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

Evidence-Base Update of Psychosocial and Combination Treatments for Child and Adolescent Depression

OBJECTIVE

This evidence-based update (EBU) builds on three previous reviews (1998, 2008, 2017) sponsored by the Society of Clinical Child and Adolescent Psychology with the aim of evaluating the empirical support for psychosocial interventions for depression in youth.

METHOD

In the current review period (2014-2022), 25 randomized controlled trials (RCT) were identified: four in children and 21 in adolescents. Descriptive effect sizes and number-needed-to-treat (NNT) ratios were calculated for primary outcomes. Results were integrated with prior reviews, and cumulative evidence used to classify treatments as well-established, probably efficacious, possibly efficacious, or experimental. Published secondary analyses of predictors, moderators, and mediators were examined.

RESULTS

For adolescents, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT-A), CBT in combination with antidepressant medication, and collaborative care programs were all classified as well-established. The evidence was considerably weaker for children, with no treatments achieving well-established or probably efficacious status. New developments include greater exploration of parent- and family-mediated treatment models and increasing evidence on technology-assisted interventions. Data on predictors, moderators, and mediators continued to be focused on adolescent depression samples and drawn from a limited number of RCT datasets.

CONCLUSION

Since the prior EBU, there has been incremental progress in youth depression treatment research. There is an urgent need to: (a) develop innovative approaches to substantially improve on the modest effects seen in most RCTs, (b) expand the evidence base for children and other underserved groups, (c) craft evidence-based guidelines for choosing between interventions when multiple efficacious treatments do exist, and (d) address issues of treatment effectiveness and scalability to ameliorate the wide prevalence and high impact of depression in youth.

Integrated care models for youth mental health: A systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of integrated models of mental healthcare in enhancing clinical outcomes, quality of life, satisfaction with care and health service delivery outcomes in young people aged 12-25 years. A secondary objective was to identify common components of integrated mental health interventions.

METHODS

A systematic review and meta-analysis of studies published 2001-2023 that assessed clinical or health service use outcomes of integrated care, relative to treatment as usual, for any mental health condition in 12-25 years old accessing community-based care.

RESULTS

Of 11,444 titles identified, 15 studies met inclusion criteria and 6 studies were entered in the meta-analysis. Pooled effect size found integrated care was associated with a greater reduction in depressive symptoms relative to treatment as usual at 4-6 months (standardised mean difference = -0.260, 95% confidence interval = [-0.39, -0.13], p = 0.001). Of the seven studies reporting access or engagement, all reported higher rates of both in the intervention arm. The most frequent components of integration were use of a multidisciplinary team (13/15 studies), shared treatment planning (11/15) and workforce training in the model (14/15).

CONCLUSIONS

Integrated models of mental healthcare are associated with a small, but significant, increase in effectiveness for depressive symptoms relative to treatment as usual. Given integrated care may increase access and engagement, future research should focus on assessing the impact of integrated care in a wider range of settings and outcomes, including clinical and functional recovery, satisfaction with care and system-level outcomes such as cost-effectiveness.

Creation of the Youth Integration Project Framework: A Narrative Synthesis of the Youth Mental Health Integrated Care Literature

Introduction

Integrated care has been posited as a potential solution to the global burden of youth mental health (YMH), but there is limited evidence on how best to design, staff, and evaluate different integrated care models. Our review aimed to consolidate the evidence on integrated models of mental healthcare for young people, to identify the core components of integration, and create a framework that can be used to analyse levels of YMH integration.

Methods

We conducted a systematic review of literature across PubMed, SCOPUS, and PsycINFO databases and the grey literature We performed a narrative synthesis extracting core components of integrated YMH care.

Results

Inductive themes from the literature described core components of integrated care. These themes were mapped into a novel framework combining the World Health Organisation health system building blocks and six intensity levels of integrated care to consider how best to implement and sustain integrated care within the YMH system.

