Worldwide Prevalence and Disability From Mental Disorders Across Childhood and Adolescence: Evidence From the Global Burden of Disease Study

Importance

The period from childhood to early adulthood involves increased susceptibility to the onset of mental disorders, with implications for policy making that may be better appreciated by disaggregated analyses of narrow age groups.

Objective

To estimate the global prevalence and years lived with disability (YLDs) associated with mental disorders and substance use disorders (SUDs) across 4 age groups using data from the 2019 Global Burden of Disease (GBD) study.

Design, Setting, and Participants

Data from the 2019 GBD study were used for analysis of mental disorders and SUDs. Results were stratified by age group (age 5 to 9, 10 to 14, 15 to 19, and 20 to 24 years) and sex. Data for the 2019 GBD study were collected up to 2018, and data were analyzed for this article from April 2022 to September 2023.

Exposure

Age 5 to 9 years, 10 to 14 years, 15 to 19 years, and 20 to 24 years.

Main Outcomes and Measures

Prevalence rates with 95% uncertainty intervals (95% UIs) and number of YLDs.

Results

Globally in 2019, 293 million of 2516 million individuals aged 5 to 24 years had at least 1 mental disorder, and 31 million had an SUD. The mean prevalence was 11.63% for mental disorders and 1.22% for SUDs. For the narrower age groups, the prevalence of mental disorders was 6.80% (95% UI, 5.58-8.03) for those aged 5 to 9 years, 12.40% (95% UI, 10.62-14.59) for those aged 10 to 14 years, 13.96% (95% UI, 12.36-15.78) for those aged 15 to 19 years, and 13.63% (95% UI, 11.90-15.53) for those aged 20 to 24 years. The prevalence of each individual disorder also varied by age groups; sex-specific patterns varied to some extent by age. Mental disorders accounted for 31.14 million of 153.59 million YLDs (20.27% of YLDs from all causes). SUDs accounted for 4.30 million YLDs (2.80% of YLDs from all causes). Over the entire life course, 24.85% of all YLDs attributable to mental disorders were recorded before age 25 years.

Conclusions and Relevance

An analytical framework that relies on stratified age groups should be adopted for examination of mental disorders and SUDs from childhood to early adulthood. Given the implications of the early onset and lifetime burden of mental disorders and SUDs, age-disaggregated data are essential for the understanding of vulnerability and effective prevention and intervention initiatives.

Talking 'Bout Better outcomes for Adolescent Depression: Youth and Caregiver Perspectives on an Integrated Care Pathway for Depression

BACKGROUND

Depression is a common condition among adolescents, with rates continuing to rise. A gap exists between evidence-based recommendations for the treatment of depression and clinical practice. Integrated Care Pathways (ICPs) can help address this gap, but to date no study has examined how young people and their caregivers experience ICPs and whether these pathways are an acceptable form of care. This study used focus groups with adolescents, caregivers, and service providers to examine experiences of an ICP.

METHODS

Six individual interviews with service providers, four focus groups with youth, and two focus groups with caregivers were completed. Data was analyzed consistent with Braun & Clarke's Thematic Analysis Framework within an interpretivist paradigm.

RESULTS AND CONCLUSION

The study demonstrated that ICPs are acceptable to youth and their caregivers and that ICPs facilitate shared decision making between youth/caregivers and care providers. Findings also indicated that youth are willing to engage with ICPs particularly when there is a trusted clinician involved who helps interpret and tailor the ICP to the young person's experience. Further questions include how to best integrate these into the overall system and how to further tailor these pathways to support youth with diagnostic complexity and treatment resistance.

An Integrated Care Pathway for depression in adolescents: protocol for a Type 1 Hybrid Effectiveness-implementation, Non-randomized, Cluster Controlled Trial

INTRODUCTION

Our group developed an Integrated Care Pathway to facilitate the delivery of evidence-based care for adolescents experiencing depression called CARIBOU-2 (Care for Adolescents who Receive Information 'Bout OUtcomes, 2nd iteration). The core pathway components are assessment, psychoeducation, psychotherapy options, medication options, caregiver support, measurement-based care team reviews and graduation. We aim to test the clinical and implementation effectiveness of the CARIBOU-2 pathway relative to treatment-as-usual (TAU) in community mental health settings.

METHODS AND ANALYSIS

We will use a Type 1 Hybrid Effectiveness-Implementation, Non-randomized Cluster Controlled Trial Design. Primary participants will be adolescents (planned n = 300, aged 13-18 years) with depressive symptoms, presenting to one of six community mental health agencies. All sites will begin in the TAU condition and transition to the CARIBOU-2 intervention after enrolling 25 adolescents. The primary clinical outcome is the rate of change of depressive symptoms from baseline to the 24-week endpoint using the Childhood Depression Rating Scale-Revised (CDRS-R). Generalized mixed effects modelling will be conducted to compare this outcome between intervention types. Our primary hypothesis is that there will be a greater rate of reduction in depressive symptoms in the group receiving the CARIBOU-2 intervention relative to TAU over 24 weeks as per the CDRS-R. Implementation outcomes will also be examined, including clinician fidelity to the pathway and its components, and cost-effectiveness.

