a median of 2-3 years later). We compared the risk prediction model to a simple comparison model based on screening for depressive symptoms. Decision curve analysis was used to identify which model-predicted risk score thresholds were associated with the greatest clinical benefit.

RESULTS

The MDD risk prediction model discriminated between those adolescents who did and did not develop MDD in the development (C-statistic = .783, IQR (interquartile range) = .779, .778) and the validation samples (C-statistic = .722, IQR = -.694, .741). Calibration in the validation sample was good to excellent (calibration intercept = .011, C-slope = .851). The MDD risk prediction model was superior to the simple comparison model where discrimination was no better than chance (C-statistic = .544, IQR = .536, .572). Decision curve analysis found that the highest clinical utility was at the lowest risk score thresholds (0.01-0.05).

CONCLUSIONS

The developed risk prediction model successfully discriminated adolescents who developed MDD from those who did not. In practice, this model could be further developed with user involvement into a tool to target individuals for low-intensity, selective preventive intervention.

Meta-Analysis: Relapse Prevention Strategies for Depression and Anxiety in Remitted Adolescents and Young Adults

OBJECTIVE

Depression and anxiety cause a high burden of disease and have high relapse rates (39%-72%). This meta-analysis systematically examined effectiveness of relapse prevention strategies on risk of and time to relapse in youth who remitted.

METHOD

PubMed, PsycInfo, Embase, Cochrane, and ERIC databases were searched up to June 15, 2021. Eligible studies compared relapse prevention strategies to control conditions among youth (mean age 13-25 years) who were previously depressed or anxious or with ≥30% improvement in symptoms. Two reviewers independently assessed titles, abstracts, and full texts; extracted study data; and assessed risk of bias and overall strength of evidence. Random-effects models were used to pool results, and mixed-effects models were used for subgroup analyses. Main outcome was relapse rate at last follow-up (PROSPERO ID: CRD42020149326).

RESULTS

Of 10 randomized controlled trials (RCTs) that examined depression, 9 were eligible for analysis: 4 included psychological interventions (n = 370), 3 included antidepressants (n = 80), and 2 included combinations (n = 132). No RCTs for anxiety were identified. Over 6 to 75 months, relapse was half as likely following psychological treatment compared with care as usual conditions (k = 6; odds ratio 0.56, 95% CI 0.31 to 1.00). Sensitivity analyses including only studies with ≥50 participants (k = 3), showed similar results. Over 6 to 12 months, relapse was less likely in youth receiving antidepressants compared with youth receiving pill placebo (k = 3; OR 0.29, 95% CI 0.10 to 0.82). Quality of studies was suboptimal.

CONCLUSION

Relapse prevention strategies for youth depression reduce risk of relapse, although adequately powered, high-quality RCTs are needed. This finding, together with the lack of RCTs on anxiety, underscores the need to examine relapse prevention in youth facing these common mental health conditions.

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.

The Association of Biochemical and Genetic Biomarkers in VEGF Pathway with Depression

VEGF is an important neurotrophic and vascular factor involved in mental disorders. The objective of this study was to verify the effect of genetic polymorphisms in the VEGF pathway on the risk for depression, symptom intensity, and suicide attempts. To examine the association between the VEGF pathway and depression, we genotyped polymorphisms and measured the plasma concentrations of VEGF, KDR, and FLT1 proteins. The participants were 160 patients with depression and 114 healthy controls. The questionnaires that assessed the clinical profile of the patients were the MINI-International Neuropsychiatric Interview, GRID-HAMD₂₁, CTQ, BSI, and the number of suicide attempts. Genotyping of participants was performed using the real-time PCR and protein measurements were performed using the enzyme-linked immunosorbent assay (ELISA). VEGF and its inhibitors were reduced in depression. Individuals with depression and displaying the homozygous AA of the rs699947 polymorphism had higher plasma concentrations of VEGF (p-value = 0.006) and were associated with a greater number of suicide attempts (p-value = 0.041). Individuals with depression that were homozygous for the G allele of the FLT1 polymorphism rs7993418 were associated with lower symptom severity (p-value = 0.040). Our results suggest that VEGF pathway polymorphisms are associated with the number of suicide attempts and the severity of depressive symptoms.

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.

"I Wanted to See How Bad it Was": Online Self-screening as a Critical Transition Point Among Young Adults with Common Mental Health Conditions

Young adults have high rates of mental health conditions, yet they are the age group least likely to seek traditional treatment. They do, however, seek information about their mental health online, including by filling out online mental health screeners. To better understand online self-screening, and its role in help-seeking, we conducted focus groups with 50 young adults who voluntarily completed a mental health screener hosted on an advocacy website. We explored (1) catalysts for taking the screener, (2) anticipated outcomes, (3) reactions to the results, and (4) desired next steps. For many participants, the screener results validated their lived experiences of symptoms, but they were nevertheless unsure how to use the information to improve their mental health moving forward. Our findings suggest that online screeners can serve as a transition point in young people's mental health journeys. We discuss design implications for online screeners, post-screener feedback, and digital interventions broadly.

Severe and complex youth depression: Clinical and historical features of young people attending a tertiary mood disorders clinic

AIM

The concept of severe and complex youth depression has evolved from clinical experience. Here we conducted a file audit study to evaluate supporting data for the construct.

METHODS

A retrospective file audit was undertaken with 84 consecutively discharged patients over 6-months from Orygen's Youth Mood Clinic (YMC; 50% female).

RESULTS

Over a third (36.9%) were disengaged from vocation and education, with exposure to traumatic events common (84.5%). Almost all patients (91.7%) reported past 2-week suicidal ideation at clinic entry. Hospital emergency departments were the most frequent referral source (31.0%). Most (72.6%) had received previous mental health treatment. Multimorbidity was frequently observed. The presence of a substance use disorder, or ≥ 3 comorbidities were both associated with a greater likelihood of prior suicide attempt.

CONCLUSIONS

These data highlight the clinical needs associated with severe and complex depression. Findings have implications for youth experiencing mood disorders attending tertiary and community mental health settings.

