A Clinical Trial for Adolescent Depression: Predictors of Additional Treatment in the Acute and Follow-up Phases of the Trial

doi:10.1097/00004583-199903000-00012

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 38, Issue 3, March 1999, Pages 263-270

https://doi.org/10.1097/00004583-199903000-00012 Get rights and content

ABSTRACT

Objective

To examine the predictors of additional service use among participants in a clinical trial for depression.

Method

107 adolescents with DSM-III-R depression were randomly assigned to receive either cognitive-behavioral therapy, systemic behavioral family therapy, or nondirective supportive therapy for 12 to 16 weeks of acute treatment and followed up periodically for 24 months after the termination of acute treatment.

Results

More than half (53.3%) of the 107 randomized adolescents received additional treatment beyond that provided in the clinical trial, with a median time to additional treatment from intake of 7.2 months. The rates and times to additional treatment were similar in the 3 treatment groups, despite the superior efficacy of cognitive-behavioral therapy in the acute phase. The severity of the index depressive episode and comorbid dysthymia were a predictor of additional treatment in the acute phase, whereas in the follow-up period the severity of depressive symptomatology, the presence of disruptive disorders, and family problems predicted additional treatment.

Conclusions

Subsequent clinical trials for early-onset depression must focus on the entire depressive episode, rather than just the acute phase, to prevent depressive relapse. In addition, attendant family difficulties and comorbid behavioral problems must be addressed.

REFERENCES (44)

AT Beck et al.
Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation
Clin Psychol Rev
(1988)
B Birmaher et al.
Child and adolescent depression, part I: a review of the past ten years
J Am Acad Child Adolesc Psychiatry
(1996)
DA Brent et al.
Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression
J Am Acad Child Adolesc Psychiatry
(1998)
G Clarke et al.
Cognitive-behavioral group treatment of adolescent depression: prediction of outcome
Behav Ther
(1992)
GN Clarke et al.
Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents: a randomized trial of group cognitive intervention
J Am Acad Child Adolesc Psychiatry
(1995)
IM Goodyer et al.
Short-term outcome of major depression, I: comorbidity and severity at presentation as predictors of persistent disorder
J Am Acad Child Adolesc Psychiatry
(1997)
EM Gutterman et al.
Determinants for hospitalization from an emergency mental health service
J Am Acad Child Adolesc Psychiatry
(1993)
R Harrington et al.
Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves
J Am Acad Child Adolesc Psychiatry
(1998)
M Kovacs
Presentation and course of major depressive disorder during childhood and later years of the life span
J Am Acad Child Adolesc Psychiatry
(1996)
L Kroll et al.
Pilot study of continuation cognitive-behavioral therapy for major depression in adolescent psychiatric patients
J Am Acad Child Adolesc Psychiatry
(1996)

PM Lewinsohn et al.

Cognitive-behavioral treatment for depressed adolescents

Behav Ther

(1990)

L Mufson et al.

Interpersonal psychotherapy for depressed adolescents: a one-year naturalistic follow-up study

J Am Acad Child Adolesc Psychiatry

(1996)

H Orvaschel et al.

Retrospective assessment of prepubertal major depression with the Kiddie-SADS-E

J Am Acad Child Psychiatry

(1982)

M Sanford et al.

Predicting the one-year course of adolescent major depression

J Am Acad Child Adolesc Psychiatry

(1995)

P Vostanis et al.

A randomised controlled out-patient trial of cognitive-behavioural treatment for children and adolescents with depression: 9-month follow-up

J Affect Disord

(1996)

JF Alexander et al.

Functional Family Therapy

(1982)

American Psychiatric Association

Diagnostic and Statistical Manual of Mental Disorders 3rd edition-revised (DSM-III-R)

(1987)

JR Asarnow et al.

One-year outcomes of depressive disorders in child psychiatric in-patients: evaluation of the prognostic power of a brief measure of expressed emotion

J Child Psychol Psychiatry

(1993)

JR Asarnow et al.