ETHICS AND DISSEMINATION

Research ethics board approvals have been obtained. Should our results support our hypotheses, systematic implementation of the CARIBOU-2 intervention in other community mental health agencies would be indicated.

Cognition and Educational Achievement in the Toronto Adolescent and Youth Cohort Study: Rationale, Methods, and Early Data

BACKGROUND

Both cognition and educational achievement in youths are linked to psychosis risk. One major aim of the Toronto Adolescent and Youth (TAY) Cohort Study is to characterize how cognitive and educational achievement trajectories inform the course of psychosis spectrum symptoms (PSSs), functioning, and suicidality. Here, we describe the protocol for the cognitive and educational data and early baseline data.

METHODS

The cognitive assessment design is consistent with youth population cohort studies, including the NIH Toolbox, Rey Auditory Verbal Learning Test, Wechsler Matrix Reasoning Task, and Little Man Task. Participants complete an educational achievement questionnaire, and report cards are requested. Completion rates, descriptive data, and differences across PSS status are reported for the first participants (N = 417) ages 11 to 24 years, who were recruited between May 4, 2021, and February 2, 2023.

RESULTS

Nearly 84% of the sample completed cognitive testing, and 88.2% completed the educational questionnaire, whereas report cards were collected for only 40.3%. Modifications to workflows were implemented to improve data collection. Participants who met criteria for PSSs demonstrated lower performance than those who did not on numerous key cognitive indices (p < .05) and also had more academic/educational problems.

CONCLUSIONS

Following youths longitudinally enabled trajectory mapping and prediction based on cognitive and educational performance in relation to PSSs in treatment-seeking youths. Youths with PSSs had lower cognitive performance and worse educational outcomes than youths without PSSs. Results show the feasibility of collecting data on cognitive and educational outcomes in a cohort of youths seeking treatment related to mental illness and substance use.

The Toronto Adolescent and Youth Cohort Study: Study Design and Early Data Related to Psychosis Spectrum Symptoms, Functioning, and Suicidality

BACKGROUND

Psychosis spectrum symptoms (PSSs) occur in a sizable percentage of youth and are associated with poorer cognitive performance, poorer functioning, and suicidality (i.e., suicidal thoughts and behaviors). PSSs may occur more frequently in youths already experiencing another mental illness, but the antecedents are not well known. The Toronto Adolescent and Youth (TAY) Cohort Study aims to characterize developmental trajectories in youths with mental illness and understand associations with PSSs, functioning, and suicidality.

METHODS

The TAY Cohort Study is a longitudinal cohort study that aims to assess 1500 youths (age 11-24 years) presenting to tertiary care. In this article, we describe the extensive diagnostic and clinical characterization of psychopathology, substance use, functioning, suicidality, and health service utilization in these youths, with follow-up every 6 months over 5 years, including early baseline data.

RESULTS

A total of 417 participants were enrolled between May 4, 2021, and February 2, 2023. Participants met diagnostic criteria for an average of 3.5 psychiatric diagnoses, most frequently anxiety and depressive disorders. Forty-nine percent of participants met a pre-established threshold for PSSs and exhibited higher rates of functional impairment, internalizing and externalizing symptoms, and suicidality than participants without PSSs.

CONCLUSIONS

Initial findings from the TAY Cohort Study demonstrate the feasibility of extensive clinical phenotyping in youths who are seeking help for mental health problems. PSS prevalence is much higher than in community-based studies. Our early data support the critical need to better understand longitudinal trajectories of clinical youth cohorts in relation to psychosis risk, functioning, and suicidality.

Neuroimaging and Biosample Collection in the Toronto Adolescent and Youth Cohort Study: Rationale, Methods, and Early Data

BACKGROUND

The Toronto Adolescent and Youth (TAY) Cohort Study will characterize the neurobiological trajectories of psychosis spectrum symptoms, functioning, and suicidality (i.e., suicidal thoughts and behaviors) in youth seeking mental health care. Here, we present the neuroimaging and biosample component of the protocol. We also present feasibility and quality control metrics for the baseline sample collected thus far.

METHODS

The current study includes youths (ages 11-24 years) who were referred to child and youth mental health services within a large tertiary care center in Toronto, Ontario, Canada, with target recruitment of 1500 participants. Participants were offered the opportunity to provide any or all of the following: 1) 1-hour magnetic resonance imaging (MRI) scan (electroencephalography if ineligible for or declined MRI), 2) blood sample for genomic and proteomic data (or saliva if blood collection was declined or not feasible) and urine sample, and 3) heart rate recording to assess respiratory sinus arrhythmia.

