Mark A. Reinecke

Cognitive-behavioral therapy of depression and depressive symptoms during adolescence: a review and meta-analysis.

OBJECTIVE Outcome studies support the effectiveness of cognitive-behavioral approaches for treating depression among adults. The effectiveness of these approaches for adolescents, however, has received less empirical attention. This article critically reviews the literature on cognitive-behavioral therapy with depressed and dysphoric adolescents. METHOD A meta-analysis was conducted to assess the effectiveness of these approaches and the stability of therapeutic gains. RESULTS Fourteen posttreatment-control comparisons and 10 follow-up-control comparisons resulted from six studies containing 217 subjects. The overall effect size posttreatment was -1.02, whereas the overall effect size at follow-up was -0.61. The effect sizes in both of these analyses were homogeneous and were supported by Fail-Safe-N calculations. CONCLUSION Results suggest the short- and long-term effectiveness of cognitive-behavioral approaches for treating depressive symptoms with this population.

Randomized clinical trial of an Internet-based depression prevention program for adolescents (Project CATCH-IT) in primary care: 12-week outcomes.

Objective: The authors sought to evaluate 2 approaches with varying time and complexity in engaging adolescents with an Internet-based preventive intervention for depression in primary care. The authors conducted a randomized controlled trial comparing primary care physician motivational interview (MI, 5–10 minutes) + Internet program versus brief advice (BA, 1–2 minutes) + Internet program. Setting: Adolescent primary care patients in the United States, aged 14 to 21 years. Participants: Eighty-four individuals (40% non-white) at increased risk for depressive disorders (subthreshold depressed mood >3–4 weeks) were randomly assigned to either the MI group (n = 43) or the BA group (n = 40). Main Outcome Measures: Patient Health Questionnaire-Adolescent and Center for Epidemiologic Studies Depression Scale (CES–D). Results: Both groups substantially engaged the Internet site (MI, 90.7% vs BA 77.5%). For both groups, CES–D-10 scores declined (MI, 24.0 to 17.0, p < .001; BA, 25.2 to 15.5, p < .001). The percentage of those with clinically significant depression symptoms based on CES–D-10 scores declined in both groups from baseline to 12 weeks, (MI, 52% to 12%, p < .001; BA, 50% to 15%, p < .001). The MI group demonstrated declines in self-harm thoughts and hopelessness and was significantly less likely than the BA group to experience a depressive episode (4.65% vs 22.5%, p = .023) or to report hopelessness (MI group of 2% vs 15% for the BA group, p = .044) by 12 weeks. Conclusions: An Internet-based prevention program in primary care is associated with declines in depressed mood and the likelihood of having clinical depression symptom levels in both groups. Motivational interviewing in combination with an Internet behavior change program may reduce the likelihood of experiencing a depressive episode and hopelessness.

Treatment for Adolescents with Depression Study (TADS): Rationale, design, and methods

OBJECTIVES A rapidly growing empirical literature on the treatment of major depressive disorder (MDD) in youth supports the efficacy of short-term treatment with depression-specific cognitive-behavioral therapy or medication management with a selective serotonin reuptake inhibitor. These studies also identify a substantial probability of partial response and of relapse, which might be addressed by more intensive, longer-term treatments. METHOD Funded by the National Institute of Mental Health, the Treatment for Adolescents With Depression Study (TADS) is a multicenter, randomized, masked effectiveness trial designed to evaluate the short-term (12-week) and long-term (36-week) effectiveness of four treatments for adolescents with MDD: fluoxetine, cognitive-behavioral therapy, their combination, and, acutely, pill placebo. A volunteer sample of 432 subjects aged 12-17 years (inclusive) with a primary DSM-IV diagnosis of MDD who are broadly representative of patients seen in clinical practice will enter the study. The primary dependent measures rated blindly by an independent evaluator are the Childrens Depression Rating Scale and, for responder analysis, a dichotomized Clinical Global Impressions-Improvement score. Consistent with an intent-to-treat analysis, all patients, regardless of treatment status, return for all scheduled assessments. RESULTS This report describes the design of the trial, the rationale for the design choices made, and the methods used to carry out the trial. CONCLUSION When completed, TADS will improve our understanding of how best to initiate treatment for adolescents with MDD.

Recovery and Recurrence Following Treatment for Adolescent Major Depression

CONTEXT Major depressive disorder in adolescents is common and impairing. Efficacious treatments have been developed, but little is known about longer-term outcomes, including recurrence. OBJECTIVES To determine whether adolescents who responded to short-term treatments or who received the most efficacious short-term treatment would have lower recurrence rates, and to identify predictors of recovery and recurrence. DESIGN Naturalistic follow-up study. SETTING Twelve academic sites in the United States. PARTICIPANTS One hundred ninety-six adolescents (86 males and 110 females) randomized to 1 of 4 short-term interventions (fluoxetine hydrochloride treatment, cognitive behavioral therapy, their combination, or placebo) in the Treatment for Adolescents With Depression Study were followed up for 5 years after study entry (44.6% of the original Treatment for Adolescents With Depression Study sample). MAIN OUTCOME MEASURES Recovery was defined as absence of clinically significant major depressive disorder symptoms on the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version interview for at least 8 weeks, and recurrence was defined as a new episode of major depressive disorder following recovery. RESULTS Almost all participants (96.4%) recovered from their index episode of major depressive disorder during the follow-up period. Recovery by 2 years was significantly more likely for short-term treatment responders (96.2%) than for partial responders or nonresponders (79.1%) (P < .001) but was not associated with having received the most efficacious short-term treatment (the combination of fluoxetine and cognitive behavioral therapy). Of the 189 participants who recovered, 88 (46.6%) had a recurrence. Recurrence was not predicted by full short-term treatment response or by original treatment. However, full or partial responders were less likely to have a recurrence (42.9%) than were nonresponders (67.6%) (P = .03). Sex predicted recurrence (57.0% among females vs 32.9% among males; P = .02). CONCLUSIONS Almost all depressed adolescents recovered. However, recurrence occurs in almost half of recovered adolescents, with higher probability in females in this age range. Further research should identify and address the vulnerabilities to recurrence that are more common among young women.