Family-expressed emotion, childhood-onset schizophrenia spectrum disorders: is expressed emotion a nonspecific correlate of child psychopathology or a specific risk factor for depression?

J Abnorm Child Psychol

(1994)

AT Beck et al.

Cognitive Therapy of Depression

(1979)

AT Beck et al.

Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation

Am J Psychiatry

(1985)

AT Beck et al.

The measurement of pessimism: the Hopelessness Scale

J Consult Clin Psychol

(1974)

Cited by (79)

Precision therapeutics—personalizing psychological therapy for depression in adolescents
2022, Shaping the Future of Child and Adolescent Mental Health: Towards Technological Advances and Service Innovations
Several psychological therapy approaches have demonstrated effectiveness for improving adolescent depression, but many still do not benefit sufficiently. This chapter provides an overview of emerging methods being used to guide the selection of psychological therapy approaches for depression most likely to benefit an individual adolescent. We address testing moderators, attempting to match individuals to therapy based on their baseline characteristics, the use of machine learning approaches, Sequential Multiple Assignment Randomized Trial designs, and measurement-based care. We also introduce an alternative approach based on the general psychopathology factor and provide a demonstration in a large pragmatic trial sample. We note the importance of evaluating and implementing psychological therapies for adolescents in low- and middle-income countries. Lastly, we discuss the role of individual preferences and provide an overview of current issues and prospects in the field of personalized psychological therapy for adolescent depression.
Psychopharmacological Treatment for Depression in Children and Adolescents: Promoting Recovery and Resilience
2016, Positive Mental Health, Fighting Stigma and Promoting Resiliency for Children and Adolescents
Depressive disorders are prevalent in youth, and these conditions are not benign, often leading to significant impairment in functioning. Efficacious evidenced-based psychosocial and psychopharmacological treatments are available for depressed youth, but many do not receive sufficient treatment, in part due to stigma and other barriers to care. This chapter will provide a clinical framework for fighting stigma, enhancing wellness, and promoting resiliency in depressed youth by (1) summarizing the foundation necessary to assess depression and partner with youth and their families, (2) reviewing systematic psychopharmacological treatment strategies, and (3) focusing on achieving wellness, not simply symptom reduction.
Antidepressant use in children, adolescents, and young adults: 10 years after the food and drug administration black box warning
2014, Journal for Nurse Practitioners
Depression in children, adolescents, and young adults can jeopardize health status, well-being, and development. Almost a decade ago, risks and benefits of antidepressant use in this group prompted the Food and Drug Administration (FDA) to ask manufacturers to include black box warnings on antidepressant prescriptions. This article reviews initial FDA decisions related to black box warnings for antidepressants in youth, reviews effects of the warnings, and considers clinical implications of prescribing antidepressants for treatment of youth depression. Health care providers must consider the risks and benefits of initiating antidepressant medication treatment, closely monitoring adherence, patient outcomes, and suicidal ideation.
Examination of disruptive behavior outcomes and moderation in a randomized psychotherapy trial for mood disorders
2013, Journal of the American Academy of Child and Adolescent Psychiatry
Citation Excerpt :
This is the first RCT of a psychosocial treatment for children with depressive and bipolar disorders examining the effect of a psychosocial mood treatment on DBD symptoms and the impact of DBDs on mood outcome. The results are consistent with findings from RCTs of adolescents with depression, which indicated that DBDs did not affect treatment response.15-18 Although previous studies in youth have reported mixed findings for the effect of mood treatments on DBD symptoms, the present study suggests MF-PEP may offer some benefit for disruptive behaviors.19-27
Multifamily psychoeducational psychotherapy (MF-PEP) is an efficacious treatment for children with mood disorders. Given the comorbidity between disruptive behaviors and mood disorders, this study examined associations between disruptive behaviors and impairment, impact of MF-PEP on disruptive behaviors, and whether disruptive behaviors affected treatment response of mood symptoms.
Secondary analyses examined a randomized controlled trial of MF-PEP versus waitlist control (N = 165 children 8–11 years old with mood disorders and their parents). Comorbid behavioral diagnoses occurred in 97% of children. All participants continued treatment as usual.
Greater degree of disruptive behaviors was associated with worse mood symptoms and impairment. Between-group analyses examining outcome of disruptive behaviors were nonsignificant. Within-group analyses and between-group effect sizes suggested that MF-PEP was associated with decreases in attention-deficit/hyperactivity disorder (d = 0.39), oppositional defiant disorder (d = 0.30), and overall disruptive behavior symptoms (d = 0.30), but not conduct disorder symptoms. Baseline severity of disruptive behaviors did not affect treatment response of mood symptoms to MF-PEP.