Childhood ADHD and Executive Functioning: Unique Predictions of Early Adolescent Depression

Given the increasing prevalence of adolescent depression, identification of its early predictors and elucidation of the mechanisms underlying its individual differences is imperative. Controlling for baseline executive functioning (EF), we tested separate ADHD dimensions (i.e., inattention, hyperactivity-impulsivity) as independent predictors of early adolescent depression, including temporally-ordered causal mediation by academic functioning and social problems, using structural equation modeling. At baseline, participants consisted of 216 children (67% male) ages 6–9 years old with (n = 112) and without (n = 104) ADHD who subsequently completed Wave 2 and 3 follow-ups approximately two and four years later, respectively. Predictors consisted of separate parent and teacher ratings of childhood ADHD and laboratory-based assessments of key EF domains. At Wave 2, parents and teachers completed normed rating scales of youth academic and social functioning; youth completed standardized assessments of academic achievement. At Wave 3, youth self-reported depression. Baseline inattention positively predicted early adolescent depression whereas childhood hyperactivity-impulsivity and EF did not. Neither academic nor social functioning significantly mediated predictions of depression from baseline ADHD and EF. We consider prediction of early adolescent depression from inattention, including directions for future intervention and prevention research.

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.

Preventive interventions in offspring of parents with mental illness: a systematic review and meta-analysis of randomized controlled trials

Children with parents suffering from a psychiatric disorder are at higher risk for developing a mental disorder themselves. This systematic review and meta-analysis of randomized controlled trials aims to evaluate the efficacy of psychosocial interventions to prevent negative mental health outcomes in the offspring of parents with mental illness. Eight electronic databases, grey literature and a journal hand-search identified 14 095 randomized controlled trials with no backward limit to June 2021. Outcomes in children included incidence of mental disorders (same or different from parental ones) and internalizing and externalizing symptoms at post-test, short-term and long-term follow-up. Relative risks and standardized mean differences (SMD) for symptom severity were generated using random-effect meta-analyses. Twenty trials were selected (pooled n = 2689 children). The main therapeutic approaches found were cognitive-behavioural therapy and psychoeducation. A significant effect of interventions on the incidence of mental disorders in children was found with a risk reduction of almost 50% [combined relative risk = 0.53, 95% confidence interval (CI) 0.34-0.84]. Interventions also had a small but significant effect on internalizing symptoms at post-test (SMD = -0.25, 95% CI -0.37 to -0.14) and short-term follow-up (-0.20, 95% CI -0.37 to -0.03). For externalizing symptoms, a decreasing slope was observed at post-test follow-up, without reaching the significance level (-0.11, 95% CI -0.27 to 0.04). Preventive interventions targeting the offspring of parents with mental disorders showed not only a significant reduction of the incidence of mental illness in children, but also a diminution of internalizing symptoms in the year following the intervention.

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.

Prediction Along a Developmental Perspective in Psychiatry: How Far Might We Go?

Most mental disorders originate in childhood, and once symptoms present, a variety of psychosocial and cognitive maladjustments may arise. Although early childhood problems are generally associated with later mental health impairments and psychopathology, pluripotent transdiagnostic trajectories may manifest. Possible predictors range from behavioral and neurobiological mechanisms, genetic predispositions, environmental and social factors, and psychopathological comorbidity. They may manifest in altered neurodevelopmental trajectories and need to be validated capitalizing on large-scale multi-modal epidemiological longitudinal cohorts. Moreover, clinical and etiological variability between patients with the same disorders represents a major obstacle to develop effective treatments. Hence, in order to achieve stratification of patient samples opening the avenue of adapting and optimizing treatment for the individual, there is a need to integrate data from multi-dimensionally phenotyped clinical cohorts and cross-validate them with epidemiological cohort data. In the present review, we discuss these aspects in the context of externalizing and internalizing disorders summarizing the current state of knowledge, obstacles, and pitfalls. Although a large number of studies have already increased our understanding on neuropsychobiological mechanisms of mental disorders, it became also clear that this knowledge might only be the tip of the Eisberg and that a large proportion still remains unknown. We discuss prediction strategies and how the integration of different factors and methods may provide useful contributions to research and at the same time may inform prevention and intervention.

Persistent Low Positive Affect and Sleep Disturbance across Adolescence Moderate Link between Stress and Depressive Symptoms in Early Adulthood

The purpose of this study was to characterize the association between recent major life events and depressive symptoms during early adulthood, and to determine whether adolescents with chronically low positive affect or persistent sleep disturbance were more vulnerable to the link between stress and depressive symptoms. Adolescents (n = 147; 63.9% female; 33.7% non-Hispanic white) were recruited in 10th-11th grade and re-assessed 2 and 4 years later. At each assessment, adolescents completed measures of positive affect and sleep disturbances. At the final assessment, participants reported on their exposure to major life events in the past 12 months. Exposure to more major life events in the past year was associated with greater depressive symptoms in early adulthood. Chronically low positive affect and persistent sleep disturbances throughout adolescence each independently moderated this relationship. Specifically, only participants reporting low positive affect across the three assessments showed a positive and significant association between major life events and depressive symptoms. Further, only participants reporting sleep disturbances at all three assessments showed a positive and significant association between major life events and depressive symptoms. Chronically low positive affect and persistent sleep disturbances during adolescence may be useful indicators of risk for depression during early adulthood. Further, interventions targeting adolescent sleep disturbances and improving positive affect may be useful in reducing the risk for depression following life stress during this high risk developmental phase.

Trajectories of health-related quality of life in children of parents with mental health problems: results of the BELLA study

PURPOSE

Children of parents with mental health problems (CPM) have an increased risk for impaired health-related quality of life (HRQoL). This study aims at investigating the age- and gender-specific course of HRQoL and at exploring predictors of HRQoL in CPM based on longitudinal data (baseline, 1-year and 2-year follow-up) of a German population-based sample.

METHODS

Longitudinal data from the German BELLA study was analyzed (n = 1429; aged 11 to 17 years at baseline). The SCL-S-9 in combination with the cutoff for the General Severity Index (GSI) from the longer SCL-90-R served to identify CPM (n = 312). At first, we compared domain-specific HRQoL according to the KIDSCREEN-27 in CPM versus Non-CPM. Focusing on CPM, we used individual growth modeling to investigate the age and gender-specific course, and to explore effects of risk and (personal, familial and social) resource factors on self-reported HRQoL in CPM.

RESULTS

Self-reported HRQoL was reduced in CPM compared to Non-CPM in all domains, but in social support & peers. However, a minimal important difference was only reached in girls for the domain autonomy & parent relation. Internalizing and externalizing mental health problems were associated with impaired HRQoL in CPM. Self-efficacy, social support and family climate were identified as significant resources, but parental mental health problems over time were not associated with any investigated domain of HRQoL in CPM.

