Psychotherapies at a Glance: Consensus Guideline-Recommended Psychotherapies for Adults With Psychiatric Disorders.

Clinical decision making by psychiatrists and informed consent by patients require knowledge of evidence-based psychotherapies (EBPs) and their indications. However, many mental health professionals are not versed in the empirical literature on EBPs or the consensus guideline recommendations derived from this literature. The authors compared rigorous national consensus guidelines for EBP treatment of DSM-defined adult psychiatric disorders-derived from well-conducted randomized controlled trials and meta-analyses and from expert opinions from the United States, United Kingdom, and Canada-to create the Psychotherapies-at-a-Glance tool. Recommended EBPs are cognitive-behavioral therapy, family therapy, contingency management, dialectical behavior therapy, eye movement desensitization reprocessing, interpersonal psychotherapy, mentalization-based treatment, motivational interviewing, peer support, problem-solving therapy, psychoeducation, short-term psychodynamic psychotherapy, and 12-step facilitation. The Psychotherapies-at-a-Glance tool summarizes the indications, rationales, and therapeutic tasks that characterize these differing psychotherapies and psychosocial treatments. The tool is intended for use in clinical teaching, treatment planning, and patient communications.

An Integrated Care Pathway for depression in adolescents: protocol for a Type 1 Hybrid Effectiveness-implementation, Non-randomized, Cluster Controlled Trial.

INTRODUCTION: Our group developed an Integrated Care Pathway to facilitate the delivery of evidence-based care for adolescents experiencing depression called CARIBOU-2 (Care for Adolescents who Receive Information 'Bout OUtcomes, 2nd iteration). The core pathway components are assessment, psychoeducation, psychotherapy options, medication options, caregiver support, measurement-based care team reviews and graduation. We aim to test the clinical and implementation effectiveness of the CARIBOU-2 pathway relative to treatment-as-usual (TAU) in community mental health settings. METHODS AND ANALYSIS: We will use a Type 1 Hybrid Effectiveness-Implementation, Non-randomized Cluster Controlled Trial Design. Primary participants will be adolescents (planned n = 300, aged 13-18 years) with depressive symptoms, presenting to one of six community mental health agencies. All sites will begin in the TAU condition and transition to the CARIBOU-2 intervention after enrolling 25 adolescents. The primary clinical outcome is the rate of change of depressive symptoms from baseline to the 24-week endpoint using the Childhood Depression Rating Scale-Revised (CDRS-R). Generalized mixed effects modelling will be conducted to compare this outcome between intervention types. Our primary hypothesis is that there will be a greater rate of reduction in depressive symptoms in the group receiving the CARIBOU-2 intervention relative to TAU over 24 weeks as per the CDRS-R. Implementation outcomes will also be examined, including clinician fidelity to the pathway and its components, and cost-effectiveness. ETHICS AND DISSEMINATION: Research ethics board approvals have been obtained. Should our results support our hypotheses, systematic implementation of the CARIBOU-2 intervention in other community mental health agencies would be indicated.

Predictors, Moderators, and Mediators Associated With Treatment Outcome in Randomized Clinical Trials Among Adolescents With Depression: A Scoping Review.

