Efficacy of Behavioural Interventions for Depression in Adolescent - Research Paper Example

Critical Evaluation: Efficacy of Behavioural Interventions for Depression in Adolescent The prevalence of depression in adolescents is highly recognised in many research studies: a clinically significant episode of depression before reaching the age of 18 is found in a ratio of 1:5 young adolescents (Lewinsohn, et al. 1993, as cited in Weersing & Brent, 2006, p. 939); an 18% rate of depression is found from a large sample of 9,863 young students (Saluja, et al., 2004, as cited in Hayes, Bach & Boyd, 2010, p. 1); while other more studies found (Apter, Kronenberg, & Brent, 2005; Merry, McDowell, Hedrick, Bir, & Muller, 2004) clinical depression in adolescents at a rate between 3-8% (as cited in Hayes, Bach & Boyd, 2010, p. 1). Far more disturbing are the adverse effects of depression to adolescent’s growth and development such as, lower educational attainment, poor work history, substance abuse, and recurrent episodes of mood disorder (Rohde, Lewinsohn, & Seeley, 1994; Weissman et al., 1999; as cited in Weersing & Brent, 2006, p. 940). Moreover, depression is found to highly (40-95%) occur with comorbid mental health problems; most common of which are anxiety disorders and behavioural disorders (Parker & Roy, 2001, cited in Hayes, Bach, and Boyd, 2010, p. 1). With these annoying high prevalence and adverse effects of depression in young adolescents, varied studies have been pursued as to its best treatment with behavioural therapy taking much attention (Compton, et al., 2004, as cited Weersing & Brent, 2006, p. 939; Horowitz, Garber, Ciesla, Young & Mufson, 2007; Mufson, Weissman, Moreau & Garfinkel, 1999; Birmaher, et al., 2000; O’Kearney, Gibson, Christensen & Griffiths, 2006). As such, this study attempts to establish the efficacy of behavioural interventions for treating depression in adolescents by critically evaluating four studies on behavioural therapies with adolescent depression conducted in varied settings. A. Four Research Studies Evaluated 1. Efficacy of Interpersonal Psychotherapy for depressed adolescents (Mufson, Weissman, Moreau, & Garfinkel, 1999) This was a comparative study between randomized 12-week controlled clinical trial of IPT-A and clinical monitoring among forty-eight (48/57) average intelligent English-speaking adolescents (12-18 years old) with major depressive disorder (DSM-III-R and HRSD score of 15 or more), who were recruited from school-based clinics in New York between 1993 and 1996 with the informed consent of their legal guardians. These 48 participants were randomly assigned to either weekly IPT-A or clinical monitoring in a controlled 12-week clinical trial. Both groups were assessed bi-weekly of symptoms, social functioning, and social problem-solving skills by a ‘blind’ independent evaluator. The study expected that IPT-A will greatly decrease depressive symptoms in youths and will greatly improve their global and social functioning. The main outcome variables considered were diagnosis, symptoms, global and social functioning, and problem-solving skills and common adolescent developmental issues in IPT-A plus the issue of single-parent families, with the two treatment groups compared demographically (sex differences, ethnicity, mean age and parental education). Results of the study positively affirmed the target behaviour: A remarkable decrease in depressive symptoms and an impressive improvement in the overall social functioning and specific problem-solving are found in patients treated with IPT-A. (pp. 573-575) This showed the greater advantage of IPT-A over clinical monitoring in terms of low rate of attrition and high rate of attendance, the reduction of depressive symptom, and the improvement of social functioning, despite the study’s limitations more attributable to the control group. It also confirmed findings with adult studies that psychosocial treatment is far longer to take effect (Elkin, et al., 1989, as cited in p. 578). However, this positive result of the study cannot be generalised due to the smallness of the sample size. 2. Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder (Birmaher, et al., 2000) This is a naturalistic study that evaluated in two years the clinical outcome of a short-term (12-16 wks) randomized psychotherapy trial based on three group-designs: CBT, systemic behavioural family therapy (FT), and nondirective supportive therapy (ST) for a sample of 107 adolescents (13-18 years old) with depressive disorder, who were recruited through advertisements (75%) and from university clinics (25%). Patients were randomly assigned to CBT, FT, and ST. After which, 62 patients completing the psychotherapy trial received 2-4 ‘booster’ treatments in the same model, while 57 patients (53.3%) received an additional open treatment at separate periods for 1 or more problems: Depression (40), behaviour difficulties (14), and family conflicts (15). Also, 33/57 patients received treatment with selective serotonin reuptake inhibitors. Among the three behavioural interventions tested, CBT was expected to come out with better long-term result. The