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

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

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

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

Internet-based cognitive behavioral therapy intervention for youth with type 1 diabetes and depressive symptoms: a pilot and feasibility study

Depression is more common in youth with type 1 diabetes (T1D) compared to youth without diabetes. This study aims to assess the efficacy of Competent Adulthood Transition with Cognitive Humanistic and Interpersonal Teaching (CATCH-IT), an internet-based cognitive behavioral therapy (CBT) intervention, in adolescents with T1D and depressive symptoms. Adolescents (13 to 17 years old) with T1D and mild (score 5-9) or moderate (score 10-14) depressive symptoms on Patient Health Questionnaire-Adolescent (PHQ-A) screening assessment were recruited to participate and received online access to the CATCH-IT modules for 6 months (requested to complete in 12 weeks). Statistical analyses included paired t-test for changes in Center for Epidemiologic Studies Depression Scale (CES-D), PHQ-A, Problem Areas in Diabetes-Teen version (PAID-T), and hemoglobin A1c (HbA1c). Nineteen patients were consented, 15 met inclusion criteria and received the intervention. In the seven participants that completed the modules, there was a trend towards improvements in PHQ-A, CES-D and HbA1c. Participants provided robust qualitative feedback on the modules and areas for improvement in subsequent iterations, such as inclusion of diabetes-related content. Given the prevalence of depression in diabetes, feasible, low resource interventions are needed. Internet programs such as CATCH-IT can serve as an effective first line intervention in this high-risk population. A modified version of CATCH-IT tailored for adolescents with T1D may be beneficial in this patient population.

A study protocol for the randomized controlled trial SAFIR FAMILY TALK: a selective primary preventive intervention vs. service as usual for children of parents with mental illness

BACKGROUND

Children of parents with mental illness have an increased risk of developing mental illness themselves throughout their lifespan. This is due to genetic factors but also environmental disadvantages during childhood associated with parental mental illness. Selective primary preventive interventions for the children are recommended to mitigate risk factors and strengthen protective factors, but large-scale, longitudinal studies are needed. This study aims to investigate the effect of the Family Talk Preventive Intervention in a cohort of children and their parents with mental illness.

METHODS

The study is a randomized controlled trial with 286 planned families with at least one parent with any mental illness and at least one child aged 7 to 17 years. It will be carried out in the mental healthcare system in the Capital Region of Denmark. Families will be referred from hospitals and municipalities. The children and parents will be assessed at baseline and then randomized and allocated to either the Family Talk Preventive Intervention or service as usual. The intervention group will be assigned to Family Talk Preventive Intervention, a manualized programme consisting of ~ seven sessions for the family, including psychoeducation about parental mental illness and resilience in children, stimulating dialogue between family members and creating a common family narrative. The study period for both groups will be 12 months. Follow-up assessments will be conducted after 4 months and 12 months. The primary outcomes are the children's level of functioning, parental sense of competence and family functioning.

DISCUSSION

Given the prevalence of transgenerational transmission of mental illness, a systematic approach to prevention is needed in the mental healthcare setting. This study provides valuable knowledge on the Family Talk Preventive Intervention with a large sample size, inclusion of any parental mental illness and examination of the primary outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05615324. Registered on 26 October 2022. Retrospectively registered.

The Transition to Adulthood in Children of Depressed Parents: Long-Term Follow-Up Data from the Family Talk Preventive Intervention Project

Little is known about the effects of parental depression on offspring as they transition to adulthood-a challenging time developmentally, when late adolescents must separate from home, achieve intimate relationships, and develop a sense of identity. We present long-term quantitative and qualitative data from early adolescents with a depressed parent who were randomized to one of two family-based preventive interventions and followed over time, across the transition to young adulthood. Specifically, we present clinical measures of psychopathology and Likert-scale questionnaire data from young adults and their parents regarding the transition to adulthood and perceptions of the interventions. We also report in-depth qualitative interview data from young adults about the effects of parental depression on their transition to adulthood. Findings suggest that leaving home, establishing relationships, and coping with stressors may be challenging for emerging adults. Furthermore, the interviews highlight the importance of siblings, the burden of parental depression, and the development of self-understanding and empathy in young adults who grew up with a depressed parent. Data suggest that clinicians, policy makers, educators, and employers must address the preventive and clinical needs of young people and their families as they transition to young adulthood after growing up with depressed parents.