Importance: The application of precision medicine principles for the treatment of depressive disorders in adolescents requires an examination of the variables associated with depression outcomes in randomized clinical trials (RCTs). Objective: To describe predictors, moderators, and mediators associated with outcomes in RCTs for the treatment of depressive disorders in adolescents. Evidence Review: A scoping review of RCTs for the treatment of depression in adolescents was conducted. Databases searched included MEDLINE, Embase, APA PsycInfo, and CINAHL. Included publications tested predictors, moderators, and/or mediators associated with depression symptom outcomes (eg, symptom reduction, response, remission) in RCTs pertaining to the treatment of adolescents, ages 13 to 17 years. Predictors were defined as variables that were associated with depression outcomes, independent of treatment group. Moderators were defined as baseline variables that were associated with differential outcomes between treatment groups. Mediators were defined by a formal mediation analysis. In duplicate, variables were extracted and coded with respect to analysis type (univariable or multivariable), statistical significance, direction of effect size, reporting of a priori hypotheses, and adjustment for multiple comparisons. Aggregated results were summarized by variable domain and RCT sample. Findings: Eighty-one articles reporting on variables associated with outcomes across 33 RCTs were identified, including studies of biological (10 RCTs), psychosocial (18 RCTs), and combined (4 RCTs) treatments as well as a service delivery model (1 RCT). Fifty-three variable domains were tested as baseline predictors of depression outcome, 41 as moderators, 19 as postbaseline predictors, and 5 as mediators. Variable domains that were reported as significant in at least 3 RCTs included age, sex/gender, baseline depression severity, early response to treatment, sleep changes, parent-child conflict, overall psychopathology, suicidal ideation, hopelessness, functional impairment, attendance at therapy sessions, and history of trauma. Two publications reported a priori hypotheses and adjustment for multiple comparisons, both finding that baseline depression severity and family conflict were associated with poorer outcomes. Conclusions and Relevance: This review identified commonly researched variables requiring more scrutiny as well as underresearched variables to inform future study designs. Further efforts to discover predictors, moderators, and mediators associated with treatment response have great potential to optimize care for adolescents with depression.

Youth Perspectives on Seeking Psychotherapy: A Concurrent Mixed Methods Study.

OBJECTIVE: Psychotherapy is the recommended first line of treatment for depression among youth; however, few youth seek professional support. This study compares barriers and facilitators to seeking psychotherapy among both youth who have and have not seen a psychotherapist. The study further explores reasons youth discontinue psychotherapy. METHODS: A concurrent mixed methods study design was used. Eligible participants completed a survey (N=104) and a subset of participants completed a semi-structured interview (N=60). The survey and interview data were analyzed concurrently using a triangulation design. RESULTS: Surveys were conducted among youth who had experienced psychotherapy (N=53) and youth who had not (N=51). The majority of participants were female. Common reasons for not seeking psychotherapy included wanting to handle their problems on their own (87.6%), thinking their problems would improve on its own (87.6%), and not knowing who to see (74.3%). Several barriers were common across the two groups, including stigma, concerns about the therapeutic relationship, and a preference for self-management. Common facilitators included improving coping skills and addressing functional impairment. There was some overlap between the barriers to seeking psychotherapy and the reasons for discontinuing, although aging out of youth-oriented service also constituted a termination factor. CONCLUSIONS: : As this study highlights the multiple factors that influence youth's psychotherapy-seeking behavior, a widespread, multi-level approach is needed to address barriers and facilitators at the individual level, but also at the community, policy, and organizational levels. Strategies such as increasing service availability and quality are needed to increase service seeking and improve retention.

OBJECTIF: La psychothérapie est le traitement de première intention recommandé pour la dépression chez les jeunes, toutefois, peu de jeunes recherchent un soutien professionnel. La présente étude compare ce qui fait obstacle et ce qui facilite la recherche de psychothérapie chez les jeunes qui ont vu ou pas un psychothérapeute. L'étude explore en outre les raisons pour lesquelles les jeunes cessent la psychothérapie. MÉTHODES: Une étude concomitante à méthodes mixtes a été utilisée. Les participants admissibles ont rempli un sondage (N = 104) et un sous-ensemble de participants a répondu à une entrevue semi-structurée (N = 60). Les données du sondage et de l'entrevue ont été analysées simultanément à l'aide d'une méthode de triangulation. RÉSULTATS: Les sondages ont été menés auprès des jeunes qui avaient l'expérience de la psychothérapie (N = 53) et des jeunes qui ne l'avaient pas (N = 51). La majorité des participants était de sexe féminin. Les raisons communes de ne pas rechercher la psychothérapie étaient notamment vouloir régler leurs problèmes par eux-mêmes (87,6 %), croire que leurs problèmes allaient se régler d'eux-mêmes (87,6 %), et ne pas savoir qui consulter (74,3 %). Plusieurs obstacles étaient partagés par les deux groupes, dont les stigmates, des préoccupations quant à la relation thérapeutique, et une préférence pour la gestion autonome. Ce qui facilitait communément était notamment améliorer les compétences d'adaptation et remédier à la déficience fonctionnelle. Il y avait un chevauchement entre les obstacles à la recherche de psychothérapie et les raisons d'y mettre fin bien que le fait de vieillir hors de la zone des services pour les jeunes constitue un facteur d'abandon. CONCLUSIONS: Comme cette étude mentionne les multiples facteurs qui influencent la recherche de thérapie chez les jeunes, il faut une approche étendue multi-niveaux pour aborder obstacles et facilitateurs au niveau individuel, mais aussi à l'échelle communautaire, politique et organisationnelle. Des stratégies comme accroître la disponibilité et la qualité des services sont nécessaires pour hausser la recherche des services et améliorer le maintien en place.

Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis.

BACKGROUND: Problem-solving training is a common ingredient of evidence-based therapies for youth depression and has shown effectiveness as a versatile stand-alone intervention in adults. This scoping review provided a first overview of the evidence supporting problem solving as a mechanism for treating depression in youth aged 14 to 24 years. METHODS: Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for controlled trials of stand-alone problem-solving therapy; secondary analyses of trial data exploring problem-solving-related concepts as predictors, moderators, or mediators of treatment response within broader therapies; and clinical practice guidelines for youth depression. Following the scoping review, an exploratory meta-analysis examined the overall effectiveness of stand-alone problem-solving therapy. RESULTS: Inclusion criteria were met by four randomized trials of problem-solving therapy (524 participants); four secondary analyses of problem-solving-related concepts as predictors, moderators, or mediators; and 23 practice guidelines. The only clinical trial rated as having a low risk of bias found problem-solving training helped youth solve personal problems but was not significantly more effective than the control at reducing emotional symptoms. An exploratory meta-analysis showed a small and non-significant effect on self-reported depression or emotional symptoms (Hedges' g = - 0.34; 95% CI: - 0.92 to 0.23) with high heterogeneity. Removing one study at high risk of bias led to a decrease in effect size and heterogeneity (g = - 0.08; 95% CI: - 0.26 to 0.10). A GRADE appraisal suggested a low overall quality of the evidence. Tentative evidence from secondary analyses suggested problem-solving training might enhance outcomes in cognitive-behavioural therapy and family therapy, but dedicated dismantling studies are needed to corroborate these findings. Clinical practice guidelines did not recommend problem-solving training as a stand-alone treatment for youth depression, but five mentioned it as a treatment ingredient. CONCLUSIONS: On its own, problem-solving training may be beneficial for helping youth solve personal challenges, but it may not measurably reduce depressive symptoms. Youth experiencing elevated depressive symptoms may require more comprehensive psychotherapeutic support alongside problem-solving training. High-quality studies are needed to examine the effectiveness of problem-solving training as a stand-alone approach and as a treatment ingredient.

Forks in the road: Definitions of response, remission, recovery, and other dichotomized outcomes in randomized controlled trials for adolescent depression. A scoping review.

BACKGROUND: Definitions of dichotomous outcome terms, such as "response," "remission," and "recovery" are central to the design, interpretation, and clinical application of randomized controlled trials of adolescent depression interventions. Accordingly, this scoping review was conducted to document how these terms have been defined and justified in clinical trials. METHOD: Bibliographic databases MEDLINE, Embase, APA PsycInfo, and CINAHL were searched from inception to February 2020 for randomized controlled trials evaluating treatments for adolescent depression. Ninety-eight trials were included for data extraction and analysis. RESULTS: Assessment of outcome measurement instruments, metric strategies, methods of aggregation, and measurement timing, yielded 53 unique outcome definitions of "response" across 45 trials that assessed response, 47 unique definitions of "remission" in 29 trials that assessed remission, and 19 unique definitions of "recovery" across 11 trials that assessed recovery. A minority of trials (N = 35) provided a rationale for dichotomous outcomes definitions, often by citing other studies that used a similar definition (N = 11). No rationale included input from youth or families with lived experience. CONCLUSION: Our review revealed that definitions of "response," "remission," "recovery," and related terms are highly variable, lack clear rationales, and are not informed by key stakeholder input. These limitations impair pooling of trial results and the incorporation of trial findings into pragmatic treatment decisions in clinical practice. Systematic approaches to establishing outcome definitions are needed to enhance the impact of trials examining adolescent depression treatment.