outcome variables included in the study were clinical severity, comorbid disorders, parental psychopathology, and family conflict. Results of the study noted CBT’s short-term efficacy only over the other 2 psychotherapies: A faster and complete reprieve from depressive symptoms and a 60% higher remission rate are found in patients intensely treated with CBT (p. 29). But, as to the long-term effects of the short-term psychotherapy in adolescents with depressive disorder, no significant differences across the 3 psychotherapy groups were detected as to their clinical outcome variables ‘(including depressive symptoms, functional status, and cognitive and family variables)’. All 3 intervention groups showed only limited efficacy on rates of remission, recovery (84%), recurrence (30%), or level of functioning. (pp. 29-34) In other words, the study only validated the short-term efficacy of the three behavioural interventions tested with CBT taking the lead, but it does not also say that these are not effective in long-term treatment, because the treatments were only tested in short-term period. One important finding though was: Most participants have ultimately recovered and have considerably improved their functional status, which could only suggest long-term treatment. Furthermore, although the target behaviour was not validated and although the limitations of the study rendered its result open-ended, the results still provide good insights on future research priorities in this area, because the study is done rigorously from the establishment of baseline data up to the measurement of outcome data. Meaning to say, whatever limited success the study had achieved these are good results. 3. Effects of a Cognitive-Behavioural Internet Programme on depression, vulnerability to depression & stigma in adolescent males: A school-based controlled trial (O’Kearney, Gibson, Christensen & Griffiths, 2006) This study was a 5-week school-based controlled trial that for the first time examined the efficacy of CB Internet Programme (MoodGYM) for depressive symptoms (CES-D measured), attributional style (internal-external, stable-unstable and global-specific), self-esteem (self-report 10-item RSES based) and beliefs about/ attitude to depression (9 items from the personal attitudes subscale of the Depression Stigma Scale), and on depression and depression-vulnerable status in a sample of 78/120 male adolescents (15-16 years old) all belonging to year 9 at a secondary school in Canberra, Australia. MoodGYM was examined in the context of personal development activities integrated within the school curriculum. The intervention group received self-paced interactive Internet program MoodGYM comprising 5 main modules; each to be completed in 30-60 minutes which patients undertook in their 45-minute tutor group (10-15 students) period in the school’s computer lab at a rate of one module/ week, whereas, the control group undertook private study, ad hoc discussion and physical activities, without discussing depression. After five-week trial, both groups resumed doing the school’s normal personal development activities. It was expected that the CB Internet Programme (MoodGYM) will reduce depressive symptoms and vulnerability to depression in terms of an improved positive attributional style and self-esteem in year 9 adolescent boys with depressive disorder. Results of the study show no significant differences for both groups, as each show small to medium effectiveness in different outcome variables, with the intervention group essentially showing slight advantage for depressive symptoms (Effect Size, ES50.34), attributional style (ES50.17), self-esteem (ES50.16) – the only sustained at follow-up, reduced risk of depression (9%) – though not sustained at follow-up, and reduced vulnerability to depression (17%) at post-treatment program over the controlled group, which advantage was noted only in beliefs about depression (ES50.40). (pp. 43-50) Although not too significant, the study still showed the relative efficacy of CB through Internet Programme (MoodGYM) in almost all outcome variables except for beliefs about depression. Being a new study using the internet as a medium, the study contributed more in opening further research to best utilize the internet with CB in treating depression in adolescents. This also showed the efficacy of CB in different settings. 4. Prevention of depressive symptoms in adolescents: A randomized trial of Cognitive-Behavioural & Interpersonal Prevention Program (Horowitz, Garber, Ciesla, Young & Mufson, 2007) This is a study that evaluated the efficacy CB and IPT–AST programs in an eight-week randomized trial of CB and IP prevention program for preventing depressive symptoms in 380 high school students in wellness classes in three suburban/rural high schools randomly assigned to two intervention groups and no-intervention control group. Participants were randomly assigned to the intervention groups: CB (112) and IPT-AST (99) and to the no-intervention control group (169) with each group undertaking eight 90-minute weekly sessions in small groups during wellness classes. The intervention groups were