Development and Pilot Test of a Group Cognitive Behavioral Intervention for Women Recovering From Fistula Repair Surgery in Ethiopia

Obstetric fistula is a serious complication that affects thousands of women in low-income countries. Women who suffer from obstetric fistulae are at risk of developing mental health problems, but to date most interventions have focused on repairing the physical consequences of fistulae through surgery. The goal of the current study is to develop an evidence-based intervention targeting symptoms of depression, anxiety, and trauma in women recovering from fistula repair surgery. First, hospital staff and patients awaiting surgery at a fistula hospital in Ethiopia participated in qualitative interviews to provide information on the mental health needs of women with fistulae, how the hospital tends to these women's psychological needs, and the training needs of staff members. Data from these interviews were used to develop the COFFEE intervention (CBT with Obstetric Fistula for Education and Empowerment). COFFEE is a modular, group intervention that teaches psycho-education, behavioral activation, relaxation, problem solving, cognitive restructuring, and includes a trauma narrative. Patients then participated in an open trial of the COFFEE intervention at the University of Gondar Hospital. Five separate groups were conducted with 24 women who were enrolled post-fistula repair surgery. Women completed pre-treatment self-report questionnaires, participated in group sessions conducted by nurses (with 8 sessions delivered across 10–14 days), and were assessed post-treatment and at 3-month follow-up. Results indicate a significant reduction on depression and anxiety symptoms scores across the three time points [F_{(2, 40)} = 68.45, p < 0.001 partial η² = 0.774]. Additionally, there was a significant decrease in traumatic stress scores from baseline to post-treatment [F_{(1.10, 21.98)} = 100.51, p < 0.001 partial η² = 0.834]. Feedback forms completed by nurses and patients suggest the intervention was well-received. Results of this open-trial suggest the COFFEE intervention is feasible, acceptable, and clinically beneficial to treat symptoms of depression, anxiety, and traumatic stress in women post-fistula repair surgery in a hospital setting.

Depressive Symptoms Among Adolescents: Testing Vulnerability-Stress and Protective Models in the Context of COVID-19

Adolescents who experience negative life events may be at risk for depression, particularly those with psychosocial vulnerabilities. We investigate longitudinally the impact of vulnerability/protective factors on the relation between a large-scale negative life event, the COVID-19 pandemic, and depressive symptoms. Adolescents (N = 228, M_age = 14.5 years, 53% female, 73% white) self-reported depressive symptoms 2-4 months before the pandemic (Time 1), and again 2 months following stay-at-home orders (Time 2). At T2, adolescents also completed measures of vulnerability, protective factors, and COVID-19-related distress. Depressive symptoms increased at T2, and COVID-19 distress interacted with resilience and negative cognitive style in predicting increases in T2 depression. Focusing on vulnerability and protective factors in adolescents distressed by large scale negative life events appears crucial.

Society of Behavioral Medicine (SBM) Position Statement: increase access to mental health services due to COVID-19-related parent and family stress

COVID-19 has caused drastic increases in family stress contributing to deleterious social and emotional ramifications. Before COVID-19, millions of Americans lacked access to mental health resources, and now in the midst of a global pandemic, resources are more limited in times of greater need. In March 2020, the Coronavirus Aid, Relief, and Economic Security (CARES) Act provided funding for mental health reforms; yet many barriers remained to receiving sufficient care. In February 2021, the Society of Behavioral Medicine recommended federal legislators expand Community Behavioral Healthcare Centers, increase funding for Federally Qualified Healthcare Centers and School Based Health Centers, incentivize providers to accept Medicaid, and institute more statewide licensing flexibilities to expand the reach of mental health care. In March 2021, the American Rescue Plan was signed into law and provided an additional ~$4 billion in funding for community mental health services, implementing substance abuse prevention and treatment programs, increasing the behavioral health workforce, promoting behavioral telehealth within primary care, increasing school-based mental health services, implementing suicide prevention programs, and improving services for traumatized families. This significant investment in parents and children’s mental health is a tremendous step in the right direction and provides reassurance that relief is underway. Ongoing surveillance of the programmatic and clinical outcomes that result from these new policy reforms will be important for identifying areas that may need continual support as our nation recovers from COVID-19.