Discussion

The Youth Integration Project framework can form a basis for the development, implementation and evaluation of well-articulated models of youth integrated mental health pathways, assisting services identify what operational changes are needed to best implement and sustain integrated care.

Supporting Quality Integrated Care for Adolescent Depression in Primary Care: A Learning System Approach

Background

Quality integrated care, which involves primary care and mental health clinicians working together, can help identify and treat adolescent depression early. We explored systemic barriers to quality integrated care at the provincial level in Ontario, Canada using a learning system approach.

Methods

Two Ontario Health Teams (OHTs), regional networks designed to support integrated care, completed the Practice Integration Profile (PIP) and participated in focus groups.

Results

The OHTs had a median PIP score of 69 out of 100. Among the PIP domains, the lowest median score was case identification (50), and the highest one was workspace (100). The focus groups generated 180 statements mapped to the PIP domains. Workflow had the highest number of coded statements (59, 32.8%).

Discussion

While the primary care practices included mental health clinicians on-site, the findings highlighted systemic barriers with adhering to the integrated care pathway for adolescent depression. These include limited access to mental health expertise for assessment and diagnosis, long wait times for treatment, and shortages of clinicians trained in evidence-based behavioral therapies. These challenges contributed to the reliance on antidepressants as the first line of treatment due to their accessibility rather than evidence-based guidelines.

Conclusion

Primary care practices, within regional networks such as OHTs, can form learning systems to continuously identify the strategies needed to support quality integrated care for adolescent depression based on real-world data.

Pilot Study of Group Interpersonal Psychotherapy for Depression Among Young People With Chronic Illness

OBJECTIVE

Interpersonal psychotherapy (IPT) is an evidence-based treatment for depression, demonstrating efficacy with adolescents and young adults. Social support is proposed to be an important treatment component and may be helpful for adolescents and young adults with chronic illness. The authors sought to assess the feasibility of delivering IPT to this population and to examine changes in depressive symptoms and perceived social support.

METHODS

An open-label feasibility trial of group-based IPT was conducted for adolescents and young adults with chronic illness (N=17). The 12-session group IPT was concurrent with group members' individual psychotherapy, and group IPT was focused on providing support in navigating interpersonal challenges related to the participants' chronic illness. Participants completed questionnaires assessing depressive symptoms and social support before treatment, midtreatment (6 weeks), and after treatment (12 weeks). Generalized estimating equation models, adjusted for repeated measures, were used to assess changes in depressive symptoms and social support over the course of treatment.

RESULTS

Deidentified clinical examples illustrated how IPT was practiced in a community mental health setting. Evidence for the feasibility of group IPT was mixed. Although participants had poor session attendance, there was a significant decrease in depressive symptoms (β=-2.94, 95% CI=-5.30 to -0.59, p=0.014) and a significant increase in perceived social support (β=4.24, 95% CI=0.51 to 7.98, p=0.026) by the end of treatment.

CONCLUSIONS

IPT may help address depressive symptoms and enhance social support among adolescents and young adults with chronic illness. Further research and adaptation are needed to address feasibility challenges in delivering group IPT to this population.

Depression Prevention in Pediatric Primary Care: Implementation and Outcomes of Interpersonal Psychotherapy-Adolescent Skills Training

This study evaluated the fidelity, feasibility, acceptability, and preliminary outcomes of a depression prevention program, interpersonal psychotherapy-adolescent skills training (IPT-AST), in urban pediatric primary care (PC) with a sample of primarily Black youth. Twenty-two adolescents with elevated depressive symptoms participated in this open clinical trial. Adolescents were identified through a screening questionnaire completed at well visits. Ratings of IPT-AST fidelity and session attendance were recorded. Youth and caregivers reported on their attitudes toward the intervention and completed measures of adolescents' symptoms and functioning pre- and post-intervention. Results demonstrated high levels of fidelity, attendance, and acceptability, despite some difficulties with recruitment. Adolescents and caregivers reported significant improvements in functioning. There were marginally significant reductions in self-reported depression, anxiety, and total mental health symptoms. Caregivers reported a significant decrease in total mental health symptoms. Findings provide preliminary information regarding the implementation and effects of IPT-AST when delivered in PC.