limited only to a maximum of 15 students per group. Three outcome variables seen as moderators were included: Initial levels of depressive symptoms, gender, and personality characteristics. The CB and IP therapy prevention programs were expected to come out far better than the no-intervention control group in preventing depressive symptoms. Results of the study showed both intervention groups (CB and IPT–AST) to be significantly better than the no-intervention control group in lowering the patients’ depressive symptoms, with the largest difference noted in patients with high levels of depressive symptoms at baseline. Sociotropy and achievement orientation for the whole sample were also noted to moderate the interventions’ effect. However, it was noted that the effects of the intervention were only short termed and were not sustained at 6-month follow-up. (pp. 693-702) It can be noted that the positive intervention effects on the entire sample although evidence to the efficacy of behavioural therapy may be seen in two ways: (1) these may have been magnified by high-risk patients; or (2) these may not be necessary caused by the behavioural intervention given, but possibly, it is more of an issue of having any intervention than nothing at all. What the study implied though in comparing two behavioural interventions with both producing positive effect is the utility of multiple approaches in preventing depressive symptoms in adolescents. B. Summary In various earlier studies, the significant prevalence of depression in adolescents and the retrogressive effects of depression in the youth’s total development as a growing person were consistently noted, not to say the comorbid mental health problems that usually occur with it, enough to make adolescent depression an issue much worth of concern in the field of psychiatry. With this disturbing information, varied interventions as to its treatment were experimented, with behavioural intervention showing the most positive effects. To establish the efficacy of behavioural interventions for the treatment of adolescent depression, four studies dealing with this problem were evaluated on their own merit. All four studies are short-term (ranging from 5 weeks to 16 weeks) psychotherapy trials in adolescent (ages range from 12-18 years old) patients diagnosed with depressive disorder (DSM-III-R) with 1 to 2-year follow-up. The behavioural interventions tested in different settings (with the Internet as the newest setting in testing CB for the treatment of depression) are cognitive-behavioural, interpersonal, family, and supportive therapies, with CB taking the most attention , as 3 studies dealt with its efficacy. In fact, Weisz, McCarty, and Valeri (2006) noted that of published psychotherapy trials CBT protocols were the most tested (80%) for adolescent depression (as cited in Weersing and Brent, 2006, p. 139). All 4 studies tested the interventions rigorously from the selection of participants – researchers made sure that participating patients do not suffer from other major mental health illnesses (actively suicidal, chronic medial illness, psychosis, on-going physical/sexual abuse, Bipolar I & II, conduct/eating/substance abuse disorder, obsessive compulsive disorder) that may be more of the cause rather than the effect of depression in adolescent, making the samples relatively ‘clean’ – to the measurement of outcomes – researchers made use of appropriate tools validated for their efficacy in testing depression (e.g. Beck Depression Inventory), functionality (e.g. Social Adjustment Scale-Self-report version), cognition (e.g. Coping Orientation in Problems Experienced Inventory), family environment (Family Assessment Device), sociotropy and achievement outcome (e.g. Sociotropy Achievement Scale for Children), and self-esteem (e.g. Depression Stigma Scale). Also, all four studies conducted their research with the full consent of the participants and their parents. Participants’ consent to undertake the trial is very important as this would determine their cooperation without which the study may fail. Related to this, a study on the impact of patient-therapist alliance as to the efficacy of CBT in adolescent depression conducted by Shirk, Gudmundsen, Kaplinski and McMakin (2008) complemented Kazdin, et al. (2005) findings in adolescents with disruptive behavior disorders, that alliance-outcome relations are significant in CBT (as cited in Shirk et al, 2008, p. 638). Limitations of the four studies fall generally on the specific implementation of the experimental design such as, sample (size and demography), control condition (substantial attrition, nature, absence of rigorous experimental control), setting (time-span, possible bias of patients), and data (missing and incomplete). Nevertheless, such did not alter the positive findings of the study, rather presented important improvement considerations to achieve maximum result. Results of the study generally favour the efficacy of behavioural interventions (especially CBT) for adolescent depression. However, these positive findings are limited by the following: (1) their short-term effect, suggesting the need for