RESUMO
BACKGROUND: Youth anxiety and depression have long been combined within the empirically derived internalizing syndrome. The two conditions show substantial comorbidity, symptom co-occurrence, and overlap in treatment procedures, but paradoxically diverge in psychotherapy outcomes: strong, positive effects for anxiety and weak effects for depression. METHODS: Drawing on recent research, we examine candidate explanations for this paradox to help identify strategies for addressing it by improving outcomes for youth depression. RESULTS: Candidate explanations include that youth depression, compared with youth anxiety, has more varied comorbidities and more heterogeneous symptom combinations, has greater uncertainty regarding mediators and mechanisms of change, is treated with more complex and potentially confusing protocols, and has characteristics that may impede client engagement. Candidate strategies for shrinking the psychotherapy effectiveness gap include personalizing through transdiagnostic modular treatment, simplifying therapy by focusing on empirically supported principles of change, developing effective strategies for engaging family members as intervention allies, using shared decision-making to inform clinical decisions and boost client engagement, capitalizing on youth-friendly technological advances, and shortening and digitizing treatments to enhance their accessibility and appeal. CONCLUSIONS: Recent advances suggest explanations for the internalizing paradox, which in turn suggest strategies for shrinking the youth anxiety-depression psychotherapy outcome gap; these form an agenda for a promising new era of research.
Assuntos
Ansiedade , Depressão , Humanos , Adolescente , Depressão/terapia , Ansiedade/terapia , Transtornos de Ansiedade/terapia , Psicoterapia/métodos , ComorbidadeRESUMO
Intervention scientists have published more than 600 randomized controlled trials (RCTs) of youth psychotherapies. Four decades of meta-analyses have been used to synthesize the RCT findings and identify scientifically and clinically significant patterns. These meta-analyses have limitations, noted herein, but they have advanced our understanding of youth psychotherapy, revealing (a) mental health problems for which our interventions are more and less successful (e.g., anxiety and depression, respectively); (b) the beneficial effects of single-session interventions, interventions delivered remotely, and interventions tested in low- and middle-income countries; (c) the association of societal sexism and racism with reduced treatment benefit in majority-girl and majority-Black groups; and, importantly, (d) the finding that average youth treatment benefit has not increased across five decades of research, suggesting that new strategies may be needed. Opportunities for the future include boosting relevance to policy and practice and using meta-analysis to identify mechanisms of change and guide personalizing of treatment.
Assuntos
Psicoterapia , Telemedicina , Feminino , Humanos , Adolescente , Ansiedade , Transtornos de AnsiedadeRESUMO
OBJECTIVE: Understanding the efficacy of each module of cognitive behavioral therapy (CBT) may inform efforts to improve outcomes for youth depression, but effects of specific modules have been difficult to examine. Idiographic interrupted time series models offer a robust way to estimate module effects on an individual's symptoms. This study examined the association of specific CBT modules for depression on internalizing symptoms among depressed youths who received modular CBT in a randomized trial. METHODS: Individual models were created for three youths who met study criteria. Youths completed weekly symptom reports, and clinicians completed records of modules delivered. First order auto-regressive models quantified the change in average internalizing symptom severity between pre- and post-module delivery. RESULTS: All youths had 1-3 modules that were significantly associated with symptom reduction and 1-3 modules associated with deterioration. The 5 modules associated with improvement in at least one youth also lacked association (engagement, relaxation, cognitive reframing), or were associated with worsening (activity selection, parent psychoeducation) in others. Seven modules showed no measurable benefit, or detriment to any youth. CONCLUSION: This study demonstrated that specific modules have measurable effects, but more work is needed to build an evidence base of specific module effects to inform treatment personalization for youth depression.
Assuntos
Terapia Cognitivo-Comportamental , Depressão , Humanos , Adolescente , Depressão/terapia , Resultado do Tratamento , Pais/psicologiaRESUMO
Suicidal thoughts and behaviors among juvenile justice populations are elevated. However, the characteristics of justice-involved youth who consider and attempt suicide are not well understood. This study examined suicidal ideation and attempt with first-time, preadjudicated diverted youth, and the relationship with commonly associated risk factors. The sample included 135 youth (50% male, M age = 14.48) that provided complete responses to self-reported lifetime suicidal ideation and attempt items. Analyses examined relationships between suicidal ideation/attempt and mental health, child welfare involvement, delinquency, self-cutting, and substance use. First time, preadjudicated diverted youth reported high rates of lifetime suicidal ideation (27%) and attempt (17%). Suicidal ideation and attempt were associated with sexually minoritized status and self-cutting, while child welfare involvement was only associated with suicidal ideation. This high-risk population would benefit from refined suicide screening and prevention services not always available to justice-involved youth living in the community.