CONCLUSIONS

Adolescent female CPM may be especially at risk for reduced HRQoL. When developing support programs for CPM, self-efficacy, social support and family climate should be considered, HRQoL and mental health problems in CPM should be addressed.

Evaluation of a Family-Based Intervention Program for Children of Mentally Ill Parents: Study Protocol for a Randomized Controlled Multicenter Trial

Background: Children of mentally ill parents have a three to seven times higher risk of developing mental disorders compared to the general population. For this high-risk group, specialized prevention and intervention programs have already been developed. However, there has been insufficient sytematic evaluation to date. Moreover, effectiveness and the cost-effectiveness data of the respective programs until today is very scarce and at the same time constitutes the pre-condition for the program's implementation into regular health care. Methods: The study consists of a two-group randomized controlled multicenter trial conducted at seven study sites throughout Germany and Switzerland. Participants are families with mentally ill parents and their children aged from 3 to 19 years. The intervention comprises 6 to 8 semi-structured sessions over a period of about 6 months. Topics discussed in the intervention include parental mental illness, coping, family relations and social support. Families in the control condition will receive treatment as usual. The children's mental health, assessed using the K-SADS-PL by blinded external raters will constitute the primary efficacy outcome. Further outcomes will be assessed from the parents' as well as from the children's perspectives. Participants are investigated at baseline, 6, 12, and 18 months after baseline assessment. In addition to the assessment of various psychosocial outcomes, a comprehensive health-economic evaluation will be performed. Discussion: This paper describes the evaluation of a family-based intervention program for children of mentally ill parents (CHIMPs) in the regular health care system in Germany and Switzerland. A methodically sophisticated study design has been developed to reflect the complexity of the actual health care situation. This trial will contribute to the regular health care for the high-risk group of children of mentally ill parents. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02308462; German Clinical Trials Register: DRKS00006806.

Posttraumatic Stress Disorder and the Developing Adolescent Brain

Posttraumatic stress disorder (PTSD) in adolescents is common and debilitating. In contrast to adult PTSD, relatively little is known about the neurobiology of adolescent PTSD, nor about how current treatments may alter adolescent neurodevelopment to allow recovery from PTSD. Improving our understanding of biological mechanisms of adolescent PTSD, taken in the context of neurodevelopment, is crucial for developing novel and personalized treatment approaches. In this review, we highlight prevailing constructs of PTSD and current findings on these domains in adolescent PTSD. Notably, little data exist in adolescent PTSD for prominent adult PTSD constructs, including threat learning and attentional threat bias. Most work to date has examined general threat processing, emotion regulation, and their neural substrates. These studies suggest that adolescent PTSD, while phenomenologically similar to adult PTSD, shows unique neurodevelopmental substrates that may impair recovery but could also be targeted in the context of adolescent neuroplasticity to improve outcomes. Both cross-sectional and longitudinal data suggest abnormal frontolimbic development compared with typically developing youths, a pattern that may differ from resilient youths. Whether current treatments such as trauma-focused psychotherapy engage these targets and restore healthy neurodevelopment remains an open question. We end our review by highlighting emerging areas and knowledge gaps that could be addressed to better characterize the biology underlying adolescent PTSD. Emerging studies in computational modeling of decision making, caregiver-related transmission of traumatic stress, and other areas may offer new targets that could harness adolescent neurobehavioral plasticity to improve resilience and recovery for some of our most vulnerable youths.

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.

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).

Effectiveness of a Guided Web-Based Self-help Intervention to Prevent Depression in Patients With Persistent Back Pain: The PROD-BP Randomized Clinical Trial

IMPORTANCE

Depression is a frequent comorbid condition in patients with persistent back pain and is associated with substantial adverse consequences, including the risk of developing opioid use disorders. Shifting the focus from depression treatment to preventing depression might be a viable way to reduce the disease burden.

OBJECTIVE

To evaluate the effectiveness of a web-based self-help intervention to reduce the incidence of major depressive episode (MDE) in patients with persistent back pain.

DESIGN, SETTING, AND PARTICIPANTS

Prevention of Depression in Back Pain Patients (PROD-BP) was a pragmatic, observer-blinded randomized clinical trial with a parallel design conducted in Germany. Eligible adults with a diagnosis of persistent back pain and subclinical depressive symptoms, but who were depression free, were recruited either on-site or after discharge from 82 orthopedic clinics between October 1, 2015, and July 31, 2017. All analyses were conducted according to the intention-to-treat principle from October 31, 2018, to April 30, 2019.

INTERVENTIONS

The intervention group received an e-coach-guided, web-based self-help intervention that was based on cognitive behavioral therapy and tailored to the needs of patients with persistent back pain. The intervention included 6 obligatory modules and 3 optional modules to be completed by participants as well as feedback from e-coaches. Both the intervention and control groups had unrestricted access to treatment as usual.

MAIN OUTCOMES AND MEASURES

Primary outcome was time to onset of an MDE over a 12-month period as assessed by blinded diagnostic raters using the Structured Clinical Interview for DSM-5. Secondary outcomes included depression severity, quality of life, pain intensity, pain-related disability, pain self-efficacy, work capacity, and user satisfaction assessed with a variety of instruments.

RESULTS

A total of 295 participants (mean [SD] age, 52.8 [7.7] years; 184 women [62.4%]) were recruited and randomized to either the intervention group (n = 149) or control group (n = 146). The intervention reduced the risk of MDE onset by 52% (hazard ratio, 0.48; 95% CI, 0.28-0.81; P < .001). Twenty-one participants (14.1%) in the intervention group and 41 participants (28.1%) in the control group experienced an MDE over the 12-month period. The number needed to treat to prevent 1 new case of MDE was 2.84 (95% CI, 1.79-9.44).

CONCLUSIONS AND RELEVANCE

Results of this trial showed that among patients with persistent back pain, depression can be prevented by a guided web-based self-help intervention in addition to treatment as usual. This finding suggests that using a scalable digital approach to integrate psychological treatment into routine pain management is feasible.

TRIAL REGISTRATION

German Clinical Trials Register Identifier: DRKS00007960.