MF-PEP is an effective intervention for children with mood disorders and provides some benefit for disruptive behaviors. Given that disruptive behavior severity does not affect children’s ability to experience improved mood symptoms, MF-PEP may be an important early intervention for children with comorbid mood and disruptive behavior disorders. Subsequent intervention targeting behavioral symptoms after improvement in mood may be beneficial. Studies examining treatment sequencing for children with comorbid mood and disruptive behavior disorders are needed. Clinical trial registration information—Family psychoeducation for children with mood disorders; http://clinicaltrials.gov; NCT00050557.
Depressed Adolescents Treated with Exercise (DATE): A pilot randomized controlled trial to test feasibility and establish preliminary effect sizes
2013, Mental Health and Physical Activity
Citation Excerpt :
There is an established history of successfully treating adolescents and children particularly with fluoxetine (Emslie et al., 2002, 2008; Emslie, Rush, Weinberg, Gullion, et al., 1997; Emslie, Rush, Weinberg, Kowatch, et al., 1997; Hughes et al., 2007), and fluoxetine now has FDA approval for use in children and adolescents. One consistent finding across the antidepressant studies of youth and adults is that around 30–40% do not respond to antidepressants (Birmaher & Brent, 1998; Brent, Kolko, Birmaher, Baugher, & Bridge, 1999). Many who do respond to treatment are left with residual symptoms of the illness (Kennard et al., 2006) such as poor quality of sleep and increased weight.
The Depressed Adolescents Treated with Exercise (DATE) study evaluated a standardized aerobic exercise protocol to treat nonmedicated adolescents that met DSM-IV-TR criteria for major depressive disorder. From an initial screen of 90 individuals, 30 adolescents aged 12–18 years were randomized to either vigorous exercise (EXER) (>12 kg/kcal/week [KKW]) or a control stretching (STRETCH) activity (<4 KKW) for 12 weeks. The primary outcome measure was the blinded clinician rating of the Children's Depression Rating Scale – Revised (CDRS-R) to assess depression severity and Actical (KKW) accelerometry 24hr/7days a week to assess energy expenditure and adherence. Follow-up evaluations occurred at weeks 26 and 52. The EXER group averaged 77% adherence and the STRETCH group 81% for meeting weekly target goals for the 12 week intervention based on weekly sessions completed and meeting KKW requirements. There was a significant increase in overall weekly KKW expenditures (p < .001) for both groups with the EXER group doubling the STRETCH group in weekly energy expenditure. Depressive symptoms were significantly reduced from baseline for both groups with the EXER group improving more rapidly than STRETCH after six weeks (p < .016) and nine weeks (p < .001). Both groups continued to improve such that there were no group differences after 12 weeks (p = .07). By week 12, the exercise group had a 100% response rate (86% remission), whereas the stretch group response rate was 67% (50% remission) (p = .02). Both groups had improvements in multiple areas of psychosocial functioning related to school and relationships with parents and peers. Anthropometry reflected decreased waist, hip and thigh measurements (p = .02), more so for females than males (p = .05), but there were no weight changes for either gender. The EXER group sustained 100% remission at week 26 and 52. The STRETCH group had 80% response and 70% remission rates at week 26 and by week 52 only one had not fully responded. The study provides support for the use of exercise as a non-medication intervention for adolescents with major depressive disorders when good adherence and energy expenditure (KKW) are achieved.
DATE: Depressed adolescents treated with exercise: Study rationale and design for a pilot study
2009, Mental Health and Physical Activity
There is an important need for non-medication interventions for depressed youth. The aim of this study is to evaluate the feasibility of using a standardized aerobic exercise regime to treat non-medicated clinically depressed adolescents based on adherence and completion rates, including 1) establishing effect sizes for the primary outcomes including the Chidren's Depression Rating Scale – Revised (CDRS-R) and Actical (energy expenditure data) as well as selected secondary outcomes; (e.g., Clinical Global Improvement, depression rating scales, exercise logs, attitudes), and 2) determining whether moderate to strenuous exercise (12 kcal/kg/week [KKW]) versus a control stretching activity (<4 KKW) for 12 weeks leads to a clinically meaningful reduction in depressive symptoms and/or improved psychosocial functioning. The challenge is to develop an exercise intervention that can motivate a typically sedentary depressed adolescent to exercise on a regular basis. The goal is to demonstrate that exercise alone can provide an important and effective non-medication intervention for adolescent depression. This paper reports on the rationale and design of a pilot study which aims to inform the design of a larger trial to evaluate the efficacy of aerobic exercise to treat adolescent depression. After describing the case for exercise within the broader context of the prevalence of adolescent depression and other treatments, the paper describes the intervention and procedures for data collection.