RESUMO
Objectives: We examined the prevalence of sexting, related motivations, demographics, and association with behavioral health problems among justice-involved adolescents. Hypotheses: We hypothesized positive associations between sexting and sexual risk, substance use, delinquency, and mental health problems. Methods: Participants were 307 community-supervised justice-involved adolescents with a first-time offense (Mage =14.50 years, 44.6% female) and their caregivers. Adolescents answered questions on technology use and sexting by sending, receiving, or forwarding sexually suggestive text messages and images (pictures or videos). They also completed measures of recent (past 4-month) sexual activity, unprotected sex, cigarette, alcohol, marijuana, and other drug use, and delinquency; current trauma symptoms, internalizing problems, and adaptive functioning. Results: Prevalence of sexting were 37.7% (lifetime overall; 17.0% sent texts; 17.4% sent images) and 29.5% (past-year overall; 12.8% sent texts; 13.6% sent images). Sexts were commonly sent as presents to partners, in response to sexts received, or to have fun. "Sexters" were older than "non-sexters" and more likely to identify as lesbian, gay, bisexual, or questioning. Past-year sexting was significantly associated with recent sexual activity; unprotected sex; alcohol use and days of use; marijuana and other drug use; delinquency and variety of delinquent acts; and elevated trauma symptoms and internalizing problems. Conclusions: Sexting is prevalent among adolescents with a first-time offense and co-occurs with multiple behavioral health needs. Intervention for this population may be informed by routinely assessing sexting in community settings. Familiarity with local reporting laws could help clinicians navigate the legal implications of sexting among adolescents with existing justice-system involvement.
RESUMO
An emerging trend in youth psychotherapy is measurement-based care (MBC): treatment guided by frequent measurement of client response, with ongoing feedback to the treating clinician. MBC is especially needed for treatment that addresses internalizing and externalizing problems, which are common among treatment-seeking youths. A very brief measure is needed, for frequent administration, generating both youth- and caregiver-reports, meeting psychometric standards, and available at no cost. We developed such a measure to monitor youth response during psychotherapy for internalizing and externalizing problems. Across 4 studies, we used ethnically diverse, clinically relevant samples of caregivers and youths ages 7-15 to develop and test the Behavior and Feelings Survey (BFS). In Study 1, candidate items identified by outpatient youths and their caregivers were examined via an MTurk survey, with item response theory methods used to eliminate misfitting items. Studies 2-4 used separate clinical samples of youths and their caregivers to finalize the 12-item BFS (6 internalizing and 6 externalizing items), examine its psychometric properties, and assess its performance in monitoring progress during psychotherapy. The BFS showed robust factor structure, internal consistency, test-retest reliability, convergent and discriminant validity in relation to three well-established symptom measures, and slopes of change indicating efficacy in monitoring treatment progress during therapy. The BFS is a brief, free youth- and caregiver-report measure of internalizing and externalizing problems, with psychometric evidence supporting its use for MBC in clinical and research contexts.
Assuntos
Comportamento Infantil/psicologia , Emoções/fisiologia , Psicometria/métodos , Psicoterapia/métodos , Adolescente , Criança , Feminino , Humanos , Estudos Longitudinais , Masculino , Reprodutibilidade dos Testes , Inquéritos e Questionários , Resultado do TratamentoRESUMO
We examined whether pre-existing parent psychological distress moderated juvenile offenders' substance use, sexual risk, and mental health outcomes in a randomized trial. Forty-seven parent-adolescent dyads received either Family-based Affect Management Intervention (FAMI) for adolescent substance use and HIV prevention or adolescent-only Health Promotion Intervention (HPI). Parents' self-reported distress at baseline significantly moderated adolescents' self-reported marijuana use and alcohol use but not other outcomes at 3 months postintervention, producing crossover interactions. FAMI outperformed HPI when parents reported high-level distress, whereas HPI outperformed FAMI when parents reported low-level distress. This finding that the relative efficacy of interventions depends on the severity of parent psychological distress could inform efforts to match substance-using, justice-involved adolescents with the intervention most likely to benefit them.
Assuntos
Regulação Emocional , Delinquência Juvenil/prevenção & controle , Pais/psicologia , Angústia Psicológica , Adolescente , Consumo de Bebidas Alcoólicas/epidemiologia , Feminino , Humanos , Masculino , Uso da Maconha/epidemiologia , Psicologia do Adolescente , Comportamento Sexual/estatística & dados numéricos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs). The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health. FINDINGS: The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths' environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics. CONCLUSION: The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians' use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families.