Moderators of psychological and psychoeducational interventions for the prevention of depression: A systematic review

Psychological and psychoeducational interventions have proven to be effective in preventing depression. However, the identification of the patients that benefit the most from each type of intervention has not yet been established. A systematic review was performed of the literature on moderators of preventive psychological and psychoeducational interventions for depression in all types of population. A search was performed on PubMed, PsycINFO, Web of Science, Embase, Cochrane Central Register of Controlled Trials and OpenGrey up to July 2019. Fulfillment of eligibility criteria, data collection, and study quality assessment were assessed by two independent researchers. Outcomes were moderators of the reduction of depressive symptoms or the incidence of depression. Twenty-seven moderator effect studies performed in 19 randomized controlled trials were included. Thirty-four potential sociodemographic, clinical, interpersonal, personality and life-event moderators were evaluated. Baseline depressive symptoms, gender, age, baseline parental depression and social support were the most frequently studied potential moderators. In interventions for children and adolescents, the moderator for which evidence was strongest was having parents free of depression at baseline. Psychological and psychoeducational interventions seem to be more effective in children and adolescents who exhibit a lower use of substances and whose parents do not have symptoms of depression at baseline. In adults, a lower age was associated with greater effects of preventive interventions. ETHICS: As this systematic review is based on published data, approval from the local ethics committee was not required.

The Association Between Parental Depression and Child Psychosocial Intervention Outcomes: Directions for Future Research

Recent studies suggest that parental depressive symptoms may affect a child's ability to benefit from interventions for anxiety and depression. This article reviews the current literature, suggesting that, when parents experience current depressive symptoms, children are less likely to benefit from psychosocial interventions for anxiety and depression. Opportunities for future research are discussed, including moderators and mechanisms of the association between parental depressive symptoms and child intervention outcomes.

Effects of Family-Focused Therapy vs Enhanced Usual Care for Symptomatic Youths at High Risk for Bipolar Disorder: A Randomized Clinical Trial

IMPORTANCE

Behavioral high-risk phenotypes predict the onset of bipolar disorder among youths who have parents with bipolar disorder. Few studies have examined whether early intervention delays new mood episodes in high-risk youths.

OBJECTIVE

To determine whether family-focused therapy (FFT) for high-risk youths is more effective than standard psychoeducation in hastening recovery and delaying emergence of mood episodes during the 1 to 4 years after an active period of mood symptoms.

DESIGN, SETTINGS, AND PARTICIPANTS

This multisite randomized clinical trial included referred youths (aged 9-17 years) with major depressive disorder or unspecified (subthreshold) bipolar disorder, active mood symptoms, and at least 1 first- or second-degree relative with bipolar disorder I or II. Recruitment started from October 6, 2011, and ended on September 15, 2016. Independent evaluators interviewed participants every 4 to 6 months to measure symptoms for up to 4 years. Data analysis was performed from March 13 to November 3, 2019.

INTERVENTIONS

High-risk youths and parents were randomly allocated to FFT (12 sessions in 4 months of psychoeducation, communication training, and problem-solving skills training; n = 61) or enhanced care (6 sessions in 4 months of family and individual psychoeducation; n = 66). Youths could receive medication management in either condition.

MAIN OUTCOMES AND MEASURES

The coprimary outcomes, derived using weekly psychiatric status ratings, were time to recovery from prerandomization symptoms and time to a prospectively observed mood (depressive, manic, or hypomanic) episode after recovery. Secondary outcomes were time to conversion to bipolar disorder I or II and longitudinal symptom trajectories.

RESULTS

All 127 participants (82 [64.6%] female; mean [SD] age, 13.2 [2.6] years) were followed up for a median of 98 weeks (range, 0-255 weeks). No differences were detected between treatments in time to recovery from pretreatment symptoms. High-risk youths in the FFT group had longer intervals from recovery to the emergence of the next mood episode (χ2 = 5.44; P = .02; hazard ratio, 0.55; 95% CI, 0.48-0.92;), and from randomization to the next mood episode (χ2 = 4.44; P = .03; hazard ratio, 0.59; 95% CI, 0.35-0.97) than youths in enhanced care. Specifically, FFT was associated with longer intervals to depressive episodes (log-rank χ2 = 6.24; P = .01; hazard ratio, 0.53; 95% CI, 0.31-0.88) but did not differ from enhanced care in time to manic or hypomanic episodes, conversions to bipolar disorder, or symptom trajectories.

CONCLUSIONS AND RELEVANCE

Family skills-training for youths at high risk for bipolar disorder is associated with longer times between mood episodes. Clarifying the relationship between changes in family functioning and changes in the course of high-risk syndromes merits future investigation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01483391.

Problem-solving intervention to prevent depression in non-professional caregivers: a randomized controlled trial with 8 years of follow-up

BACKGROUND

Studies of psychological interventions for the prevention of depression have found significant effects in the short-term, but the long-term efficacy has yet to be determined. This study evaluated the 8-year effect of a randomized controlled trial for indicated prevention of depression in female caregivers.

METHODS

A total of 173 non-professional female caregivers with subclinical depressive symptoms not meeting criteria for a major depressive episode (MDE) were randomized to either a brief problem-solving intervention (n = 89) or usual-care control group (n = 84). Blinded evaluators conducted an assessment at the 8-year follow-up. The primary outcome was Depression Status, defined by diagnoses of MDE since the 1-year follow-up using the Structured Clinical Interview for the Disorders of the DSM-5. The secondary outcome was current Depressive Symptom Severity. Regression analyses were conducted to evaluate the effect of the intervention on the outcomes.

RESULTS

There were no significant differences in the Depression Status between the problem-solving (30.3%) and control groups (26.2%) (adjusted OR 1.25, 95% CI -0.58 to 2.69). Depressive Symptom Severity, however, was significantly lower in the problem-solving group compared to the control group at this follow-up, amounting to a small effect size of Cohen's d = 0.39 (adjusted B = -3.32, p = 0.018).

CONCLUSIONS

This is the first study to assess such a long-term follow-up of intervention of indicated prevention of depression. Results seem to indicate that the protective effect of the intervention became smaller over time during follow-up. Future research should replicate these results.

Meta-Analysis: 13-Year Follow-up of Psychotherapy Effects on Youth Depression

OBJECTIVE

Youth depression is a debilitating condition that constitutes a major public health concern. A 2006 meta-analysis found modest benefits for psychotherapy versus control. Has 13 more years of research improved that picture? We sought to find out.