Understanding Adolescent Expressions of Sadness: A Qualitative Exploration

PURPOSE

Primary care providers are positioned to identify adolescents at risk for depression and prevent major depressive disorder. To identify subthreshold depression, we examined the language adolescents use to describe their symptoms.

METHODS

Adolescents ages 13-18 with elevated levels on the Center for Epidemiologic Studies Depression (CES-D) scale and/or a history of depression who were part of a large randomized clinical trial to prevent depressive disorder were included. We used content analysis to analyze transcripts of semi-structured interviews.

RESULTS

Saturation was reached at 37 interviews. Adolescents self-identified as African American (N = 15), Hispanic (N = 10), and White (N = 21). Three domains were revealed; external sources of stress, adolescent expressions of sadness, and seeking help and care. Within these domains, 12 distinct themes emerged contextualizing these domains. No variations in the expression of the themes identified for subthreshold depression were found between the three ethno-cultural groups.

IMPLICATIONS FOR PRACTICE

Our study identifies, in adolescents' own words, how adolescents with subthreshold depression express feelings and cope with symptoms, and may guide primary care providers to recognize subthreshold depression early. These findings are a step toward filling the gap in the empirical literature needed to improve identification of adolescents at risk for depression in nonspecialist settings.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

Cost-Effectiveness of Preventing Depression Among At-Risk Youths: Postintervention and 2-Year Follow-Up

OBJECTIVE

Youth depression can be prevented, yet few programs are offered. Decision makers lack cost information. This study evaluated the cost-effectiveness of a cognitive-behavioral prevention program (CBP) versus usual care.

METHODS

A cost-effectiveness analysis was conducted with data from a randomized controlled trial of 316 youths, ages 13-17, randomly assigned to CBP or usual care. Youths were at risk of depression because of a prior depressive disorder or subthreshold depressive symptoms, or both, and had parents with a prior or current depressive disorder. Outcomes included depression-free days (DFDs), quality-adjusted life years (QALYs), and costs.

RESULTS

Nine months after baseline assessment, youths in CBP experienced 12 more DFDs (p=.020) and .018 more QALYs (p=.007), compared with youths in usual care, with an incremental cost-effectiveness ratio (ICER) of $24,558 per QALY. For youths whose parents were not depressed at baseline, CBP youths had 26 more DFDs (p=.001), compared with those in usual care (ICER=$10,498 per QALY). At 33 months postbaseline, youths in CBP had 40 more DFDs (p=.05) (ICER=$12,787 per QALY). At 33 months, CBP youths whose parents were not depressed at baseline had 91 more DFDs (p=.001) (ICER=$13,620 per QALY). For youths with a currently depressed parent at baseline, CBP was not significantly more effective than usual care at either 9 or 33 months, and costs were higher.

CONCLUSIONS

CBP produced significantly better outcomes than usual care and was particularly cost-effective for youths whose parents were not depressed at baseline. Depression prevention programs could improve youths' health at a reasonable cost; services to treat depressed parents may also be warranted.

Building resilient families: Developing family interventions for preventing adolescent depression and HIV in low resource settings

Depression contributes significantly to the global burden of disease in low- and middle-income countries. In South Africa, individuals may be at elevated risk for depression due to HIV and AIDS, violence, and poverty. For adolescents, resilience-focused prevention strategies have the potential to reduce onset of depression. Involving families in promoting adolescent mental health is developmentally appropriate, but few existing interventions take a family approach to prevention of adolescent depression. We conducted a qualitative investigation from 2013-2015 to inform the development of a family intervention to prevent adolescent depression in South Africa among families infected or at risk for HIV. Using focus groups with adolescents and parents (eight groups, n = 57), and interviews (n = 25) with clinicians, researchers, and others providing mental health and related services, we identified context-specific factors related to risk for family depression, and explored family interactions around mental health more broadly as well as depression specifically. Findings indicate that HIV and poverty are important risk factors for depression. Future interventions must address linguistic complexities in describing and discussing depression, and engage with the social interpretations and meanings placed upon depression in the South African context, including bewitchment and deviations from prescribed social roles. Participants identified family meetings as a context-appropriate prevention strategy. Family meetings offer opportunities to practice family problem solving, involve other family members in communal parenting during periods of parental depression, and serve as forums for building Xhosa-specific interpretations of resilience. This study will guide the development of Our Family Our Future, a resilience-focused family intervention to prevent adolescent depression (ClinicalTrials.gov #NCT02432352).