Scoping review of stepped care interventions for mental health and substance use service delivery to youth and young adults

AIMS

Many young people with mental health and/or substance use concerns do not have access to timely, appropriate, and effective services. Within this context, stepped care models (SCMs) have emerged as a guiding framework for care delivery, inspiring service innovations across the globe. However, substantial gaps remain in the evidence for SCMs as a strategy to address the current systemic challenges in delivering services for young people. This scoping review aims to identify where these gaps in evidence exist, and the next steps for addressing them.

METHODS

A scoping review was conducted involving both peer-reviewed and grey literature. Eligible studies explored SCMs implemented in the various health care settings accessed by young people aged 12-24 seeking treatment for mental health and substance use challenges. After screening titles and abstracts, two reviewers examined full-text articles and extracted data to create a descriptive summary of the models.

RESULTS

Of the 656 studies that were retrieved, 51 studies were included and grouped by study team for a final yield of 43 studies. Almost half of the studies were focused on the adult population (i.e., 18 and over), and most did not specify interventions for young people. Among the SCMs, substantial variability was found in almost every aspect of the models.

CONCLUSIONS

Considering the current body of evidence, there is an urgent need for a consensus position on the definition, implementation, and outcome measures required for rigorously assessing the utility of SCMs for young people.

Achieving Quality Integrated Care for Adolescent Depression: A Scoping Review

INTRODUCTION

While primary care is often the first point of contact for adolescents with depression, more than half of depressed adolescents are either untreated or undertreated. A scoping review had been completed to summarize approaches for achieving quality integrated care in primary care focused on adolescent depression.

METHODS

The scoping review followed the methodological framework for scoping studies from Arksey and O'Malley. Articles were grouped into themes and mapped to 6 quality domains for integrated care from the practice integration profile survey and 3 levels of stakeholders based on WHO's definition for health systems (patient/family, primary care team, and national/sub-national health system).

RESULTS

A total of 868 records were screened resulting in 22 articles at the patient/family-level (5/22), the primary care team-level (18/22), and the national/sub-national health system-level (16/22). The results highlighted multilevel approaches to support the delivery of quality integrated care for adolescent depression in primary care: (1) population-focused using patient registries, routine screening based on standardized algorithms, and patient-centered strategies, (2) team-driven where primary care clinicians collaborate with mental health clinicians as part of a primary care team, (3) evidence-based delivery of mental health services across the integrated care pathway from screening to follow-up visits, and (4) measurement-guided by leveraging the electronic health record infrastructure to learn from patient outcomes.

CONCLUSION

More research is needed on how to provide quality integrated care for adolescent depression, specifically on patient engagement and retention, grounded in the frontline experiences of patients, families, and clinicians and supported by national and/or sub-national guidelines. A learning system could help integrate mental health services in primary care in a way that is consistent across the national and/or sub-national health system.

Bringing Inclusion Into Pediatric Primary Health Care: A Systematic Review of the Behavioral Health Treatment of Racial and Ethnic Minority Youth

INTRODUCTION

Currently, pediatric behavioral health care accounts for one of the fastest growing health care expenditures. Children representing racial and ethnic minority groups are still found to experience significant behavioral health needs. Primary health care represents the first level of contact with the health care system.

METHOD

The purpose of this systematic review was to synthesize articles discussing the behavioral health needs and treatment of racial and ethnic minority in primary care settings.

RESULTS

Results yielded 40 articles meeting the inclusion criteria. Themes included: provider screening, provider selected treatments, prevalence and need, and stigma and patient-provider communication.