How have predictors, moderators, mediators, treatment response, remission and resistance been defined and measured in randomised controlled trials for adolescent depression? A scoping review protocol.

INTRODUCTION: Among randomised controlled trials for depressed adolescents, the extent of variation in how depressive symptom outcomes are defined is unknown. The variability in which potential predictors of these outcomes are tested is also unclear. This paper is a protocol describing the methods of a planned scoping review. The scoping review will examine and summarise how change in depressive symptoms have been described in RCT treatment studies to date. This review will report the measures used to describe change in depressive symptoms and whether the measure was used as a continuous or binary outcome or both. This review will describe how dichotomous outcome terms are defined to describe change in depression severity. This review will also examine predictors, moderators and mediators of change in depressive symptoms within RCTs. METHODS AND ANALYSIS: In this paper, we describe the protocol for our scoping review. Following the format outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews, a research librarian will develop an operationalised search strategy, which we will apply to the MEDLINE, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature databases. We will search for papers from inception to 6 February 2020. A hand search for key citations will also be conducted. Investigator-raters will screen articles, first via the titles and abstracts and then through full-text reviews. We will include articles with randomised control design which assess the treatment of adolescents with major depressive disorder. We will systematically extract and synthesise prespecified data which includes: definition of depression used for participant inclusion, measures used to evaluate changes in depression, type of outcome used (continuous, binary or both), definitions of dichotomous terms to denote change in depression (eg, response, remission, recovery, etc) and reported predictors/moderators/mediators of change. ETHICS AND DISSEMINATION: Ethics approval is not required. Findings will be presented in journal publications and at conferences.

Systematic scoping review identifies heterogeneity in outcomes measured in adolescent depression clinical trials.

OBJECTIVES: The objective of this review was to identify outcomes reported in adolescent major depressive disorder trials and quantify outcome heterogeneity. STUDY DESIGN AND SETTING: Three databases were searched to identify trials evaluating therapies for major depressive disorder in adolescents published from 2008 to 2017. Identified outcomes were thematically grouped and mapped into predefined outcome core areas (physiological/clinical, life impact, resource use, adverse events, and death). Outcome heterogeneity was quantified using descriptive analyses. RESULTS: Of 2,686 articles yielded from the search, 42 articles describing 32 trials were included. A total of 434 outcomes measured using 118 different outcome measurement instruments were grouped into 86 unique outcome terms. Most outcome terms mapped to the physiological/clinical core area (62%), followed by the life impact (27%). Nearly half (45%) were reported in only a single trial each. Of 18 primary outcomes reported, 13 (72%) were each only reported in a single trial. "Depressive symptom severity", reported in 30 trials (94%), was measured using 19 different outcome measurement instruments. CONCLUSION: Heterogeneity exists in the outcomes and outcome measurement instruments used in adolescent depression trials. To enable reproducibility, comparison, and synthesis of trial results, a standard set of agreed-on outcomes and methods of measurement is needed.

Primary outcome reporting in adolescent depression clinical trials needs standardization.