Impact of an online depression prevention intervention on suicide risk factors for adolescents and young adults

BACKGROUND

Adolescent death by suicide is an emergent health crisis in the United States of America. Although many suicide prevention programs have been created to address suicide in this population, rates continue to increase. Online interventions can disseminate treatments world-wide and reach large numbers of users. Thus, the purpose of the present study was to determine the effects of CATCH-IT, an Internet-based depression prevention intervention on risk factors for suicide (i.e., suicidal ideation, hopelessness, low self-esteem and social isolation).

METHODS

A total of 83 participants aged 14-21 years [mean =17.5; standard deviation (SD) =2.04] consented to take part in the intervention study.

RESULTS

Results indicated that suicidal ideation decreased from baseline to post-intervention. For those who completed the entire CATCH-IT program, the effect size was moderate (d =0.60, P<0.05). For those who partially completed the program the effect size was small (d =0.22, P<0.05). Interestingly, scales measuring hopelessness and social isolation were not associated with changes in suicidal ideation.

CONCLUSIONS

The findings provide initial evidence that online depression prevention programs could be related to decreased suicidal ideation, and that those who complete the entire program may benefit more than those who complete only a part of CATCH-IT.

The feasibility and acceptability of a preventive intervention programme for children with depressed parents: study protocol for a randomised controlled trial

Background

One of the most important risk factors for childhood depression is being the child of a depressed parent. These at-risk children have two to four times the probability of having an affective episode compared with their peers. Preventive interventions such as Beardslee’s Preventive Intervention Program (PIP) that are targeted at children of depressed parents have proven effective in many countries. The PIP is a family-based approach that works by promoting resilience in children and increasing positive interactions within the family. In this pilot randomised controlled trial (RCT), we will determine the acceptability and feasibility of an adapted version of this intervention in Chile.

Methods/design

We are conducting a pilot RCT with a manualized intervention. The intervention will be delivered in seven weekly sessions at the family home. It is targeted mostly at parents but will also measure outcomes among the children. Control subjects will follow their treatment as usual. Feasibility and acceptability will be assessed by recruitment, adherence, dropout and level of missing data, as well as the burden of scales and measurement tools. Families will be followed for 11 months.

Discussion

Given the negative lifelong consequences of depression and the burden they represent, preventive programmes are not only feasible but necessary. Despite the successful implementation of this intervention in different countries, an adaptation to the Chilean reality will be prerequisite. The results of this pilot study will inform a definitive trial that will make the case for its national implementation.

Trial registration

Clinicaltrials.gov trial identifier: NCT02593266. Registration date: 30 Octo 2015.

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

IMPORTANCE

Adolescents whose parents have a history of depression are at risk for developing depression and functional impairment. The long-term effects of prevention programs on adolescent depression and functioning are not known.

OBJECTIVE

To determine whether a cognitive-behavioral prevention (CBP) program reduced the incidence of depressive episodes, increased depression-free days, and improved developmental competence 6 years after implementation.

DESIGN, SETTING, AND PARTICIPANTS

A 4-site randomized clinical trial compared the effect of CBP plus usual care vs usual care, through follow-up 75 months after the intervention (88% retention), with recruitment from August 2003 through February 2006 at a health maintenance organization, university medical centers, and a community mental health center. A total of 316 participants were 13 to 17 years of age at enrollment and had at least 1 parent with current or prior depressive episodes. Participants could not be in a current depressive episode but had to have subsyndromal depressive symptoms or a prior depressive episode currently in remission. Analysis was conducted between August 2014 and June 2015.

INTERVENTIONS

The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Usual care consisted of any family-initiated mental health treatment.

