Expanding Behavioral Activation to Depressed Adolescents: Lessons Learned in Treatment Development

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Abstract

Depression during adolescence represents a significant public health concern. It is estimated that up to 20% of adolescents experience an episode of depression that interferes with academic and social functioning and is associated with an increased risk for self-harm. Although significant progress has been made in the last decade in treating mental health problems in young people, effective treatment of depression has been harder to demonstrate. In this paper, we describe the application of a promising evidence-based treatment for adult depression, behavioral activation (BA), to the treatment of depressed adolescents. We briefly present the history and overview of the standard BA approach to adult depression and discuss the rationale for the extension of this approach to adolescent depression. We then focus in detail on the process of adapting the treatment to be adolescent-specific by presenting an early client whom we treated without success. The paper closes with a discussion of lessons learned from our experience of treatment failure, including the need to (a) take a more nuanced view of rumination with a focus on shaping brooding into reflective problem solving, (b) maintain a structured but flexible approach that allows for early introduction of treatment skills most relevant to the individual adolescent, (c) build in careful tracking of suicide risk, and (d) attend to family engagement. Implications for future research and clinical practice also are addressed.

Section snippets

History and Overview of BA

An initial dismantling study, comparing the cognitive and behavioral components of cognitive therapy (CT; Beck, Rush, Shaw, & Emery, 1979), found that the BA component was comparable to CT in treating depressed adults, both acutely and over a 2-year follow-up period (Gortner et al., 1998, Jacobson et al., 1996). Dimidjian and colleagues (2005) replicated and extended these results, finding that BA was comparable in efficacy to antidepressant medication in reducing depressive symptoms and

The Rationale for Extending BA to Depressed Adolescents

Two bodies of literature provide a strong foundation supporting the extension of BA to the treatment of depressed adolescents. First, clinical trial results reveal important limitations to current treatments for depressed adolescents. Second, studies investigating the developmental psychopathology of adolescents suggest that BA may better address the developmental characteristics of adolescence that may pose challenges to other therapeutic approaches.

Of the well-controlled studies of

Case Illustration

Tim1 was a bright, 17 year-old, European-American male. He was an only child and lived in a large metropolitan area with his biological parents. Tim was referred to the ATA project by his primary care physician after experiencing depressive symptoms over several months that had significantly

Reflections and Lessons Learned

The initial pilot trial with a small number of adolescents taught us a great deal about modifications that could potentially improve BA treatment with adolescents. The work with Tim, even though unsuccessful, helped us to identify changes needed in both the structure and content of the ATA approach. The lessons we learned from this initial pilot phase, as illustrated by the case of Tim, had implications for restructuring the treatment, and informed a significant revision of our approach and

Summary

The work outlined above was conducted within the framework of the deployment focused model of treatment development (Weisz, Jensen, & McLeod, 2005). This model attempts to break down the distinction between mental health services research and clinical trials research in an effort to bring new treatments into service settings in a timely fashion. Weisz and colleagues (2005) argue that treatments should be developed and tested through a sequence of studies designed to assure that developing

Acknowledgement

This research was funded by a grant from the National Institutes of Mental Health R34MH076956. Dr. Schloredt was also supported a Clinical Faculty Scholar Award from the Seattle Children’s Hospital Research Center. We wish to thank our research staff and the adolescents and parents who participated in the Adolescents Taking Action Project.

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