METHOD

We searched PubMed, PsychINFO, and Dissertation Abstracts International for 1960 to 2017, identifying 655 randomized, English-language psychotherapy trials for individuals aged 4 to 18 years. Of these, 55 assessed psychotherapy versus control for youth depression with outcome measures administered to both treatment and control conditions at post (κ = 53) and/or follow-up (κ = 32). Twelve study and outcome characteristics were extracted, and effect sizes were calculated for all psychotherapy versus control comparisons. Using a three-level random-effects model, we obtained an overall estimate of the psychotherapy versus control difference while accounting for the dependency among effect sizes. We then fitted a three-level mixed-effects model to identify moderators that might explain variation in effect size within and between studies.

RESULTS

The overall effect size (g) was 0.36 at posttreatment and 0.21 at follow-up (averaging 42 weeks after posttreatment). Three moderator effects were identified: effects were significantly larger for interpersonal therapy than for cognitive behavioral therapy, for youth self-reported outcomes than parent-reports, and for comparisons with inactive control conditions (eg, waitlist) than active controls (eg, usual care). Effects showed specificity, with significantly smaller effects for anxiety and externalizing behavior outcomes than for depression measures.

CONCLUSION

Youth depression psychotherapy effects are modest, with no significant change over the past 13 years. The findings highlight the need for treatment development and research to improve both immediate and longer-term benefits.

Attentional bias modification is associated with fMRI response toward negative stimuli in individuals with residual depression: a randomized controlled trial

BACKGROUND

Attentional bias modification (ABM) may lead to more adaptive emotion perception and emotion regulation. Understanding the neural basis of these effects may lead to greater precision for the development of future treatments. Task-related functional MRI (fMRI) after ABM training has not been investigated in depression so far. The main aim of this randomized controlled trial was to explore differences in brain activity after ABM training, in response to emotional stimuli.

METHODS

A total of 134 people with previous depression, who had been treated for depression and had various degrees of residual symptoms, were randomized to 14 days of active ABM or a closely matched placebo training, followed by an fMRI emotion regulation task. The training procedure was a classical dot–probe task with emotional face stimuli. In the active ABM condition, the probes replaced the more positively valenced face of a given pair. As participants implicitly learned to predict the probe location, this would be likely to induce a more positive attentional bias. The placebo condition was identical, except for the contingency of the probe, which appeared equally behind positive and negative stimuli. We compared depression symptoms and subjective ratings of perceived negativity during fMRI between the training groups. We explored brain activation in predefined regions of interest and across the whole brain. We explored activation in areas associated with changes in attentional bias and degree of depression.

RESULTS

Compared with the placebo group, the ABM group showed reduced activation in the amygdala and the anterior cingulate cortex when passively viewing negative images. We found no group differences in predefined regions of interest associated with emotion regulation strategies. Response in the temporal cortices was associated with the degree of change in attentional bias and the degree of depressive symptoms in ABM versus placebo.

LIMITATIONS

These findings should be replicated in other samples of patients with depression, and in studies using fMRI designs that allow analyses of within-group variability from baseline to follow-up.

CONCLUSION

Attentional bias modification training has an effect on brain function in the circuitry associated with emotional appraisal and the generation of affective states.

CLINICALTRIALS.GOV IDENTIFIER

NCT02931487

Recent advances in understanding and managing self-harm in adolescents

Adolescent suicide is a serious public health problem, and non-suicidal self-injury (NSSI) is both highly comorbid with suicidality among adolescents and a significant predictor of suicide attempts (SAs) in adolescents. We will clarify extant definitions related to suicidality and NSSI and the important similarities and differences between these constructs. We will also review several significant risk factors for suicidality, evidence-based and evidence-informed safety management strategies, and evidence-based treatment for adolescent self-harming behaviors. Currently, dialectical behavior therapy (DBT) for adolescents is the first and only treatment meeting the threshold of a well-established treatment for self-harming adolescents at high risk for suicide. Areas in need of future study include processes underlying the association between NSSI and SAs, clarification of warning signs and risk factors that are both sensitive and specific enough to accurately predict who is at imminent risk for suicide, and further efforts to sustain the effects of DBT post-treatment. DBT is a time- and labor-intensive treatment that requires extensive training for therapists and a significant time commitment for families (generally 6 months). It will therefore be helpful to assess whether other less-intensive treatment options can be established as evidence-based treatment for suicidal adolescents.

Chronic mild stress leads to aberrant glucose energy metabolism in depressed Macaca fascicularis models

BACKGROUND

Major depressive disorder (MDD) is a pathophysiologically uncharacterized mental illness with complex etiology and clinical manifestations. Rodent depression-like models have been widely used to mimic the morbid state of depression. However, research on emotional disorders can also benefit from the use of models in non-human primates, which share a wide range of genetic and social similarities with humans.

METHODS

To investigate the pathophysiological mechanisms of depression, we established two models, naturally occurring depression cynomolgus (NOD) and social plus visual isolation-induced depression cynomolgus (SVC), imitating chronic mild or acute intense stress, respectively. We used i-TRAQ (isobaric tags for relative and absolute quantitation)-based quantitative proteomics and shotgun proteomics to identify differentially expressed proteins in cerebrospinal fluid (CSF) of the two monkey models and human MDD patients. We also used DAVID and ingenuity pathway analysis (IPA) for further bioinformatic investigation.

RESULTS

In behavioral tests, NOD monkeys achieved higher scores in depression-like and anxiety-like behavioral measures, and spent more time on ingesting, thermoregulatory, and locomotive actions than SVC monkeys. A total of 902 proteins were identified by i-TRAQ, and 40 differentially expressed proteins were identified in each of the NOD-CON1 and SVC-CON2 groups. Application of DAVID revealed dysregulation of energy metabolism in the NOD group, whereas lipid metabolism and inflammatory response pathways were significantly altered in the SVC group. Use of IPA and Cytoscape showed that the oxygen species metabolic process glycolysis I/gluconeogenesis I, accompanied by downregulation of tubulin beta 3 class III (TUBB3), RAC-alpha serine/threonine-protein kinase (AKT1), and glyceraldehyde-3-phosphate dehydrogenase (GAPDH), was the most significantly affected pathway in the NOD group. Furthermore, 152 differentially expressed proteins in human MDD patients also revealed disruption of glucose energy metabolism. Significantly aberrant energy metabolism in various brain regions and the plasma and liver of chronic unpredictable mild stress rodent samples were also observed in a previous study.