MAIN OUTCOMES AND MEASURES

The Depression Symptoms Rating scale was used to assess the primary outcome, new onsets of depressive episodes, and to calculate depression-free days. A modified Status Questionnaire assessed developmental competence (eg, academic or interpersonal) in young adulthood.

RESULTS

Over the 75-month follow-up, youths assigned to CBP had a lower incidence of depression, adjusting for current parental depression at enrollment, site, and all interactions (hazard ratio, 0.71 [95% CI, 0.53-0.96]). The CBP program's overall significant effect was driven by a lower incidence of depressive episodes during the first 9 months after enrollment. The CBP program's benefit was seen in youths whose index parent was not depressed at enrollment, on depression incidence (hazard ratio, 0.54 [95% CI, 0.36-0.81]), depression-free days (d = 0.34, P = .01), and developmental competence (d = 0.36, P = .04); these effects on developmental competence were mediated via the CBP program's effect on depression-free days.

CONCLUSIONS AND RELEVANCE

The effect of CBP on new onsets of depression was strongest early and was maintained throughout the follow-up period; developmental competence was positively affected 6 years later. The effectiveness of CBP may be enhanced by additional booster sessions and concomitant treatment of parental depression.

TRIAL REGISTRATION

clinicaltrials.gov Identifier:NCT00073671.

Developmental risk of depression: experience matters

This article focuses on discussing risks for depression onset and the role of environmental factors in promoting resilience in children and adolescents. The authors review the current literature on specific (eg, family history of depression) and nonspecific (eg, poverty, stressful life events) risk factors for youth depression to underscore the need for prevention efforts promoting resiliency in this population.

Transmission and prevention of mood disorders among children of affectively ill parents: a review

OBJECTIVE

To provide a conceptual review of the literature on children of depressed parents over the past 12 years.

METHOD

This selective review focused on published studies that delineate the diagnosis of depression in parents, have large samples, describe children 6 to 17 years old, and are methodologically rigorous. The review emphasized conceptual advances and major progress since 1998. Recent efforts in prevention research were discussed, gaps in the existing literature were noted, and directions for targeted research on children of depressed parents were highlighted.

RESULTS

Over the past 12 years there has been considerable progress in delineating the gene-by-environment interplay in determining the range of outcomes in children. In addition, progress has been made in identifying risk mechanisms and moderators that underlie the transmission of disorder and in developing effective prevention programs.

CONCLUSIONS

This review highlights directions for further research, including different areas affected by parental depression in parents and children, and in understanding the underlying mechanisms involved in the intergenerational transmission of depression, so that preventive and treatment efforts can be tailored effectively.

Internet-based depression prevention over the life course: a call for behavioral vaccines

Technology-based approaches for the prevention of depression offer considerable benefits including easy access, patient autonomy, and "nonconsumable" services that are autonomous from traditional (face-to-face) interventions. The authors have previously worked to develop Internet interventions based on the frameworks for conventional, face-to-face effective community-based interventions, and propose to integrate these models into a "behavioral vaccine model" aptly applicable to technology-based delivery. This article reviews the literature on Internet-based depression prevention programs using this behavioral vaccine development model, reviewing literature relevant to each component of the model in turn.

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

CONTEXT

Adolescent offspring of depressed parents are at markedly increased risk of developing depressive disorders. Although some smaller targeted prevention trials have found that depression risk can be reduced, these results have yet to be replicated and extended to large-scale, at-risk populations in different settings.

OBJECTIVE

To determine the effects of a group cognitive behavioral (CB) prevention program compared with usual care in preventing the onset of depression.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter randomized controlled trial conducted in 4 US cities in which 316 adolescent (aged 13-17 years) offspring of parents with current or prior depressive disorders were recruited from August 2003 through February 2006. Adolescents had a past history of depression, current elevated but subdiagnostic depressive symptoms, or both. Assessments were conducted at baseline, after the 8-week intervention, and after the 6-month continuation phase.

INTERVENTION

Adolescents were randomly assigned to the CB prevention program consisting of 8 weekly, 90-minute group sessions followed by 6 monthly continuation sessions or assigned to receive usual care alone.