BACKGROUND: Evidence-based health care is informed by results of randomized clinical trials (RCTs) and their syntheses in meta-analyses. When the trial outcomes measured are not clearly described in trial publications, knowledge synthesis, translation, and decision-making may be impeded. While heterogeneity in outcomes measured in adolescent major depressive disorder (MDD) RCTs has been described, the comprehensiveness of outcome reporting is unknown. This study aimed to assess the reporting of primary outcomes in RCTs evaluating treatments for adolescent MDD. METHODS: RCTs evaluating treatment interventions in adolescents with a diagnosis of MDD published between 2008 and 2017 specifying a single primary outcome were eligible for outcome reporting assessment. Outcome reporting assessment was done independently in duplicate using a comprehensive checklist of 58 reporting items. Primary outcome information provided in each RCT publication was scored as "fully reported", "partially reported", or "not reported" for each checklist item, as applicable. RESULTS: Eighteen of 42 identified articles were found to have a discernable single primary outcome and were included for outcome reporting assessment. Most trials (72%) did not fully report on over half of the 58 checklist items. Items describing masking of outcome assessors, timing and frequency of outcome assessment, and outcome analyses were fully reported in over 70% of trials. Items less frequently reported included outcome measurement instrument properties (ranging from 6 to 17%), justification of timing and frequency of outcome assessment (6%), and justification of criteria used for clinically significant differences (17%). The overall comprehensiveness of reporting appeared stable over time. CONCLUSIONS: Heterogeneous reporting exists in published adolescent MDD RCTs, with frequent omissions of key details about their primary outcomes. These omissions may impair interpretability, replicability, and synthesis of RCTs that inform clinical guidelines and decision-making in this field. Consensus on the minimal criteria for outcome reporting in adolescent MDD RCTs is needed.

A Way through the woods: Development of an integrated care pathway for adolescents with depression.

AIMS: Depression in adolescents is common and debilitating. Treatment approaches vary widely across clinics and may not reflect evidence-based care. Integrated care pathways (ICPs) are implementation tools to facilitate bridging the gap between rigorous but often complex clinical practice guidelines and what is actually practiced. We describe the development of an ICP for the treatment of Adolescents with Major Depressive Disorder (MDD-A) based on the best-available clinical practice guidelines and derived in collaboration with clinicians, administrators, youth partners and caregivers. METHODS: With clinician and health service manager input, we took the recommendations from a high quality clinical practice guideline (the National Institute of Health and Care Excellence Clinical Practice Guideline for Depression in Children and Young People) and translated them into an ICP. Feedback from youth partners and clinicians was iteratively incorporated into the current version of the pathway using a collaborative approach. RESULTS: The current iteration of the pathway at a Canadian tertiary care teaching hospital is described. All youth (and caregivers, if applicable) are offered a multi-family psychoeducation session, a 16-session Group Cognitive Behaviour Therapy and team reviews every 4 weeks that include measurement-based care. Conditional branches of the pathway include a medication algorithm and an 8-session group for caregivers. CONCLUSIONS: The resulting ICP provides a tool to facilitate bridging the gap between evidence and clinical practice.

Service provision for depressed children and youth: a survey of the scope and nature of services in Ontario.

BACKGROUND: The worldwide prevalence of depressive disorders among children and youth has been reported in ranges from just under 3% to over 10%. In Canada, 7% of youth report past year depression, which is higher than any other age demographic. Yet, many of these youth do not receive evidence based interventions, increasing their risk for serious lifetime consequences. To better understand low service use, it is crucial to map and evaluate current services. This study aimed to determine the scope and nature of services available to depressed children and youth, and compare services to best evidence treatment guidelines. METHODS: Several government and non-government resources were utilized to develop a new multi-sectoral database of depression services for children and youth across Ontario. An online survey was sent to program managers serving children/youth with depression, examining agency characteristics, populations served, services provided, patterns of service use, evaluation activities, and research priorities. RESULTS: 413 agencies with 869 program managers participated, representing mental health, addictions and other sectors. Age groups served included children up to 12 years of age (31%), adolescents aged 13-17 (70%) and transition aged youth (18-25 years) (81%). Over half of respondents worked in the mental health (43.4%) or mental health and addiction (24.4%) sectors. The most frequently provided services were assessment, psychotherapy, case management, and psychoeducation; the most common types of psychotherapy provided included cognitive behavioral therapy, social skills training, and solution-focused therapy. Psychotherapies are offered in widely varying formats, frequencies and durations. Discontinuation rates varied, with higher discontinuation among transition aged youth as compared to children. Respondents identified effective treatment, improving access, and reducing service gaps as top future research priorities. CONCLUSIONS: This study provides important new data on service provision and uptake for depressed children and youth. Comparing these results with best-evidence practice guidelines raises significant concerns about the services most commonly offered and their delivery formats. In addition, high early discontinuation rates raise questions about the service experiences of children, youth and their families. Other factors which may contribute to ongoing treatment engagement challenges include access barriers, service or client characteristics, and unintentional treatment impacts.