RESULTS

Of the first 417 participants who consented to participate between May 4, 2021, and February 2, 2023, 412 agreed to participate in the imaging and biosample protocol. Of these, 334 completed imaging, 341 provided a biosample, 338 completed respiratory sinus arrhythmia, and 316 completed all 3. Following quality control, data usability was high (MRI: T1-weighted 99%, diffusion-weighted imaging 99%, arterial spin labeling 90%, resting-state functional MRI 95%, task functional MRI 90%; electroencephalography: 83%; respiratory sinus arrhythmia: 99%).

CONCLUSIONS

The high consent rates, good completion rates, and high data usability reported here demonstrate the feasibility of collecting and using brain imaging and biosamples in a large clinical cohort of youths seeking mental health care.

Systematic Review: The Measurement Properties of the Suicidal Ideation Questionnaire and Suicidal Ideation Questionnaire-Jr

OBJECTIVE

The Suicidal Ideation Questionnaire (SIQ) and the Suicidal Ideation Questionnaire-Junior (SIQ-Jr) were designed to capture suicidal ideation in adolescents and are often used in clinical trials. Our aim was to identify and appraise the published literature with respect to the validity, reliability, responsiveness, and interpretability of the SIQ and SIQ-Jr.

METHOD

We conducted a systematic review following COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines to identify, appraise, and synthesize published literature on measurement properties and interpretability of the SIQ and SIQ-Jr. We searched MEDLINE, Embase, APA PsycINFO, CINAHL, Web of Science, and Scopus from inception to May 16, 2023, to identify sources relevant to our aim.

RESULTS

We identified 15 sources meeting our eligibility criteria. The body of literature did not meet COSMIN standards to make recommendations for use with regard to these measurement instruments.

CONCLUSION

Further research is needed, with a focus on content validity and structural validity, prior to recommending the SIQ and SIQ-Jr for use in clinical practice and in clinical trials. No specific grant funding was used for this review.

Suicidal behaviour and ideation among adolescents during the COVID-19 pandemic

Adolescence is a period of elevated risk for suicide, and mental health professionals expressed concerns that suicidal behaviours and suicide rates may increase among this age group during the COVID-19 pandemic. Adolescent suicide rates, attempts, and ideation during the pandemic varied depending on the country, data collection methodology, and population (e.g., general population vs. emergency department). Many pre-pandemic risk factors for suicidal behaviour or ideation were identified as risk factors during the pandemic; however, there was also some evidence that certain groups were disproportionately at risk, such as girls, and adolescents identifying as Black, Asian, American Indian/Alaska Native, or Asian/Pacific Islander. Given the trend of increased adolescent suicide in many countries over the past two decades, there is an ongoing need to direct resources toward prevention programs, screening, and evidence-based interventions for suicide risk.

Review: Adverse event monitoring and reporting in studies of pediatric psychosocial interventions: a systematic review

BACKGROUND

Adverse event monitoring in studies of psychotherapy is crucial to clinical decision-making, particularly for weighing of benefits and harms of treatment approaches. In this systematic review, we identified how adverse events are defined, measured, and reported in studies of psychosocial interventions for children with mental disorders.

METHOD

Medline, PsycINFO, Embase, ProQuest Dissertations and Theses Global, and the Cochrane Library were searched from January 2011-January 2023, and Google Scholar from January 2011-February 2023. English language experimental and quasi-experimental studies that evaluated the efficacy or effectiveness of psychosocial interventions for childhood mental disorders were included. Information on the definition, assessment, and report of adverse events was extracted using a checklist based on Good Clinical Practice guidelines.

RESULTS

In this review, 117 studies were included. Studies most commonly involved treating anxiety disorders or obsessive-compulsive disorder (32/117; 27%); 44% of the experimental interventions tested (52/117) were cognitive behavioral therapies. Adverse events were monitored in 36 studies (36/117; 31%) with a protocol used in 19 of these studies to guide monitoring (19/36; 53%). Twenty-seven different events were monitored across the studies with hospitalization the most frequently monitored (3/36; 8%). Event severity was fully assessed in 6 studies (17%) and partially assessed in 12 studies (33%). Only 4/36 studies (11%) included assessing events for cause.

CONCLUSIONS

To date, adverse events have been inconsistently defined, measured and reported in psychosocial intervention studies of childhood mental health disorders. Information on adverse events is an essential knowledge component for understanding the potential impacts and risks of therapeutic interventions.

How much is enough? Considering minimally important change in youth mental health outcomes

To make decisions in mental health care, service users, clinicians, and administrators need to make sense of research findings. Unfortunately, study results are often presented as raw questionnaire scores at different time points and regression coefficients, which are difficult to interpret with regards to their clinical meaning. Other commonly reported treatment outcome indicators in clinical trials or meta-analyses do not convey whether a given change score would make a noticeable difference to service users. There is an urgent need to improve the interpretability and relevance of outcome indicators in youth mental health (aged 12-24 years), in which shared decision making and person-centred care are cornerstones of an ongoing global transformation of care. In this Personal View, we make a case for considering minimally important change (MIC) as a meaningful, accessible, and user-centred outcome indicator. We discuss what the MIC represents, how it is calculated, and how it can be implemented in dialogues between clinician and researcher, and between youth and clinician. We outline how use of the MIC could enhance reporting in clinical trials, meta-analyses, clinical practice guidelines, and measurement-based care. Finally, we identify current methodological challenges around estimating the MIC and areas for future research. Efforts to select outcome domains and valid measurement instruments that resonate with youth, families, and clinicians have increased in the past 5 years. In this context, now is the time to define demarcations of changes in outcome scores that are clinically relevant, and meaningful to youth and families. Through the use of MIC, youth-centred outcome measurement, analysis, and reporting would support youth-centred therapeutic decision making.