MAIN OUTCOME MEASURE

Rate and hazard ratio (HR) of a probable or definite depressive episode (ie, depressive symptom rating score of > or = 4) for at least 2 weeks as diagnosed by clinical interviewers.

RESULTS

Through the postcontinuation session follow-up, the rate and HR of incident depressive episodes were lower for those in the CB prevention program than for those in usual care (21.4% vs 32.7%; HR, 0.63; 95% confidence interval [CI], 0.40-0.98). Adolescents in the CB prevention program also showed significantly greater improvement in self-reported depressive symptoms than those in usual care (coefficient, -1.1; z = -2.2; P = .03). Current parental depression at baseline moderated intervention effects (HR, 5.98; 95% CI, 2.29-15.58; P = .001). Among adolescents whose parents were not depressed at baseline, the CB prevention program was more effective in preventing onset of depression than usual care (11.7% vs 40.5%; HR, 0.24; 95% CI, 0.11-0.50), whereas for adolescents with a currently depressed parent, the CB prevention program was not more effective than usual care in preventing incident depression (31.2% vs 24.3%; HR, 1.43; 95% CI, 0.76-2.67).

CONCLUSION

The CB prevention program had a significant prevention effect through the 9-month follow-up period based on both clinical diagnoses and self-reported depressive symptoms, but this effect was not evident for adolescents with a currently depressed parent.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00073671.

The prevention of depression in children and adolescents: a review

OBJECTIVE

To review the recent literature on the prevention of clinical diagnoses of depression in children and adolescents.

METHOD

Several preventive intervention programs targeting depressive diagnoses in youth were reviewed. These programs based their prevention strategies on cognitive-behavioural and (or) interpersonal approaches, which have been found to be helpful in the treatment of depression. In addition, family-based prevention strategies were reviewed. Also, nonspecific risk factors for youth depression, including poverty and child maltreatment, were discussed as important considerations in prevention programs targeting youth depression.

RESULTS

In general, successful prevention programs targeting youth depression are based on evidence-based treatment programs for youth depression, structured and outlined in manuals, involve careful training of personnel implementing the protocols, and include assessment of fidelity to the intervention protocols. The programs were consistent with cognitive-behavioural and (or) interpersonal psychotherapy traditions. Overall, it appears that there is reason for hope regarding the role of interventions in preventing depressive disorders in youth.

CONCLUSIONS

Several new directions for future research on the prevention of depression in youth were outlined. Future research is needed to establish an empirical base for the prevention of depression in high-risk youth and should: focus on targeted and indicated prevention approaches, attend to moderators of intervention effects, include approaches that aim to enhance the family environment, attend to nonspecific risk factors for disorder, and focus on the dissemination phase of prevention research.

Long-term effects from a randomized trial of two public health preventive interventions for parental depression

This article presents long-term effects of a randomized trial evaluating 2 standardized, manual-based prevention strategies for families with parental mood disorder: informational lectures and a brief, clinician-based approach including child assessment and a family meeting. A sample of 105 families, in which at least 1 parent suffered from a mood disorder and at least 1 nondepressed child was within the 8- to 15-year age range, was recruited. Parents and children were assessed separately at baseline and every 9 to 12 months thereafter on behavioral functioning, psychopathology, and response to intervention. Both interventions produced sustained effects through the 6th assessment point, approximately 4.5 years after enrollment, with relatively small sample loss of families (<14%). Clinician-based families had significantly more gains in parental child-related behaviors and attitudes and in child-reported understanding of parental disorder. Child and parent family functioning increased for both groups and internalizing symptoms decreased for both groups, with no significant group differences. These findings demonstrate that brief, family-centered preventive interventions for parental depression may contribute to long-term, sustained improvements in family functioning.