CONCLUSIONS

Themes were discussed through the Ecological Systems Theory lens. Study limitations included its exclusion of intellectual disabilities like Autism Spectrum Disorder, lack of literature utilizing large minority samples, and lack of attention to the intersection between race and/or ethnicity alongside other demographics of concern like gender, age, social class, and geographical location.

Mediation analysis of social deficits between self-criticism and aggression in adolescents

This research aims to determine the mediating role of social deficits in self-criticism and aggression using a sample of 695 adolescents (girls = 49%, boys = 51%), aged 12 to 19 years (M = 14.97, SD = 1.30) from an urbanized city of Pakistan. Interpersonal Difficulties Scale, Self-Criticism Scale, and Aggressive Behavior Scale were used in the present study. Results indicated a significant positive association of social deficits with self-criticism and aggression (p < .001). Furthermore, findings also suggested a significant positive association between self-criticism and aggression. Mediation analysis revealed that self-criticism partially mediated the relationship between social deficits and aggression. Findings are discussed in terms of the expression and manifestation of self-criticism, social deficits, and aggression in adolescents in collectivistic cultures.

Feasibility and acceptability of brief individual interpersonal psychotherapy among university students with mental distress in Ethiopia

Background

The prevalence of mental distress among university students in low- and middle-income countries (LMICs) is increasing; however, the majority do not receive evidence-based psychological intervention. This calls for the provision of culturally adapted psychological therapy in higher education institutions in LMICs. The aim of this pilot study is to evaluate the feasibility and acceptability of Interpersonal Psychotherapy adapted for Ethiopia (IPT-E) among Wolaita Sodo University students and to assess the preliminary outcomes of IPT-E in reducing symptoms of mental distress and in improving functioning.

Methods

We used a quasi-experimental single-group pre-post-test study design. As indicators of feasibility of IPT-E, we used consent, treatment completion and attrition. We used Client Satisfaction Questionnaire and semi-structured interview to measure the acceptability of the intervention, self-reporting IPT-E checklist to assess treatment adherence and World Health Organization Disability Assessment and Self-Reporting Questionnaire-20 tools to assess functional impairment and mental distress, respectively. We used percentage, frequency, mean and standard deviation to summarize the demographic variables, feasibility and acceptability of IPT-E. We analyzed changes from pre- to post-tests of mental distress and functioning results using paired t-test and Wilcoxon signed-rank tests. Independent sample t-test and one way-ANOVA used to assess the difference in mean score of in demographic variables at baseline and eight weeks. The qualitative data was analyzed with the support of open code 4.02.

Results

IPT-E was feasible (consent rate = 100%; completion rate = 92.31%; attrition rate = 7.69%; mean score of the sessions = 8 and mode of the session = 8). The total mean score of treatment satisfaction was 27.83 (SD = 4.47). After the delivery of IPT-E, symptoms of mental distress were decreased, functioning was improved and therapist adherence to the treatment model was 100% (i.e. treatment delivered according to the IPT-E guideline).

Conclusion

IPT-E was feasible and acceptable to treat university students with mental distress in low-income country setting. The preliminary results also suggest promising viability of IPT-E in higher education institutions of low-income country setting for students with symptoms of anxiety and depression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00570-1.

Acceptability and Feasibility of Perioperative Music Listening: A Rapid Qualitative Inquiry Approach