CARIBOU-1: A pilot controlled trial of an Integrated Care Pathway for the treatment of depression in adolescents

Background

To co-ordinate a multidisciplinary team in the delivery of guideline recommendations using a measurement-based care framework, our group previously developed a care pathway for the treatment of depression in adolescents. Core components of the pathway were: assessment, education, cognitive-behavioural therapy, a caregiver intervention group, a medication algorithm, and monthly measurement-based care "team reviews" with the adolescent present. The aim of this study was to test the feasibility of conducting a controlled clinical trial of the pathway.

Method

We conducted a 20-week pilot controlled clinical trial of the care pathway relative to treatment as usual. Participants were adolescents (age 14-18) with a primary diagnosis of Major Depressive Disorder recruited from one of two outpatient psychiatric clinics at academic hospitals. Site of presentation was the method of allocation. Thirty-five youth were allocated to the pathway and 31 were allocated to treatment as usual. As this is a pilot study, trial feasibility outcomes were of primary interest, including clinician fidelity to the care pathway.

Results

Our target sample size was recruited over a 15-month time interval. Clinician fidelity and adolescent engagement in the care pathway components on a priori checklists were high (95% and 80%, respectively). We collected baseline and 20-week endpoint data for our primary outcome of the Children's Depression Rating Scale - Revised (CDRS-R) for 83% of the sample. On linear mixed effects modelling, we observed a linear decrease in CDRS-R across 4-week intervals up to the 20-week endpoint in both groups (β = -2.07; 95% CI -3.14 to -1.01).

Conclusion

A controlled clinical trial of a complex, multi-component intervention for the treatment of depression in adolescents is feasible. Given the need to find optimal strategies to deliver effective care for adolescents with depression, a definitive randomized controlled trial of the pathway is warranted.Trial is registered at Clinicaltrials.gov: NCT03428555.

Predictors, Moderators, and Mediators Associated With Treatment Outcome in Randomized Clinical Trials Among Adolescents With Depression: A Scoping Review

Importance

The application of precision medicine principles for the treatment of depressive disorders in adolescents requires an examination of the variables associated with depression outcomes in randomized clinical trials (RCTs).

Objective

To describe predictors, moderators, and mediators associated with outcomes in RCTs for the treatment of depressive disorders in adolescents.

Evidence Review

A scoping review of RCTs for the treatment of depression in adolescents was conducted. Databases searched included MEDLINE, Embase, APA PsycInfo, and CINAHL. Included publications tested predictors, moderators, and/or mediators associated with depression symptom outcomes (eg, symptom reduction, response, remission) in RCTs pertaining to the treatment of adolescents, ages 13 to 17 years. Predictors were defined as variables that were associated with depression outcomes, independent of treatment group. Moderators were defined as baseline variables that were associated with differential outcomes between treatment groups. Mediators were defined by a formal mediation analysis. In duplicate, variables were extracted and coded with respect to analysis type (univariable or multivariable), statistical significance, direction of effect size, reporting of a priori hypotheses, and adjustment for multiple comparisons. Aggregated results were summarized by variable domain and RCT sample.

Findings

Eighty-one articles reporting on variables associated with outcomes across 33 RCTs were identified, including studies of biological (10 RCTs), psychosocial (18 RCTs), and combined (4 RCTs) treatments as well as a service delivery model (1 RCT). Fifty-three variable domains were tested as baseline predictors of depression outcome, 41 as moderators, 19 as postbaseline predictors, and 5 as mediators. Variable domains that were reported as significant in at least 3 RCTs included age, sex/gender, baseline depression severity, early response to treatment, sleep changes, parent-child conflict, overall psychopathology, suicidal ideation, hopelessness, functional impairment, attendance at therapy sessions, and history of trauma. Two publications reported a priori hypotheses and adjustment for multiple comparisons, both finding that baseline depression severity and family conflict were associated with poorer outcomes.

Conclusions and Relevance

This review identified commonly researched variables requiring more scrutiny as well as underresearched variables to inform future study designs. Further efforts to discover predictors, moderators, and mediators associated with treatment response have great potential to optimize care for adolescents with depression.

Forks in the road: Definitions of response, remission, recovery, and other dichotomized outcomes in randomized controlled trials for adolescent depression. A scoping review

BACKGROUND

Definitions of dichotomous outcome terms, such as "response," "remission," and "recovery" are central to the design, interpretation, and clinical application of randomized controlled trials of adolescent depression interventions. Accordingly, this scoping review was conducted to document how these terms have been defined and justified in clinical trials.