A family-based approach to the prevention of depressive symptoms in children at risk: evidence of parental and child change

OBJECTIVE

Depression in parents is a prevalent and impairing illness that is encountered frequently in medical practice. Children of depressed parents are at risk for psychopathology and other difficulties. A series of recent national reports have recommended the development of prevention efforts targeting children of depressed parents. Yet, to date, few controlled prevention studies of depression in children and adolescents have been conducted. In this study, we report the evaluation of 2 preventive intervention strategies that target children living in homes with depressed parents. Both are public health approaches that were designed to be used by a wide range of practitioners from a variety of disciplines, including pediatricians, internists, school counselors, nurses, and mental health practitioners. We adopted a developmental perspective and intervened with families when children were entering the age of highest risk for depression onset (ie, adolescence). We chose a family-based approach to prevention and sought to reduce risk factors and enhance protective factors for early adolescents by increasing positive interactions between parents and children, and by increasing understanding of the illness for everyone in the family. Our prevention approaches were designed to provide information about mood disorders to parents, to equip parents with the skills they need to communicate information to their children, and to open a dialogue with their children about the effects of parental depression. We hypothesized that participation in these prevention programs would result in parental change in child-related behaviors and attitudes about depression and its impact on the family. In addition, we hypothesized that this parental change would produce change in children's self-understanding, and in children's depressive symptomatology.

METHODS

We conducted a large-scale efficacy trial of 2 manual-based preventive intervention programs that were designed to be used widely in public health settings. These interventions target the relatively healthy children (ages 8-15) of parents with mood disorder. Ninety-three families (88.5% of our initial sample), including 121 children, participated in this study through the fourth assessment point. These families were assigned randomly to either a lecture or a clinician-facilitated intervention. Both interventions were specified in manuals. The lecture condition consisted of 2 separate meetings delivered in a group format without children present. The clinician-facilitated condition consisted of 6 to 11 sessions, including separate meetings with parents and children, and a family meeting in which the parents led a discussion of the illness and of positive steps that can be taken to promote healthy functioning in the children. In addition, telephone contacts or refresher meetings were conducted at 6- to 9-month intervals. In both conditions, psychoeducational material about mood disorders, risk, and resilience was presented and efforts were made to decrease feelings of guilt and blame in children. Parents were helped to build resilience in their children through encouraging their friendships, their success outside of the home, and their understanding of parental illness and of themselves. In addition, in the clinician-facilitated condition, efforts were made to link the psychoeducational material presented to the family's own unique illness experience. To address directly how their lives had changed, all family members in both conditions were assessed for psychopathology and for overall functioning at intake, and for psychopathology, functioning, and response to intervention immediately postintervention, approximately 1 year postintervention, and again approximately 2.5 years postintervention.

RESULTS

We examined the outcomes of child understanding and internalizing symptomatology, and a number of predictor variables, using repeated measures analyses with generalized estimating equations. We found that parents in both conditions reported significant change in child-related behaviors and and attitudes, and that the amount of change reported increased over time from time 3 to time 4 (chi2(1) = 18.1). Moreover, relative to parents in the lecture program (mean number of changes = 6.3), parents in the clinician-facilitated program reported more change in child-related behaviors and attitudes (mean number of changes = 9.8). Children in both conditions reported increased understanding of parental illness attributable to participation in our intervention programs. There was a positive association between the amount of change children reported in their understanding of parental illness and the number of changes couples reported in child-related behaviors/attitudes (chi2(1) = 37.3; ie, parents who had changed the most in response to intervention had children who also changed the most). Finally, internalizing scores for all children decreased with increased time since intervention (chi2(1) = 7.3). In addition, females had higher internalizing scores than males (chi2(1) = 5.3). There was no significant effect of group on children's change in internalizing symptomatology (chi2(1) = 0.2).

CONCLUSIONS

We enrolled families with relatively healthy children, administered carefully designed preventive interventions that are manual-based and relatively brief, and found that these programs do have long-standing positive effects in how families problem solve around parental illness. Our results show significant benefits from both interventions. Moreover, changes in parents' perceptions translated directly into changes in children's own understanding of parental illness. Parental behavior and attitude changes and their connection to child changes in understanding identify an important mediating variable: family change. By increasing children's understanding of parental mood disorder, our interventions were found to promote resilience-related qualities in these children at risk. This presentation represents the first and only longitudinal primary prevention study of relatively healthy children at risk for psychopathology attributable to parental mood disorder and demonstrates a significant reduction in risk factors and increase in protective factors in these families over a long time interval--2(1/2) years. Our results provide support for a family-based approach to preventive intervention.