Perioperative music decreases pain, anxiety, and analgesia requirements while increasing patient satisfaction. We investigated the acceptability of perioperative music at a women's and children's hospital in Singapore, seeking to uncover barriers and facilitators to implementation in routine practice over a 12-week period. We used an undergraduate-led Rapid Qualitative Inquiry approach that includes data collection from multiple sources, iterative analysis, and additional data collection when necessary. Participants consisted of anesthesiologists and nurses working in the preoperative area, operating room, and postoperative recovery areas. In Stage 1, nurses and anesthesiologists answered a survey assessing attitudes and knowledge about perioperative music and attended a presentation introducing the intervention. In Stage 2, the results of the Stage 1 survey were disclosed, and nurses and anesthesiologists completed a second survey (Stage 1 survey questions with an additional query about implementation). Twenty-nine nurses were interviewed with semi-structured questions on barriers and facilitators to implementation. In Stage 3, nurses retook the Stage 2 survey after one month of implementation. The implementation of perioperative music was both acceptable and feasible in Singapore. The nurses' and anesthesiologists' acceptability increased over time with mostly positive qualitative feedback. Implementation barriers, including patient interest, timing of patient turnover, and added staff workload, appeared minor and could potentially be overcome by utilizing the intervention in the preoperative instead of postoperative area, deploying music in operating rooms with slower turnover, and evenly distributing staff workload. Local implementation stakeholders may make additional recommendations for scaling-up perioperative music interventions to fit other workflows while improving the patient experience.

[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.

Pediatric Integrated Care Models: A Systematic Review

Psychiatric disorders are becoming more frequently diagnosed within the pediatric primary care setting. Despite increased diagnosis within primary care, only a minority of patients receive further psychiatric or specialty care. The integrated/collaborative care treatment model was designed to improve access within primary care. The purpose of this review is to identify randomized controlled trials and quasi-experimental studies that have investigated whether increased access improves treatment engagement, satisfaction, and improved mental health outcomes. Six studies met inclusion criteria. Studies reviewed indicated increased access to behavioral health treatment through use of the integrated/collaborative care model and improved mental health outcomes. Recommendations for screening and treatment are provided. Limitations of the reviewed studies include lack of generalizability to urban populations, minority youth, and youth younger than 4 years of age. Practice recommendations to address these limitations are identified.

Psychological Treatment for Depressive Disorder

Depression is highly prevalent and causes unnecessary human suffering and economic loss. Therefore, its treatment and prevention are of utmost importance. There are several advantages of using psychotherapy either by itself or combined with pharmacological treatment methods in the treatment of depression. First, it is well known that combining biological treatment with psychosocial methods increases the chances of recovery. Second, in some individuals, psychotherapy continues to be the only solution. Third, the use of antidepressants contains some safety risks and side effects, but psychotherapy does not. Fourth, clinically, depressive patients prefer psychotherapy to drug therapy. Use of a depression-focused psychotherapy alone is recommended as an initial treatment choice for patients with mild to moderate depression, with clinical evidence supporting the use of cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), psychodynamic psychotherapy (PDP), and problem-solving therapy (PST) in individual and group formats. Important developments took place within the past 20 years in the psychotherapy of depression. In the present chapter, we introduced several key issues, such as, Are all psychotherapies equally effective? Who benefits from psychotherapies? Is telepsychotherapy effective? Finally, we introduce the psychotherapy for special populations.

Review: The effectiveness of interpersonal psychotherapy for adolescents with depression - a systematic review and meta-analysis

BACKGROUND

Interpersonal psychotherapy for adolescents (IPT-A) is a manualised, time-limited intervention for young people with depression. This systematic review aimed to determine the effectiveness of IPT-A for treating adolescent depression.

METHOD

A systematic search of relevant electronic databases and study reference lists was conducted. Any study investigating the effectiveness of IPT-A in 12- to 20-year-olds with a depressive disorder was eligible. Synthesis was via narrative summary and meta-analysis.

RESULTS

Twenty studies were identified (10 randomised trials and 10 open trials/case studies), many of which had small sample sizes and were of varying quality. Following IPT-A, participants experienced large improvements in depression symptoms (d = -1.48, p < .0001, k = 17), interpersonal difficulties with a medium effect (d = -0.68, p < .001, k = 8) and in general functioning with a very large effect (d = 2.85, p < .001, k = 8). When compared against control interventions, IPT-A was more effective than non-CBT active controls in reducing depression symptoms (d = -0.64, p < .001, k = 5) and was no different from CBT (d = 0.05, p = .88, k = 2). There was no difference between IPT-A and active control interventions in reducing interpersonal difficulties (d = -0.26, p = .25, k = 5).