METHOD

Bibliographic databases MEDLINE, Embase, APA PsycInfo, and CINAHL were searched from inception to February 2020 for randomized controlled trials evaluating treatments for adolescent depression. Ninety-eight trials were included for data extraction and analysis.

RESULTS

Assessment of outcome measurement instruments, metric strategies, methods of aggregation, and measurement timing, yielded 53 unique outcome definitions of "response" across 45 trials that assessed response, 47 unique definitions of "remission" in 29 trials that assessed remission, and 19 unique definitions of "recovery" across 11 trials that assessed recovery. A minority of trials (N = 35) provided a rationale for dichotomous outcomes definitions, often by citing other studies that used a similar definition (N = 11). No rationale included input from youth or families with lived experience.

CONCLUSION

Our review revealed that definitions of "response," "remission," "recovery," and related terms are highly variable, lack clear rationales, and are not informed by key stakeholder input. These limitations impair pooling of trial results and the incorporation of trial findings into pragmatic treatment decisions in clinical practice. Systematic approaches to establishing outcome definitions are needed to enhance the impact of trials examining adolescent depression treatment.

Eating, sleeping and moving recommendations in clinical practice guidelines for paediatric depression: umbrella review

BACKGROUND

Current first-line treatments for paediatric depression demonstrate mild-to-moderate effectiveness. This has spurred a growing body of literature on lifestyle recommendations pertaining to nutrition, sleep and exercise for treating paediatric depression.

AIMS

Paediatric depression clinical practice guidelines (CPGs) were reviewed for quality and to catalogue recommendations on nutrition, sleep and exercise made by higher-quality CPGs.

METHOD

Searches were conducted in Medline, EMBASE, PsycINFO, Web of Science and CINAHL, and grey literature CPGs databases for relevant CPGs. Eligible CPGs with a minimum or high-quality level, as determined by the Appraisal of Guidelines for Research and Evaluation, Second Edition instrument, were included if they were (a) paediatric; (b) CPGs, practice parameter or consensus or expert committee recommendations; (c) for depression; (d) the latest version and (e) lifestyle recommendations for nutrition, sleep or exercise. Key information extracted included author(s), language, year of publication, country, the institutional body issuing the CPG, target disorder, age group, lifestyle recommendation and the methods used to determine CPG lifestyle recommendations.

RESULTS

Ten paediatric CPGs for depression with a minimum or high-quality level contained recommendations on nutrition, sleep or exercise. Lifestyle recommendations were predominately qualitative, with quantitative details only outlined in two CPGs for exercise. Most recommendations were brief general statements, with 50% lacking supporting evidence from the literature.

CONCLUSIONS

Interest in lifestyle interventions for treatment in child and youth depression is growing. However, current CPG lifestyle recommendations for nutrition, sleep or exercise are based on expert opinion rather than clinical trials.

Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis

BACKGROUND

Problem-solving training is a common ingredient of evidence-based therapies for youth depression and has shown effectiveness as a versatile stand-alone intervention in adults. This scoping review provided a first overview of the evidence supporting problem solving as a mechanism for treating depression in youth aged 14 to 24 years.

METHODS

Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for controlled trials of stand-alone problem-solving therapy; secondary analyses of trial data exploring problem-solving-related concepts as predictors, moderators, or mediators of treatment response within broader therapies; and clinical practice guidelines for youth depression. Following the scoping review, an exploratory meta-analysis examined the overall effectiveness of stand-alone problem-solving therapy.

RESULTS

Inclusion criteria were met by four randomized trials of problem-solving therapy (524 participants); four secondary analyses of problem-solving-related concepts as predictors, moderators, or mediators; and 23 practice guidelines. The only clinical trial rated as having a low risk of bias found problem-solving training helped youth solve personal problems but was not significantly more effective than the control at reducing emotional symptoms. An exploratory meta-analysis showed a small and non-significant effect on self-reported depression or emotional symptoms (Hedges' g = - 0.34; 95% CI: - 0.92 to 0.23) with high heterogeneity. Removing one study at high risk of bias led to a decrease in effect size and heterogeneity (g = - 0.08; 95% CI: - 0.26 to 0.10). A GRADE appraisal suggested a low overall quality of the evidence. Tentative evidence from secondary analyses suggested problem-solving training might enhance outcomes in cognitive-behavioural therapy and family therapy, but dedicated dismantling studies are needed to corroborate these findings. Clinical practice guidelines did not recommend problem-solving training as a stand-alone treatment for youth depression, but five mentioned it as a treatment ingredient.

CONCLUSIONS

On its own, problem-solving training may be beneficial for helping youth solve personal challenges, but it may not measurably reduce depressive symptoms. Youth experiencing elevated depressive symptoms may require more comprehensive psychotherapeutic support alongside problem-solving training. High-quality studies are needed to examine the effectiveness of problem-solving training as a stand-alone approach and as a treatment ingredient.