CONCLUSIONS

Our results reveal for the first time the overall CSF protein profiles of two cynomolgus monkey models of depression. We propose that chronic mild stress may affect the disruption of glucose energy metabolism in NOD cynomolgus monkeys and rodents. These findings promote our understanding of the pathophysiology of MDD and may help to identify novel therapeutic targets.

Prevention of Initial Depressive Disorders Among at-Risk Portuguese Adolescents

This study evaluated whether Arnarson and Craighead's (2009, 2011) developmentally based behavioral and cognitive program that prevented the initial episode of depressive disorders among Icelandic adolescents could be adapted to prevent depressive disorders among "at-risk" Portuguese adolescents. One hundred sixty-eight Portuguese mid-adolescents (primarily 14 to 15 years old), who had subsyndromal symptoms of depression but who had never met criteria for a depressive disorder, were identified by classroom screening with the CDI and subsequent K-SADS-PL interview. All 168 adolescents were offered participation in the 14-week prevention program; 70 agreed to participate in the program, and 98 agreed to participate only in an assessment control group. Psychological disorders were evaluated at baseline, 6-, 12-, 18-, and 24-month assessments. During the 2-year follow-up period, 12 students in the assessment-only group experienced an initial depressive disorder versus 2 in the prevention group. Survival analyses indicated a significantly lower rate of initial episodes of depressive disorders, χ²(1) = 4.261, p = .039, among the prevention group participants compared to the assessment only comparison group. The hazard ratio was .207, and the NNT was 11. Survival analyses indicated no significant differences between the prevention condition and the assessment only condition in the occurrence of other psychiatric disorders, χ2(1) = 1.080, p =.299. The findings indicate the program can be successfully adapted for use in Portuguese schools, and they provide a preliminary indication that those "at-risk" adolescents who chose to participate in the program, compared to those who chose to participate only in the assessments, developed fewer initial episodes of depressive disorders over the course of 24 months. The program effects were similar to the outcomes of the prior study of this program in Iceland. As in the Icelandic version of the program, its effects appeared to be specific to the depressive disorders for which the program was designed.

A risk calculator to predict adult attention-deficit/hyperactivity disorder: generation and external validation in three birth cohorts and one clinical sample

AIM

Few personalised medicine investigations have been conducted for mental health. We aimed to generate and validate a risk tool that predicts adult attention-deficit/hyperactivity disorder (ADHD).

METHODS

Using logistic regression models, we generated a risk tool in a representative population cohort (ALSPAC - UK, 5113 participants, followed from birth to age 17) using childhood clinical and sociodemographic data with internal validation. Predictors included sex, socioeconomic status, single-parent family, ADHD symptoms, comorbid disruptive disorders, childhood maltreatment, ADHD symptoms, depressive symptoms, mother's depression and intelligence quotient. The outcome was defined as a categorical diagnosis of ADHD in young adulthood without requiring age at onset criteria. We also tested Machine Learning approaches for developing the risk models: Random Forest, Stochastic Gradient Boosting and Artificial Neural Network. The risk tool was externally validated in the E-Risk cohort (UK, 2040 participants, birth to age 18), the 1993 Pelotas Birth Cohort (Brazil, 3911 participants, birth to age 18) and the MTA clinical sample (USA, 476 children with ADHD and 241 controls followed for 16 years from a minimum of 8 and a maximum of 26 years old).

RESULTS

The overall prevalence of adult ADHD ranged from 8.1 to 12% in the population-based samples, and was 28.6% in the clinical sample. The internal performance of the model in the generating sample was good, with an area under the curve (AUC) for predicting adult ADHD of 0.82 (95% confidence interval (CI) 0.79-0.83). Calibration plots showed good agreement between predicted and observed event frequencies from 0 to 60% probability. In the UK birth cohort test sample, the AUC was 0.75 (95% CI 0.71-0.78). In the Brazilian birth cohort test sample, the AUC was significantly lower -0.57 (95% CI 0.54-0.60). In the clinical trial test sample, the AUC was 0.76 (95% CI 0.73-0.80). The risk model did not predict adult anxiety or major depressive disorder. Machine Learning approaches did not outperform logistic regression models. An open-source and free risk calculator was generated for clinical use and is available online at https://ufrgs.br/prodah/adhd-calculator/.

CONCLUSIONS

The risk tool based on childhood characteristics specifically predicts adult ADHD in European and North-American population-based and clinical samples with comparable discrimination to commonly used clinical tools in internal medicine and higher than most previous attempts for mental and neurological disorders. However, its use in middle-income settings requires caution.

Practitioner Review: Therapeutics of unipolar major depressions in adolescents

BACKGROUND

Over the past two decades new and key randomized controlled trials have reported the efficacy, clinical and cost effectiveness of psychological and pharmacological treatments for adolescents with major depression.

METHODS

The literature was searched through pubmed, psychinfo, scopus and web of science for randomized controlled trials of current major depression together with meta-analyses and systematic reviews of trials between 2000 and 2017. Those specific to the adolescent years (11-18 years) were taken as the primary source for this narrative review. Additional selected studies in adults were used to illustrate methodological issues.

RESULTS

Manualized psychological therapies and the SSRI fluoxetine are more effective than active placebo in the treatment of major depressions. Mild to moderate illnesses attending community-based services are likely to benefit from psychological treatment alone. Moderately to severely ill patients attending clinic and hospital services are likely to benefit from monotherapies or combining psychological and pharmacological treatment. Antidepressants carry a small but significant side-effect risk including increased suicidality. Side effects from psychotherapies are somewhat lower but specific negative consequences remain less well characterized. There is some evidence that CBT-based approaches prevent onset of major depression episode in well adolescents at high-risk. Other psychological interventions have not been adequately studied. There has been only limited identification of treatment moderators and no clear understanding of therapeutic mechanisms.

CONCLUSIONS

There is now a range of clinically effective treatments for depressed adolescents. Future research needs to reveal moderators of and mechanisms for individual differences to treatment response, determine psychotherapies of value for milder depressions, enhance our understanding of safety and side-effects for all treatments, and consider how to reduce and treat treatment-resistant cases.

Rationale, Methods, Feasibility, and Preliminary Outcomes of a Transdiagnostic Prevention Program for At-Risk College Students

PURPOSE

Early adulthood represents one period of increased risk for the emergence of a serious mental illness. The college campus provides a unique opportunity to assess and monitor individuals in this at-risk age group. However, there are no validated early detection programs that are widely implemented on college campuses. In an effort to address this gap, we designed and tested an early detection and prevention program tailored to college students. A transdiagnostic approach was employed because of evidence for shared risk factors across major mental illnesses.