Assuntos
Psiquiatria Infantil/métodos , Medicina de Precisão/métodos , Pesquisa Biomédica/métodos , Criança , Humanos , Transtornos Mentais/terapiaRESUMO
The modest efficacy of psychological interventions for youth depression, including evidence-based psychotherapies (EBPs), suggests a question: Do the therapy components match the coping strategies youths find helpful when dealing with depressed mood? Answering this question may help strengthen treatments. We asked 105 middle schoolers across a range of depression symptom levels to identify the coping strategies they used when they felt sad (habitual responses) and those that made them feel better (perceived-effective responses). Habitual and perceived-effective responses were coded for resemblance to EBPs, and each youth's habitual responses were coded for their match to the youth's perceived-effective responses. Most perceived-effective responses (92.6%) matched EBP components (most frequent: Behavioral Activation); however, 65.0% of the EBP components did not match any youth's habitual or perceived-effective responses. Youths at higher depression symptom levels were significantly more likely than low-symptom youths to report (a) habitual responses that did not match EBP components, (b) habitual responses that did not match their own perceived-effective responses, and (c) perceiving no effective response. The higher their depression symptom level, the less likely youths were to use strategies identified by researchers and perceived by themselves as effective, and the less likely they were to identify any perceived-effective coping strategy. The findings suggest a need to (a) determine which EBP components do in fact enhance youth coping, (b) design the most effective ways to help youths master those effective components, and
Assuntos
Adaptação Psicológica , Psiquiatria do Adolescente/métodos , Depressão/psicologia , Depressão/terapia , Psicoterapia/métodos , Adolescente , Criança , Emoções , Medicina Baseada em Evidências , Feminino , Hábitos , Humanos , Entrevista Psicológica , Masculino , Escalas de Graduação Psiquiátrica , Fatores SexuaisRESUMO
Most youth psychotherapy research involves conditions quite unlike the clinical practice it is designed to strengthen. Most studies have not tested interventions with clinically referred youths and practicing clinicians in clinical care settings, nor have they tested whether new treatments produce better outcomes than usual practice. Limited exposure to real-world conditions and questions may partially explain why empirically supported treatments show such modest effects when tested under more representative conditions, against usual care. Our deployment-focused model calls for intervention development and testing with the kinds of participants (e.g., clients and clinicians) and in the contexts (e.g., clinics) for which the interventions are ultimately intended, and for randomized comparisons to usual clinical care. Research with the Child STEPs (system and treatment enhancement projects) treatment approach illustrates the methods and potential benefits of the deployment-focused model. Findings supporting Child STEPs are but one part of a rich research matrix needed to shrink the gap between intervention research and clinical practice.
Assuntos
Psiquiatria do Adolescente/métodos , Pesquisa Biomédica/métodos , Psiquiatria Infantil/métodos , Psicoterapia/métodos , Adolescente , Fatores Etários , Criança , Humanos , Transtornos Mentais/terapiaRESUMO
Prior research suggests that the effects of specific cognitive-behavioral therapy (CBT) modules on symptom outcomes can be estimated. We conducted a study utilizing idiographic and nomothetic methods to clarify which CBT modules are most effective for youth depression, and for whom they are most effective. Thirty-five youths received modular CBT for depression. Interrupted time series models estimated whether the introduction of each module was associated with changes in internalizing symptoms, whereby significant symptom reduction would suggest a therapeutic response to the module. Regression models were used to explore whether participant characteristics predicted subgroups of youths based on their estimated response to certain types (e.g., cognitive) of modules, and whether group membership was associated with posttreatment outcomes. Thirty youths (86%) had at least one module associated with a significant change in internalizing symptoms from premodule delivery to postmodule delivery. The specific modules associated with these changes varied across youths. Behavioral activation was most frequently associated with symptom decreases (34% of youths). No participant characteristics predicted estimated response to module type, and group membership was not significantly associated with posttreatment outcomes. Youths display highly heterogeneous responses to treatment modules, indicating multiple pathways to symptom improvement for depressed youths.