Primary outcome reporting in adolescent depression clinical trials needs standardization

BACKGROUND

Evidence-based health care is informed by results of randomized clinical trials (RCTs) and their syntheses in meta-analyses. When the trial outcomes measured are not clearly described in trial publications, knowledge synthesis, translation, and decision-making may be impeded. While heterogeneity in outcomes measured in adolescent major depressive disorder (MDD) RCTs has been described, the comprehensiveness of outcome reporting is unknown. This study aimed to assess the reporting of primary outcomes in RCTs evaluating treatments for adolescent MDD.

METHODS

RCTs evaluating treatment interventions in adolescents with a diagnosis of MDD published between 2008 and 2017 specifying a single primary outcome were eligible for outcome reporting assessment. Outcome reporting assessment was done independently in duplicate using a comprehensive checklist of 58 reporting items. Primary outcome information provided in each RCT publication was scored as "fully reported", "partially reported", or "not reported" for each checklist item, as applicable.

RESULTS

Eighteen of 42 identified articles were found to have a discernable single primary outcome and were included for outcome reporting assessment. Most trials (72%) did not fully report on over half of the 58 checklist items. Items describing masking of outcome assessors, timing and frequency of outcome assessment, and outcome analyses were fully reported in over 70% of trials. Items less frequently reported included outcome measurement instrument properties (ranging from 6 to 17%), justification of timing and frequency of outcome assessment (6%), and justification of criteria used for clinically significant differences (17%). The overall comprehensiveness of reporting appeared stable over time.

CONCLUSIONS

Heterogeneous reporting exists in published adolescent MDD RCTs, with frequent omissions of key details about their primary outcomes. These omissions may impair interpretability, replicability, and synthesis of RCTs that inform clinical guidelines and decision-making in this field. Consensus on the minimal criteria for outcome reporting in adolescent MDD RCTs is needed.

Feasibility and clinical effects of theta burst stimulation in youth with major depressive disorders: An open-label trial

BACKGROUND

Conventional treatments for youth depression, such as antidepressants, have modest efficacy, side effects, and ongoing controversies regarding safety. Repetitive transcranial magnetic stimulation (rTMS), specifically theta burst stimulation (TBS), applied to the dorsolateral prefrontal cortex (DLPFC) has demonstrated efficacy for the treatment of depression in adults. However, the feasibility and clinical response to TBS for youth depression has yet to be explored.

METHODS

Twenty participants between the ages of 16 to 24 years old with MDD were recruited. The intervention consisted of 10 treatment sessions over the course of two weeks, in which participants received intermittent TBS and continuous TBS stimulation to the left and right DLPFC, respectively. Change in the Hamilton Rating Scale for Depression (HRSD-17) score was the primary outcome. Clinical assessments occurred at baseline, after the fifth treatment session, and within a week after treatment completion.

RESULTS

Of the twenty participants, eighteen received all TBS sessions, and seventeen completed all clinical assessments. There was a significant reduction in depressive symptoms following treatment completion (p < 0.001). Four of the twenty patients had more than 50% reduction in their depressive symptoms, two of whom achieved remission. All participants received and tolerated at least six daily TBS treatments with no major adverse events.

LIMITATIONS

Study was an uncontrolled, open-label design.

CONCLUSION

Ten sessions of TBS was feasible, well tolerated, and appeared to have clinical effects for the treatment of depressed youth. Future sham-controlled randomized trials are warranted to validate these findings in a larger cohort of youth depression.

Effectiveness of an Integrated Care Pathway for Adolescents with Depression: A Pilot Clinical Trial Protocol

OBJECTIVE

Our group aims to improve treatment response for adolescents with depression through the use of an Integrated Care Pathway (ICP) we developed using: (1) recommendations from a high quality Clinical Practice Guideline (CPG); and, (2) a measurement-based care framework.

METHOD

Pre-specified criteria will identify eligible adolescents in two outpatient hospital study sites. Study group allocation, to the ICP versus treatment as usual (TAU), is based on site of presentation. The primary clinical outcome is reduction of depression symptoms, assessed using the Childhood Depression Rating Scale - Revised (CDRS-R). Measures will be taken at baseline and every four weeks until 20 weeks of treatment has been offered.

RESULTS

Our overall hypothesis is that the ICP will be associated with greater improvement in depressive symptoms compared to TAU. Feasibility targets for this pilot trial include the following: recruitment of 30 participants per site over a 21-month period, 95% baseline assessment completion rates, 90% clinician adherence to the ICP in the intervention arm and 80% completion of the scheduled CDRS-R measures over the 20-week interval. Focus-group feedback from youth and parents will also produce qualitative information.

CONCLUSIONS

If feasibility targets are met, and preliminary results regarding clinical outcomes are promising, then a multi-center cluster RCT would be pursued.