DESIGN

Single arm, prospective study evaluating outcomes following a 4-week intervention.

METHOD

Three in-person mental health screenings were conducted on the campus of one university. Undergraduate students with at least mildly elevated, self-reported levels of depressive or subclinical psychotic symptoms, who were not receiving treatment for these symptoms, were invited to participate in a 4-session workshop focused on increasing self- and other- awareness and emotion regulation using established mindfulness, self-compassion, and mentalization principles and experiential exercises. Symptoms, resilience-promoting capacities, and aspects of social functioning were assessed pre- and post- intervention.

RESULTS

416 students were screened and a total of 63 students participated in the workshop. 91% attended at least 3 of the 4 sessions. The majority of participants found the workshop interesting and useful and would recommend it to a friend. Significant pre-to-post reductions in symptoms (depression, anxiety, and subclinical psychotic symptoms, ps < 0.004) and improvements in resilience-promoting capacities (self-compassion and self-efficacy, ps < 0.006) and indices of social functioning (social motivation, activity, and a measure of comfort with the physical presence of others, ps < 0.04) were observed. Moreover, the significant increases in resilience-promoting capacities correlated with the reductions in affective symptoms (ps < 0.03).

CONCLUSIONS

These findings suggest that an on-campus mental health screening and early intervention program is feasible, acceptable, and may be associated with improvements in resilience-related capacities and symptom reductions in young adults with non-impairing, subclinical symptoms of psychopathology. Follow-up work will determine whether this program can improve both shorter and longer-term mental health and functional outcomes in this at-risk population.

Indicated preventive interventions for depression in children and adolescents: A meta-analysis and meta-regression

Depression contributes about 2% to the global burden of disease. A first onset of depressive disorder or subsyndromal depressive symptoms is common in adolescence, indicating that early prevention is a priority. However, trials of preventive interventions for depression in youths show conflicting results. This systematic review and meta-analysis investigated the effectiveness of group-based cognitive behavioral therapy (GB-CBT) as a preventive intervention targeting subsyndromal depression in children and adolescents. In addition, the impact of different covariates (type of comparator and use of booster sessions) was assessed. Relevant articles were identified from previous systematic reviews, and supplemented with an electronic search spanning from 01/09/2014 to 28/02/2018. The retrieved articles were assessed for eligibility and risk of bias. Relevant data were extracted. Intervention effectiveness was pooled using a random-effects model and the impact of covariates assessed using meta-regression. 38 eligible articles (34 trials) were obtained. The analysis showed GB-CBT to significantly reduce the incidence (relative risk 0.43, 95% CI 0.21-0.87) and symptoms (Cohen's d -0.22, 95% CI -0.32 to -0.11) of depression at post-test compared to all controls. Comparisons with passive comparators suggested that the effect decayed over time. However, compared to active controls, a significant intervention effect was evident only after 12 month or more. Our results suggest that the preventive effect of GB-CBT wears off, but still lasts longer than the effect of active comparators. Only a few studies included booster sessions, precluding firm conclusions. Future studies should clarify to what extent maintenance strategies can prolong the preventive effect of GB-CBT.

Master Clinician Review: Saving Holden Caulfield: Suicide Prevention in Children and Adolescents

OBJECTIVE

The rate of adolescent suicide and suicidal behavior has risen dramatically in the past decade. The title of this article comes from the classic coming-of-age novel by J.D. Salinger, The Catcher in the Rye. Its protagonist, Holden Caulfield, is a precocious adolescent who, in the face of his inability to cope with his own self-destructives urges, imagines himself saving "little kids playing some game in this big field of rye." He is standing on the edge of a cliff trying to catch "thousands of little kids" before they fall to their demise. This vignette from The Catcher in the Rye provides a useful metaphor for the relationship between mental health professionals and youth at risk for suicide, and suggests more efficient and effective alternative interventions to prevent youth suicide compared to standing by a cliff.

METHOD

These four alternative approaches are described, namely: (1) leading youth away from the cliff (ie, prevention); (2) going to where youth are (ie, improving access to care); (3) working with others to change the rules in the field (ie, changing the way care is delivered); and (4) putting a fence around the cliff (ie, restriction of access to lethal agents). The evidence to support the utility and cost-effectiveness of each of these approaches is reviewed.

CONCLUSION

There are extant, empirically supported, cost-effective approaches to the prevention and management of adolescent suicidal behavior that, if implemented widely, are likely to significantly reverse the decade-long rise in adolescent suicide.

Supporting families managing parental mental illness: Challenges and resources

Over five million children in the United States have a parent living with a serious mental illness. These offspring are at higher risk for developing mental health problems themselves due to a complex interplay of biological, psychological, and psychosocial factors. Life with a parent with psychiatric symptoms can be scary, confusing, overwhelming, and sad; children often blame themselves for their parent's problems, find their parent's behavior embarrassing, and struggle to explain the illness to their friends. Unfortunately, these children's needs and experiences are often ignored by overwhelmed parents, worried family members and relatives, separate mental health systems of care for adults and children that often fail to coordinate care, and even well-intentioned health-care providers. Family medicine teams have an opportunity to detect and support these families in unique ways. We offer four recommendations for family medicine teams to help families managing parental mental illness including assessing functioning, treatment needs, and impacts on each family member; educating all family members about mental illness; instilling hope, noting the range of effective treatments for mental illness; and encouraging the use of supports and referral options. Providers can leverage family members' strengths, work with community-based resources, and offer continuity to these families, as they struggle with an oftentimes chronic, relapsing disease that has ripple effects throughout the family system.

Subclinically Anxious Adolescents Do Not Display Attention Biases When Processing Emotional Faces - An Eye-Tracking Study

Recent research suggests that early difficulties with emotion regulation go along with an increased risk for developing psychiatric disorders, such as anxiety disorders for example. Adolescent anxiety is often referred to as a gateway disorder, due to its high predictability for lifelong persistent mental health problems. It has been shown that clinically anxious adolescents exhibit attention biases toward negative stimuli, yet whether these biases can also be found in the subclinical range of subclinically anxious adolescents is currently unclear. In this study, we set out to investigate this question by combining an emotional Go-Nogo task with eye-tracking techniques to assess attention biases for emotional faces in a subclinical sample of 23 subclinically anxious adolescent girls. This combined approach allowed us to look at both, behavioral and covert attention biases. Using both traditional and Bayesian hypothesis testing, we found no evidence for a bias toward negative, threat-relevant stimuli in the behavioral level or eye-tracking data. We believe that the results can help close a gap in the current literature by showing that like low-anxious adolescents, subclinically anxious adolescents do not exhibit attention biases when viewing de-contextualized emotional stimuli in the Overlap task. Together with previous research findings in clinically anxious participants which have reported high levels of attention biases, our results seem to suggest that attention biases do no increase linearly as a function of individual anxiety level. Future research is now needed to explore the contribution of additional factors, such as depression for example.