CONCLUSIONS

Interpersonal psychotherapy for adolescents is an effective intervention for adolescent depression, improving a range of relevant outcomes. IPT-A is consistently superior to less structured interventions and performs similarly to CBT. However, these conclusions are cautious, as they are based on a small number of controlled studies, with minor adaptations to the standard IPT-A protocol, and/or were conducted by the intervention developers. Further robust RCTs are therefore required. The lack of superiority in IPT-A for improving interpersonal difficulties highlights a need for studies to explore the underpinning mechanisms of change.

Smooth Sailing: A Pilot Study of an Online, School-Based, Mental Health Service for Depression and Anxiety

Background: Schools play an important role in supporting young people's mental health, but face challenges identifying and responding to students in need of care. To assist secondary schools, the Black Dog Institute has developed an online, school-based, mental health service (Smooth Sailing). Delivered in the classroom, Smooth Sailing uses a website to screen, assess, allocate, and deliver care for depression and anxiety. The service is based on the principles of stepped care, offering treatments with varied intensity and follow-up by a school counselor when necessary. The current study aimed to evaluate the feasibility, acceptability, and safety of this new type of service among secondary school students. Methods: Between February and June 2017, a single-arm, pre-post, pilot study was conducted among students from four NSW secondary schools. Schools were given access to the service for 6 weeks. Feasibility measures (consent rates and step allocations), acceptability measures (service use and satisfaction) and safety measures (deterioration in help-seeking intention scores and mental health symptoms) were assessed at baseline and completion of the 6-week trial period. Results: A total of 59 students took part in the service pilot (mean age, 14.57 years; SD, 0.89 years; range, 13-16 years). At baseline, 18.64% of students were found to require follow-up from the school counselor, and 80% of these were new cases. Although completion of the online modules was low, service satisfaction was high. At 6 weeks, the mean scores for help-seeking, depression, and anxiety remained relatively stable or improved. Conclusions: The current study presents important findings for the development and implementation of an online mental health service that screens students' mental health and allocates care accordingly, all within the school setting. Although the findings provide some support for the feasibility, acceptability, and safety, service improvements are needed. The modifications outlined are likely to improve the quality of the service and its effectiveness. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12617000977370.

Primary Care: Meeting the Mental Health Care Needs of Adolescents With Depression

There is considerable evidence demonstrating the negative impact adolescent depression has on youth outcomes, such as poor school performance, social isolation, comorbid substance abuse, lack of employment, and, most concerning, the development of suicidal behaviors.¹ Currently, the health system cannot meet the needs of youths with depression due to lack of access, shortage of trained clinicians, and inability to consistently deliver evidence-based care, especially in low-resource communities.² To address this problem, we are turning to other health practitioners, specifically our primary care colleagues, to help provide effective care for adolescent depression and other mental health conditions.

What's known about implementing co-located paediatric integrated care: a scoping review

Several studies have demonstrated clinical benefits of integrated care for a range of child and adolescent mental health outcomes. However, there is a significant gap between the evidence for efficacy of integrated care interventions vs their implementation in practice. While several studies have examined large-scale implementation of co-located integrated care for adults, much less is known for children. The goal of this scoping review was to understand how co-located mental health interventions targeting children and adolescents have been implemented and sustained. The literature was systematically searched for interventions targeting child and adolescent mental health that involved a mental health specialist co-located in a primary care setting. Studies reporting on the following implementation outcomes were included: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. This search identified 34 unique studies, including randomized controlled trials, observational studies, and survey/mixed method approaches. Components facilitating implementation of on-site integrated behavioural healthcare included interprofessional communication and collaboration at all stages of implementation; clear protocols to facilitate intervention delivery; and co-employment of integrated care providers by specialty clinics. Some studies found differences in service use by demographic factors, and others reported funding challenges affecting sustainability, warranting further study.