An evaluation of clinical practice guidelines for self-harm in adolescents: The role of borderline personality pathology

Borderline personality disorder (BPD) is associated with high rates of self-harm, suicide attempts, and death by suicide in adults and adolescents. Screening and assessment of BPD in self-harming adolescents could be an important clinical intervention. The aim of this article was to identify whether existing clinical practice guidelines (CPGs) for the care of self-harm in adolescents considered the screening, diagnosis, and/or treatment of BPD. Previous work by Courtney, Duda, Szatmari, Henderson, and Bennett (2018) used Preferred Reporting Items for Systematic Reviews and Meta-Analyses methods to identify 10 CPGs relevant to self-harm in children and adolescents. In this study, the 10 CPGs were reviewed for content about screening, assessment, and/or treatment recommendations for adolescents with BPD. Out of the 10 CPGs, 4 acknowledged the association between BPD and self-harm in adolescents. There was minimal to no guidance provided in the CPGs regarding specific screening, assessment, or treatment strategies for BPD. This may be due to the lack of evidence for efficacy and effectiveness of screening for BPD, thereby limiting the development of guideline recommendations. Studies that examine the impact of screening for BPD in clinical settings are needed. In the interim, CPGs should cite the prevalence of BPD in adolescents who self-harm and reference research showing the benefit of treatment with dialectical behavioral therapy for self-harm and suicide attempts in youth with BPD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Systematic Review and Quality Appraisal of Practice Guidelines for Self-Harm in Children and Adolescents

This study aimed to systematically identify and appraise clinical practice guidelines (CPGs) relating to the assessment and management of suicide risk and self-harm in children and adolescents. Our research question is as follows: For young people (under 18 years old) presenting to clinical care with suicide ideation or a history of self-harm, what is the quality of up-to-date CPGs? Using the PRISMA format, we systematically identified CPGs meeting our inclusion and exclusion criteria. Subsequently, two independent raters conducted appraisals of the eligible CPGs using the Appraisal of Guidelines for Research and Evaluation II instrument. CPGs were then classified as "poor quality," "minimum quality," and "high quality" using operationally defined criteria developed a priori. We identified 10 eligible CPGs published or renewed between 2005 and May 2017. Only the long-term management of self-harm CPGs produced by the National Institute for Health and Care Excellence met "high-quality" criteria. Despite multiple options of CPGs published to choose from, only one was identified as "high quality," where bias is adequately minimized. Clinicians are advised to direct resources to implementing the "high-quality" CPG.

The Forest and the Trees: Evidence-Based Medicine in the Age of Information

In 2005, John Hamilton² wrote in the Journal on how best to practice evidence-based medicine, namely develop an answerable question from a clinical situation and then work your way down a hierarchy of evidence to identify the best available evidence to inform your clinical decision. He advised formulating each clinical question requiring the use of evidence as population, intervention, comparison, outcome, and timing (PICOT). Actually, Hamilton referred to PECOT, where "E" stands for "exposure," but we prefer the acronym Haynes et al.³ used. For Alyssa's query, the question would be, "Among adolescents with depression (P), is venlafaxine (I) more effective than placebo (C) in decreasing depressive symptoms (O) after 12 weeks (T)?" In this Translations article, we set out to answer the question, "What approach is currently recommended for clinicians searching for high-quality evidence to guide optimal clinical decision making?" When Hamilton wrote his piece, he focused on individual randomized controlled trials as the primary source of good evidence. However, in 2018, given the amount of information available, it has become increasingly clear that it is more helpful and efficient to start with high-quality evidence syntheses of primary studies (ie, systematic reviews [SRs], meta-analyses [MAs], and clinical practice guidelines [CPGs]) rather than with the individual primary studies. This means that clinicians now need to become versed in how to distinguish a high-quality synthesis from low-quality ones.

Adjunctive Trazodone and Depression Outcome in Adolescents Treated with Serotonin Re-uptake Inhibitors

OBJECTIVES

Recent published evidence suggests that adjunctive trazodone treatment may limit serotonin reuptake inhibitor (SRI) response in depressed adolescents in the context of a controlled trial. This study examined the effects of adjunctive trazodone on depression outcome in adolescents in a naturalistic treatment environment.

METHODS

We conducted a cohort study through chart review of a clinical sample. Patients in our sample were 15 to 18 years of age treated with either a selective serotonin reuptake inhibitor or serotonin and norepinephrine reuptake inhibitor. The treatment took place in the setting of a partial hospitalization program at a tertiary care centre from 2009-2014. The main outcome measure was the change in Beck Depression Inventory II (BDI-II) score from admission to discharge. We compared this outcome in patients who were exposed to adjunctive trazodone treatment compared to adolescents who did not receive trazodone in the final four weeks of the program.

RESULTS

Exposure to trazodone was significantly associated with non-response to treatment in our sample (n= 35; β₁= -7.76; 95% CI -0.52 to - 15.0; p<0.05; R² = 0.13). In exploring potential confounders, higher baseline BDI-II scores appeared to predict greater change in BDI-II scores from pre- to post-treatment.

CONCLUSION

In keeping with previous research, we found that trazodone exposure was associated with treatment non-response in adolescents taking SRIs. The findings should be interpreted cautiously since they are limited by small sample size. Future randomized controlled trials of trazodone in samples of adolescents taking SRIs for depression are warranted.