The Burden of Bereavement: Early-Onset Depression and Impairment in Youths Bereaved by Sudden Parental Death in a 7-Year Prospective Study

OBJECTIVE

The authors sought to determine the long-term impact of sudden parental death on youths and pathways between youth bereavement and impairment.

METHODS

Youths (N=216) who lost a parent to suicide, accident, or sudden natural death and nonbereaved youths (N=172) were followed periodically for up to 7 years. The incidence and prevalence of disorder and of functional impairment, as well as pathways to impairment, were assessed using Cox and mixed-effects logistic regression and structural equation modeling.

RESULTS

Prior to parental death, bereaved youths had higher rates of psychiatric disorder, parental psychiatric disorder, and maltreatment. Even after adjustment for predeath risk factors, bereavement was associated with an increased incidence of depression, posttraumatic stress disorder, and functional impairment. The peak incidence of depression was in the first 2 years postbereavement, with incident depression occurring mainly in those who lost a parent at age 12 or younger. Youths bereaved by all three causes of death showed higher rates of impairment at all time points. Structural equation modeling found that bereavement had a direct effect on impairment and was also linked to impairment via its effects on early and later depression and through negative life events. Child psychiatric disorder prior to parental loss also contributed to functional impairment.

CONCLUSIONS

Parental death increased the incidence of depression in offspring early in the course of bereavement. Early identification and treatment of depression in bereaved youths and augmentation of family resilience may protect against later sequelae of functional impairment.

Early Intervention in Mental Health for Adolescents and Young Adults: A Systematic Review

OBJECTIVE. The purpose of this systematic review was to describe the evidence for the effectiveness of early intervention to improve and maintain performance in occupations for youths with or at risk for serious mental illness (SMI).

METHOD. Titles and abstracts of 670 articles were reviewed, 234 were retrieved for full review, and 30 met inclusion criteria.

RESULTS. Moderate to strong evidence supports cognitive remediation (CR) and mixed evidence supports cognitive–behavioral therapy (CBT) as an adjunct modality to improve general functioning. Moderate to strong evidence supports use of supported employment and supported education (SE/E) to improve social and occupational outcomes in employment and academics. Strong evidence supports family psychoeducation (FPE) to prevent relapse and rehospitalization and improve problem-solving skills and general functioning.

CONCLUSION. Occupational therapy practitioners should integrate CR, SE/E, and FPE into early intervention with youth with or at risk for SMI. In addition, CBT is an effective modality for use with this population.

Long-Term Effects from a School-Based Trial Comparing Interpersonal Psychotherapy-Adolescent Skills Training to Group Counseling

Adolescence represents a vulnerable developmental period for depression and an opportune time for prevention efforts. In this study, 186 adolescents with elevated depressive symptoms (M age = 14.01, SD = 1.22; 66.7% female; 32.2% racial minority) were randomized to receive either Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST; n = 95) delivered by research clinicians or group counseling (GC; n = 91) delivered by school counselors. We previously reported the short-term outcomes of this school-based randomized controlled trial: IPT-AST youth experienced significantly greater improvements in depressive symptoms and overall functioning through 6-month follow-up. Here, we present the long-term outcomes through 24 months postintervention. We examined differences in rates of change in depressive symptoms and overall functioning and differences in rates of depression diagnoses. Youth in both conditions showed significant improvements in depressive symptoms and overall functioning from baseline to 24-month follow-up, demonstrating the efficacy of school-based depression prevention programs. However, the two groups did not differ in overall rates of change or in rates of depression diagnoses from baseline to 24-month follow-up. Although IPT-AST demonstrated advantages over GC in the short term, these effects dissipated over long-term follow-up. Specifically, from 6- to 24-month follow-up, GC youth showed continued decreases in depressive symptoms, whereas IPT-AST youth showed a nonsignificant increase in symptoms. GC youth remained relatively stable in overall functioning, whereas IPT-AST youth experienced a small but statistically significant worsening in functioning. This study highlights the potential of school-based depression prevention efforts and the need for further research.

Trajectories of mental health problems in children of parents with mental health problems: results of the BELLA study

Children of parents with mental health problems (CPM) have an increased risk for behavioral and psychological problems. This study investigated the age- and gender-specific course as well as predictors of mental health problems in CPM using the longitudinal data (baseline 1- and 2-year follow-ups) of a German general population sample from the BELLA study. Children and adolescents aged 11-17 years (at baseline) who had a parent with mental health problems (n = 325) were analyzed. The mental health problems of the children were assessed by the self-reported version of the strengths and difficulties questionnaire (SDQ). We used individual growth modeling to investigate the age- and gender-specific course, and the effects of risk as well as personal, familial and social protective factors on self-reported mental health problems in CPM. Additionally, data were examined differentiating internalizing and externalizing mental health problems in CPM. Results indicated that female compared to male CPM showed increasing mental health problems with increasing age. Mental health problems in CPM were associated with lower self-efficacy, worse family climate and less social competence over time. Internalizing problems were associated with lower self-efficacy, less social competence and more severe parental mental health problems. Externalizing problems were associated with lower self-efficacy, worse family climate and lower social competence. The main limitations of the study are the short time period (2 years) covered and the report of mental health problems by only one parent. Our findings should be considered in the development of treatment and prevention programs for mental health problems in CPM.

Clinical Considerations When Treating Adults Who Are Parents

When providing mental health services to adults, we are often treating individuals who, among their other roles, are also parents. The goal of this article was to provide practitioners with the state of the science about both the impact of parental psychopathology on children and the role that children's well-being has in parental psychopathology. We discuss the benefits of integrated care for adult clients who are parents, as well as the barriers to providing integrated care for both parents and children in psychotherapy, and provide recommendations for practice. With this information, practitioners will gain greater awareness of their opportunities to treat adults in their parenting roles as well as to contribute to prevention of mental disorders in children.