Assuntos
Terapia Cognitivo-Comportamental , Humanos , Terapia Cognitivo-Comportamental/métodos , Feminino , Masculino , Adolescente , Resultado do Tratamento , Criança , Depressão/terapia , Depressão/psicologia , Transtorno Depressivo/terapia , Transtorno Depressivo/psicologiaRESUMO
PURPOSE: Patients receiving treatment for self-injurious thoughts and behaviors (SITBs) have diverse backgrounds, yet it remains unclear exactly who is represented in the current SITB treatment literature. METHODS: We conducted a systematic review of the past 50 years of randomized controlled trials (RCTs) testing SITB treatments to evaluate sampling practices and reporting of sample characteristics, as well as inclusion of global populations across the included 525 papers. We also assessed changes over the past five decades in these three domains. RESULTS: SITB RCTs frequently reported age and sex (98.6%-95.1%), less frequently reported race (83.4%-38.6%), socioeconomic status (48.1%-46.1%) and ethnicity (41.9%-8.1%), and rarely reported LGBTQ+ status (3.7%-1.6%). U.S.-based RCTs featured predominantly White, non-Hispanic, and non-LGBTQ+ samples. Most RCTs were conducted in high-income North American or European countries. Sample reporting practices, sample representativeness, and inclusion of global populations modestly and inconsistently improved over time. CONCLUSIONS: There has not been substantial improvement in reporting practices, sample representativeness, or inclusion of global populations in SITB RCTs over the past 50 years. Acknowledging who is being studied and representing diverse populations in SITB treatment research is key to connecting research advances with those who may need it most.
Assuntos
Ensaios Clínicos Controlados Aleatórios como Assunto , Comportamento Autodestrutivo , Humanos , Comportamento Autodestrutivo/terapia , Comportamento Autodestrutivo/epidemiologia , Suicídio/estatística & dados numéricosRESUMO
BACKGROUND: Adolescence is marked by an increasing risk of depression and is an optimal window for prevention and early intervention. Personalizing interventions may be one way to maximize therapeutic benefit, especially given the marked heterogeneity in depressive presentations. However, empirical evidence that can guide personalized intervention for youth is lacking. Identifying person-specific symptom drivers during adolescence could improve outcomes by accounting for both developmental and individual differences. OBJECTIVE: This study leverages adolescents' everyday smartphone use to investigate person-specific drivers of depression and validate smartphone-based mobile sensing data against established ambulatory methods. We describe the methods of this study and provide an update on its status. After data collection is completed, we will address three specific aims: (1) identify idiographic drivers of dynamic variability in depressive symptoms, (2) test the validity of mobile sensing against ecological momentary assessment (EMA) and actigraphy for identifying these drivers, and (3) explore adolescent baseline characteristics as predictors of these drivers. METHODS: A total of 50 adolescents with elevated symptoms of depression will participate in 28 days of (1) smartphone-based EMA assessing depressive symptoms, processes, affect, and sleep; (2) mobile sensing of mobility, physical activity, sleep, natural language use in typed interpersonal communication, screen-on time, and call frequency and duration using the Effortless Assessment of Risk States smartphone app; and (3) wrist actigraphy of physical activity and sleep. Adolescents and caregivers will complete developmental and clinical measures at baseline, as well as user feedback interviews at follow-up. Idiographic, within-subject networks of EMA symptoms will be modeled to identify each adolescent's person-specific drivers of depression. Correlations among EMA, mobile sensor, and actigraph measures of sleep, physical, and social activity will be used to assess the validity of mobile sensing for identifying person-specific drivers. Data-driven analyses of mobile sensor variables predicting core depressive symptoms (self-reported mood and anhedonia) will also be used to assess the validity of mobile sensing for identifying drivers. Finally, between-subject baseline characteristics will be explored as predictors of person-specific drivers. RESULTS: As of October 2023, 84 families were screened as eligible, of whom 70% (n=59) provided informed consent and 46% (n=39) met all inclusion criteria after completing baseline assessment. Of the 39 included families, 85% (n=33) completed the 28-day smartphone and actigraph data collection period and follow-up study visit. CONCLUSIONS: This study leverages depressed adolescents' everyday smartphone use to identify person-specific drivers of adolescent depression and to assess the validity of mobile sensing for identifying these drivers. The findings are expected to offer novel insights into the structure and dynamics of depressive symptomatology during a sensitive period of development and to inform future development of a scalable, low-burden smartphone-based tool that can guide personalized treatment decisions for depressed adolescents. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43931.