Clozapine Treatment and Cannabis Use in Adolescents with Psychotic Disorders - A Retrospective Cohort Chart Review

OBJECTIVES

To examine the association between clozapine treatment and frequency of cannabis use in adolescents with co-occurring psychotic and cannabis use disorder in a retrospective cohort chart review.

METHOD

We conducted a retrospective cohort chart review of patients diagnosed with a psychotic disorder and concurrent cannabis use disorder admitted to a tertiary care youth inpatient unit from 2010-2012. Longitudinal exposure and outcome data was coded month-by-month. Frequency of cannabis use was measured using a 7-point ordinal scale. Severity of psychosis was measured on a 3-point ordinal scale. Mixed effects regression modeling was used to describe the relationship between exposure and outcome variables.

RESULTS

Thirteen patients had exposure to clozapine and fourteen had no exposure to clozapine. Cannabis use decreased in patients treated with clozapine, compared to patients treated with other antipsychotics (OR 2.8; 95% CI 0.97-7.9). Compared to no medication, clozapine exposure was associated with significantly less cannabis use (OR 7.1; 95% CI 2.3-22.3). Relative to treatment with other antipsychotics, clozapine exposure was significantly associated with lower severity of psychotic symptoms (OR 3.7; 95% CI 1.2-11.8).

CONCLUSIONS

Clozapine may lead to decreased cannabis use and psychotic symptoms in adolescents with concurrent psychosis and substance use. Clinical trials are warranted.

Impact of Diagnosis Disclosure on Adolescents with Borderline Personality Disorder

OBJECTIVE

Establishing a diagnosis of Borderline Personality Disorder (BPD) in adolescents is often met with controversy, in part, due to potential stigmatizing effects. We wished to explore the adolescent patient experience of being diagnosed with BPD.

METHOD

The Impact of Diagnosis Scale (IODS) is a self-report measure we developed with questions targeting patients' subjective experience of receiving a diagnosis of BPD. The IODS was administered to 23 adolescents approximately one month after a diagnosis of BPD had been disclosed to them.

RESULTS

Twenty-one participants had analyzable data. The internal consistency of the measure demonstrated Cronbach's alpha of 0.66. We found wide variability in responses. Patients tended to view the diagnosis as an accurate representation of their symptoms.

CONCLUSION

The IODS represents a novel means by which clinicians might better appreciate how disclosing the diagnosis of BPD may impact a patient's understanding of one's difficulties.

Adapted Dialectical Behavior Therapy for Adolescents with Self-injurious Thoughts and Behaviors

The purpose of this study was to explore clinical changes observed in suicidal adolescents treated with an adapted form of Dialectical Behavior Therapy for adolescents (A-DBT-A) in a tertiary care setting. We conducted an open-label naturalistic study including 61 adolescents with self-injurious thoughts and behaviors and associated features of borderline personality disorder, who underwent a 15-week course of A-DBT-A. Pre- and post-treatment measures were administered, the primary outcome being the total score on the Suicidal Ideas Questionnaire. Self-harm, symptoms of borderline personality disorder, resiliency measures, predictors of response, and predictors of attrition were also explored. Among participants who completed post-treatment measures, we found a significant reduction in suicidal ideation (n = 31, p < 0.001). Secondary outcomes also suggested improvement. Baseline substance use predicted attrition (HR 2.51; 95% CI 1.03-6.14; p < 0.05), as did baseline impulsivity score on the Life Problems Inventory (HR 1.03; 95% CI 1.004-1.06; p < 0.05). Overall, we observed clinical improvements in adolescents receiving A-DBT-A.

Selective serotonin reuptake inhibitor and venlafaxine use in children and adolescents with major depressive disorder: a systematic review of published randomized controlled trials

OBJECTIVE

This review critiques published randomized placebo-controlled trials pertaining to the efficacy and safety of selective serotonin reuptake inhibitors (SSRIs) and venlafaxine in the treatment of major depressive disorder in children and adolescents.

METHOD

Medline was searched for articles meeting defined inclusion criteria. The following key terms were used: depressive disorders, antidepressive agents, fluoxetine, paroxetine, sertraline, citalopram, fluvoxamine, venlafaxine, child, and adolescent.

RESULTS

Six articles met inclusion criteria. Only 2 studies claim efficacy by significant results in primary outcomes; both have since been contested in further analysis. Not one study adequately examines safety, particularly with respect to whether a link exists between antidepressant use and induction of suicidal ideation or attempts.

CONCLUSION

Published studies on SSRI or venlafaxine use in children and adolescents are inconclusive with respect to safety and efficacy, owing to inappropriate claims of efficacy, lack of improvement in global functioning scores, nonstandardized data collection regarding adverse effects, exclusion of suicidal subjects in the recruitment process, grouping of children and adolescents together, small sample sizes, conflict of interest posed by pharmaceutical company sponsorship, and publishing bias. Future investigators should consider these factors when developing study designs.