Depression is the leading cause of disability worldwide and commonly begins in adolescence. Prevention is one viable strategy for reducing the population burden of depression because most depressed adolescents do not receive specialty mental health treatment and because untreated depression is associated with enduring deleterious effects on interpersonal relationships, educational attainment, and occupational status.
Single-site studies have demonstrated the efficacy of an adaptation of the Coping with Depression for Adolescents intervention in preventing the onset of depression relative to usual care in adolescents with subsyndromal depressive symptoms and in those with a parental history of depression. These results were replicated in our 4-site randomized clinical trial of 316 high-risk adolescents randomly assigned to either an adaptation of the Coping with Depression for Adolescents (cognitive-behavioral prevention [CBP]) plus usual care or usual care alone, which found a lower incidence of depressive episodes at 9 and 33 months after enrollment in those who received CBP.
So begins a new paper that seeks a lofty goal: using a psychological intervention to prevent depression before it starts.
This week’s Reading: “Effect of a Cognitive-Behavioral Prevention Program on Depression 6 Years After Implementation Among At-Risk Adolescents: A Randomized Clinical Trial” by Dr. David A. Brent et al., which was published in the November JAMA Psychiatry.
In this paper, Brent et al. attempt something we often dream about in psychiatry – but are so rarely able to achieve: prevention. That alone would make this paper worth considering. But there’s more: the study features an incredible follow up period (a full six years) and a consideration of the parent, not just the at-risk adolescent. Pulling it together: this is a big paper in a big journal with a big result.
So, can we take an at risk population and, with therapy, prevent them from developing a major mental illness? This is what the study authors seek to find out. As they note early in the paper: “We hypothesized that those who received CBP would have a lower hazard of depression onsets and better developmental competence during emerging adulthood.”
You can find the paper here:
Here’s what they did:
· Adolescents were recruited at 4 sites (Vanderbilt University, Judge Baker Children’s Center/Children’s Hospital, University of Pittsburgh, Kaiser Permanente Center for Health Research). Recruitment took place between August 2003 and February 2006. Participants were between 13 and 17 years of age.
· Participants had at least one parent or caretaker (“index parent”) with a history of depression – that is, depression or dysthymia in the past 3 years, or 3 past depressive episodes, or 3 years of depression in the adolescents’ life.
· Adolescents had a previous depressive episode or current subsyndromal symptoms (based on CES-D).
· Adolescents were randomized to the usual care or CBP plus the usual care. The CBP program was a modified version of the Coping with Depression for Adolescents program, which emphasizes cognitive restructuring and problem solving, delivered in a structured, format. The core program was 8 weekly sessions, but also there were 6 monthly boosters sessions, too. (!) Information sessions were held for parents.
· Assessments were conducted at baseline, and then a several points: 3 (after the acute intervention), 9, 21, 33, and 75 months.
· Various scales were used, including the SCID, the CES-D, the CDRS-r, the GAS, and more. That said, the primary scale used was the 6-point Depression Symptom Rating (DSR). Interestingly, the results were then converted over to a scale – 0.00 (DSR score of 1 – that is, no depressive symptoms) to 1.00 (DSR score of ≥4 – that is, a depressive episode) – then multiplied by 7 to give a “days in depression” estimate.
· And parents were tested too. (!) This included a SCID, but also a self-reported depression scale, CES-D, at the start of the intervention.
· Various statistical analyses were performed, including a cox regression.
Here’s what they found:
· A total of 316 participants were recruited across the 4 sites.
· At month 75, 88% of these patients were assessed. The demographics of drop-outs were similar to those assessed (age, sex, race, ethnicity, sibling status, parent employment).
· Participants attended an average of 6.5 acute sessions of CPD (median, 8.0; range, 0-8) and an average of 3.8 booster sessions (median, 5.0; range, 0-6).
· The participants who received CBP had a significantly lower hazard ratio (or HR) for depression onset compared to the participants who received usual care (HR, 0.76). Participants in the CBP group had more depression free days (1893 vs. 1862) – but that result wasn’t statistically significant.
· A big moderator of result? Whether or not the index parent had depression at the start of the study (HR, 1.89). See the figures below – the figure on the left is for adolescents without a depressed parent; the figure on the right, for adolescents with a depressed parent.
· Interestingly, there was no significant difference in service usage between the CBP and usual care groups – not with respect to outpatient or inpatient treatment, nor juvenile court treatment.
The authors write:
We found a sustained benefit of CBP on the prevention of depression among at-risk youths more than 6 years after the implementation of the intervention. The strongest differential effects of CBP on the prevention of new onsets of depression occurred within the first 9 months from enrollment, which translated to longer term benefits for youths with respect to developmental competence during early adulthood.
Overall, these findings demonstrate the effectiveness of CBP for preventing depression and promoting competence…
A few thoughts:
1. This is a great paper: it focuses on prevention (how refreshing) and a non-psychopharmacologic approach (how refreshing).
2. The good news: they find robust results for the intervention. But there is a larger message here. At least for adolescents, psychiatric care involves more than just the patient. In an interview, Dr. Brent notes: “I think that one of the most important take-home messages from this study is that, while you can prevent depression, and the intervention works and you can have lasting benefits, you really should focus on the whole family and not just on the kids, which I guess seems pretty obvious.”
3. Should we appreciate more the preventative aspects of psychological therapies? In this paper, at-risk adolescents benefit. Add this to a host of papers showing that CBT and its variants help people. Consider this Swedish paper, published in JAMA Internal Medicine, which looked at people with cardiac issues over a 9-year period. The intervention group had CBT – and did markedly better.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.