View all citing articles on Scopus

: This work was supported by NIMH grants MH-16500 and MH55123. The expert assistance of Patricia Nuss in preparation of the manuscript is appreciated. The authors gratefully acknowledge the following colleagues who aided in the design or conduct of this study: Robert Berchick, Ph.D., Carl Bonner, Ph.D., Mary Beth Boylan, M.A., Marlane Cully, M.Ed., Tom Devereaux, M.S.W., Terry Feinberg-Steinberg, M.S.W., Ellen Frank, Ph.D., Tom Gigliotti, M.S.W., Denise Harper, Diane Holder, M.S.W., Susan Hogarty, M.S.N., Satish Iyengar, Ph.D., Hope Jacobs, M.Ed., Ann Kolar, Ph.D., Marika Kovacs, Ph.D., Maureen Maber, M.S.W., James Matta, M.A., Barbara McDonnell, Apryl Miller, L.S.W., Elizabeth Perkins, M.S.W., Paul Pilkonis, Ph.D., Randy Phelps, Ph.D., Kim Poling, M.S.W., Claudia Roth, M.S.W., Matt Scaife, M.A., Joy Schweers, M.Ed., William Sherman, Jeannie Starzynski, M.S.W., Susan Wesner, M.S.N., Jerry Wessel, M.S.W., and Karen Woodall, Ph.D. Above all, the authors thank the patients and families for their participation.

View full text

ARTICLESA Clinical Trial for Adolescent Depression: Predictors of Additional Treatment in the Acute and Follow-up Phases of the Trial

ABSTRACT

Objective

Method

Results

Conclusions

Clin Psychol Rev

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Behav Ther

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Behav Ther

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Psychiatry

J Am Acad Child Adolesc Psychiatry

J Affect Disord

Functional Family Therapy

Diagnostic and Statistical Manual of Mental Disorders 3rd edition-revised (DSM-III-R)

One-year outcomes of depressive disorders in child psychiatric in-patients: evaluation of the prognostic power of a brief measure of expressed emotion

J Child Psychol Psychiatry

Family-expressed emotion, childhood-onset schizophrenia spectrum disorders: is expressed emotion a nonspecific correlate of child psychopathology or a specific risk factor for depression?

J Abnorm Child Psychol

Cognitive Therapy of Depression

Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation

Am J Psychiatry

The measurement of pessimism: the Hopelessness Scale

J Consult Clin Psychol

ARTICLES
A Clinical Trial for Adolescent Depression: Predictors of Additional Treatment in the Acute and Follow-up Phases of the Trial