a follow-up behavioural intervention to lessen remission/recurrence; (2) inability to be generalized due to experimental design limitations; and (3) insufficiency to establish the efficacy of behavioural interventions due to limited outcome. This confirms previous study (Garber, 2006) finding that different intervention components dealing with risk and protective factors in varied areas should be initially included in any intervention programs meant to prevent depression (p. S115). The strength of the studies was seen more on areas they opened-up for further research to establish the strengths of behavioural interventions as treatment for adolescent depression. Findings from the four studies show that among the behavioural interventions tested, CBT consistently showed better effect over the other three behavioural interventions tested: IPT-A, systemic behavioral family therapy, and nondirective supportive therapy, supporting earlier findings (Brent, et al., as cited in Weersing & Brent, 2006, p. 951). Even with CBT through the Internet (MoodGYM ) also shows positive result despite the many limitations noted in its implementation. However, CBT’s advantage is only short-term; yet, it does not negate its efficacy, rather shows the longer duration of time the patient must be treated with it. Next to CBT is IPT-A, which efficacy is not too far from CBT. Nevertheless, one important observation supporting Garber’s (2006) recommendation is also noted, which is the usefulness of utilizing these behavioural interventions tested in combination, as each addresses different factors affecting adolescent depression. Meaning to say, as each behavioural intervention better addresses certain factors and risks in adolescent depression, an intervention program that comprehensively utilizes varied behavioural interventions is more effective. Furthermore, all four studies similarly noted the necessity of sustained intervention to further establish the efficacy of behavioural therapy for adolescent depression. Meaning to say, the longer and the more intense a patient undergoes behavioural therapy the better and sustaining the positive effect would be. Thus to gain maximum result, the necessity to improve the methodologies of each study is most important, especially with O’Kearney, et al.’s (2006) study: “Effects of a Cognitive-Behavioural Internet Programme on Depression, Vulnerability to Depression & Stigma in Adolescent Males: A School-based Controlled Trial”, which small number of participants and methodological obstacles made its results more instructive and tentative. Actually, although all four studies show positive effects of behavioural interventions in different settings with adolescent depression, their efficacy cannot be safely established as outcome variables considered are also different. Meaning, their results cannot be generalised as each are tested in different variables. With all the limitations and potentials noted in the behavioural interventions tested for depression in adolescents, future research on the following issues are recommended: (1) sustainability of the positive effects of behavioural interventions, as these have already shown short-term efficacy; (2) the efficacy of the behavioural interventions in specific risks and factors affecting adolescent depression, for example, systemic behavioral family therapy is more effective in decreasing family-conflict; (3) specifically for MoodGYM, the need to develop a multiple-school approach with rigorous clustered randomized design; (4) factors that may positively contribute to positive responses to behavioural interventions; (5) assess the efficacy and differences of different tools used in measuring depressive symptoms as to which each best measures methodologically or substantively or both; (6) examine other potential predictors or moderators of outcome; (7) a more improved methodology addressing the limitations noted in these studies that had limited their results; and (8) testing the efficacy of the different behavioural interventions as to gender. C. Conclusion Although results may have been limited, still, the efficacy of behavioural interventions, specifically CBT, IPT, FT, and ST, for depression in adolescents was affirmed by the four studies evaluated, with the identified limitations of the study meant more to maximise and establish the efficacy results rather than negate them. Since behavioural interventions were only tested in short-term trials, the necessity for follow-up interventions was seen in order to maintain positive results and to prevent remission/recurrence of depression in adolescents. With these, it could be deduced that behavioural interventions, especially CBT, are effective for adolescent depression in short-term basis necessitating follow-up intervention for sustained and maximum results. However, these findings cannot be generalised and cannot be established due to the studies’ methodological limitations. Moreover, these cannot also be compared with the efficacy of pharmacology. What this study could strongly recommend is the combined strengths of the behavioural interventions tested for adolescent depression. Read More