Remission and recovery in the Treatment for Adolescents with Depression Study (TADS): acute and long-term outcomes.

OBJECTIVE We examine remission rate probabilities, recovery rates, and residual symptoms across 36 weeks in the Treatment for Adolescents with Depression Study (TADS). METHOD The TADS, a multisite clinical trial, randomized 439 adolescents with major depressive disorder to 12 weeks of treatment with fluoxetine, cognitive-behavioral therapy, their combination, or pill placebo. The pill placebo group, treated openly after week 12, was not included in the subsequent analyses. Treatment differences in remission rates and probabilities of remission over time are compared. Recovery rates in remitters at weeks 12 (acute phase remitters) and 18 (continuation phase remitters) are summarized. We also examined whether residual symptoms at the end of 12 weeks of acute treatment predicted later remission. RESULTS At week 36, the estimated remission rates for intention-to-treat cases were as follows: combination, 60%; fluoxetine, 55%; cognitive-behavioral therapy, 64%; and overall, 60%. Paired comparisons reveal that, at week 24, all active treatments converge on remission outcomes. The recovery rate at week 36 was 65% for acute phase remitters and 71% for continuation phase remitters, with no significant between-treatment differences in recovery rates. Residual symptoms at the end of acute treatment predicted failure to achieve remission at weeks 18 and 36. CONCLUSIONS Most depressed adolescents in all three treatment modalities achieved remission at the end of 9 months of treatment.

The Treatment for Adolescents With Depression Study (TADS): outcomes over 1 year of naturalistic follow-up.

OBJECTIVE The Treatment for Adolescents With Depression Study (TADS) evaluates the effectiveness of fluoxetine, cognitive-behavioral therapy (CBT), and their combination in adolescents with major depressive disorder. The authors report effectiveness outcomes across a 1-year naturalistic follow-up period. METHOD The randomized, controlled trial was conducted in 13 academic and community sites in the United States. Stages I, II, and III consisted of 12, 6, and 18 weeks of acute, consolidation, and continuation treatment, respectively. Following discontinuation of TADS treatments at the end of stage III, stage IV consisted of 1 year of naturalistic follow-up. The participants were 327 subjects between the ages of 12 and 17 with a primary DSM-IV diagnosis of major depressive disorder. No TADS treatment was provided during the follow-up period; treatment was available in the community. The primary dependent measures, rated by an independent evaluator blind to treatment status, were the total score on the Childrens Depression Rating Scale-Revised and the rate of response, defined as a rating of much or very much improved on the Clinical Global Impressions improvement measure. RESULTS Sixty-six percent of the eligible subjects participated in at least one stage IV assessment. The benefits seen at the end of active treatment (week 36) persisted during follow-up on all measures of depression and suicidality. CONCLUSIONS In contrast to earlier reports on short-term treatments, in which worsening after treatment is the rule, the longer treatment in the TADS was associated with persistent benefits over 1 year of naturalistic follow-up.

Cost-Effectiveness of Treatments for Adolescent Depression: Results From TADS

OBJECTIVE While the evidence base for treatments for adolescent depression is building, little is known about the relative efficiency of such treatments. Treatment costs are a relevant concern given the competing demands on family and health care budgets. The authors evaluated the cost-effectiveness of three active treatments among adolescents with major depressive disorder. METHOD Volunteers (N=439) ages 12 to 18 with a primary diagnosis of major depressive disorder participated in a randomized, controlled trial conducted at 13 U.S. academic and community clinics from 2000 to 2004. Subjects included those participants who did not drop out and had evaluable outcome and cost data at 12 weeks (N=369). Subjects were randomly assigned to 12 weeks of either fluoxetine alone (10-40 mg/day), CBT alone, CBT combined with fluoxetine (10-40 mg/day), or placebo (equivalent to 10-40 mg/day). Both placebo and fluoxetine were administered double-blind; CBT alone and CBT in combination with fluoxetine were administered unblinded. Societal cost per unit of improvement on the Childrens Depression Rating Scale-Revised and cost per quality-adjusted life year (QALY) were compared. RESULTS Results ranged from an incremental cost over placebo of

Social problem-solving among adolescents treated for depression.

24,000 per QALY for treatment with fluoxetine to

Relative cost-effectiveness of treatments for adolescent depression: 36-week results from the tads randomized trial

123,000 per QALY for combination therapy treatment. The cost-effectiveness ratio for CBT treatment was not evaluable due to negative clinical effects. The models were robust on a variety of assumptions. CONCLUSIONS Both fluoxetine and combination therapy are at least as cost-effective in the short-term as other treatments commonly used in primary care (using a threshold of

Dysfunctional Attitudes Scale Perfectionism: A Predictor and Partial Mediator of Acute Treatment Outcome among Clinically Depressed Adolescents

125,000/QALY). Fluoxetine is more cost-effective than combination therapy after 12 weeks of treatment.