Interpersonal Psychotherapy: A Scoping Review and Historical Perspective (1974-2017).

BACKGROUND: Interpersonal Psychotherapy (IPT) is an affect- and relationally focused, time-limited treatment supported by research spanning >4 decades. IPT focuses on stressful interpersonal experiences of loss, life changes, disputes, and social isolation. It emphasizes the role of relationships in recovery. This scoping review describes, within a historical perspective, IPT's evolution as an evidence-supported treatment of psychiatric disorders. METHODS: English-language publications (n = 1119) identified via EMBASE, MEDLINE, PsycINFO, and Web of Science databases (1974-2017), augmented with manual reference searches, were coded for clinical focus, population demographics, format, setting, publication type, and research type. Quantitative and qualitative analyses identified IPT publications' characteristics and trends over four epochs of psychotherapy research. RESULTS: IPT literature primarily focused on depression (n = 772 articles; 69%), eating disorders (n = 135; 12%), anxiety disorders (n = 68; 6%), and bipolar disorder (n = 44; 4%), with rising publication rates and numbers of well-conducted randomized, controlled trials over time, justifying inclusion in consensus treatment guidelines. Research trends shifted from efficacy trials to effectiveness studies and population-based dissemination initiatives. Process research examined correlates of improvement and efficacy moderators. Innovations included global initiatives, prevention trials, and digital, web-based training and treatment. CONCLUSION: Sparked by clinical innovations and scientific advances, IPT has evolved as an effective treatment of psychiatric disorders across the lifespan for diverse patients, including underserved clinical populations. Future research to elucidate mechanisms of change, improve access, and adapt to changing frameworks of psychopathology and treatment planning is needed. IPT addresses the universal centrality of relationships to mental health, which is as relevant today as it was over 40 years ago.

Evaluating perceptions of the effectiveness of the community advisory panel model for enhancing service delivery to marginalized populations.

OBJECTIVE: The objective of this study was to evaluate perceptions of the effectiveness of the community advisory panels (CAPs) at St. Michael's Hospital, in Toronto, Canada. DESIGN AND SAMPLE: A qualitative design was employed. Participants included hospital staff, patients, Community Advisory Panel chairs, and key informants from community services in the St. Michael's Hospital catchment area. MEASURES: An online survey about awareness of the CAPs and CAP accomplishments; (2) Key informants interviews; and (3) Review of memos and meeting minutes of the CAPs to assess their impact in the hospital and the community. St. Michael's Hospital was the setting of the study. Descriptive statistics were generated for the survey data. Qualitative interview data were coded for major themes. Participants included hospital staff, patients, CAP chairs, and key informants from community services in the St. Michael's Hospital catchment area. RESULTS: Although the CAPs initiated and implemented an array of programs and services at St. Michael's Hospital, the visibility of the CAPs and their service to the hospital and community were very low. Themes that emerged from the semistructured interviews involved the visibility, effectiveness, and role of the CAPs in the hospital. CONCLUSIONS: Although the CAPs at St. Michael's Hospital appear to be an effective model for community responsiveness, the visibility of their work in the hospital and community was very low.