Assuntos
Depressão , Avaliação Momentânea Ecológica , Smartphone , Humanos , Adolescente , Depressão/diagnóstico , Feminino , Masculino , Actigrafia/instrumentação , Actigrafia/métodos , Aplicativos MóveisRESUMO
Investigating the mechanisms through which psychotherapy brings about desired change can inform efforts to improve therapies. We applied meta-analytic structural equation modeling (MASEM) to assess putative change mechanisms for cognitive behavioral therapy (CBT) as mediators of youth depression treatment outcome. Then, we tested whether candidate mediators (CMs) showed evidence of treatment-specificity to CBT versus interpersonal psychotherapy (IPT). Literature searches identified 34 randomized trials (27 CBT, 6 IPT, 1 CBT/IPT, 3,868 participants, published 1982-2020) that measured seven CMs: negative cognition, social engagement, family functioning, pleasant activity engagement, problem solving, reframing, or avoidance. We assessed mediational pathways and whether posttreatment CMs mediated treatment effects on posttreatment depression symptoms, covarying pretreatment CMs, and symptoms. Treatment type was tested as a moderator of mediational pathways. Results show that negative cognition (24 trials) and pleasant activities (3 trials) mediated depression symptom outcome in CBT. Social engagement and family functioning showed stronger mediation in IPT (5 and 6 trials) than in CBT (14 and 13 trials). We conclude that negative cognition is a robust mediator of CBT but may not be treatment-specific; pleasant activities may also be a mediator of CBT. However, the lack of treatment or mediation effects involving problem solving and reframing contradicts CBT theory. In contrast, social and family mechanisms appear to be IPT-specific mediators. These conclusions are provisional due to small samples examining IPT and several CMs, limitations in CM measurement (i.e., posttreatment retrospective report), and assumptions of MASEM-and will need to be confirmed when more and better evidence accumulates. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
Assuntos
Terapia Cognitivo-Comportamental , Psicoterapia Interpessoal , Análise de Classes Latentes , Ensaios Clínicos Controlados Aleatórios como Assunto , Humanos , Terapia Cognitivo-Comportamental/métodos , Adolescente , Criança , Depressão/terapia , Depressão/psicologia , Resultado do Tratamento , Transtorno Depressivo/terapia , Transtorno Depressivo/psicologiaRESUMO
In light of recent escalations in violence and discrimination against members of the Asian American community, it is important to raise awareness about and increase visibility of academic and social inequities that Asian American women psychologists face and provide strategies for increasing support. This call to action describes a framework for understanding racism as it applies to the unique intersectional experiences of Asian American women psychologists in the United States and inequities faced at the macro and micro levels. We provide concrete recommendations for institutions and individuals to develop and enhance DEI initiatives to counteract the processes and barriers that serve to exclude, marginalize, and invisibilize Asian American women psychologists.
RESUMO
OBJECTIVE: Subthreshold depression has been found to be associated with considerable impairment and an increased risk of developing major depression. Although several randomized trials have examined the effects of psychological interventions for subthreshold depression in children and adolescents, no meta-analysis has integrated the results of these trials. METHOD: We searched 4 bibliographic databases and included randomized trials comparing psychological interventions with control conditions in children and adolescents scoring above a cut-off of a depression questionnaire but not meeting diagnostic criteria for major depression (or persistent depressive disorder) according to a diagnostic interview. Effect sizes and incidence rates of major depression were pooled with random effects meta-analyses. RESULTS: A total of 12 trials with 1,576 children and adolescents met inclusion criteria. The overall effect size indicating the difference between treatment and control at post-test was g = 0.38 (95% CI = 0.14-0.63), which corresponds to a number-needed-to-treat (NNT) of 8.4. Heterogeneity was moderate to high (I2 = 61; 95% CI = 28-79), and there was significant risk of publication bias (p < .04). The 2 studies in children less than 12 years of age showed nonsignificant effects (g = 0.01; 95% CI = -1.16 to 1.18). We found no significant effect on the incidence of major depression at follow-up (relative risk = 0.52; 95% CI = 0.25-1.08), although this may be related to low statistical power. CONCLUSION: Interventions for subthreshold depression may have positive acute effects in adolescents. There is currently insufficient evidence, however, that these interventions are effective in children less than 12 years of age, or that they prevent the onset of major depression at follow-up.
Assuntos
Depressão , Transtorno Depressivo Maior , Adolescente , Criança , Transtorno Depressivo Maior/epidemiologia , Transtorno Depressivo Maior/terapia , Humanos , PsicoterapiaRESUMO
Importance: It is not clear whether psychotherapies for depression have comparable effects across the life span. Finding out is important from a clinical and scientific perspective. Objective: To compare the effects of psychotherapies for depression between different age groups. Data Sources: Four major bibliographic databases (PubMed, PsychINFO, Embase, and Cochrane) were searched for trials comparing psychotherapy with control conditions up to January 2019. Study Selection: Randomized trials comparing psychotherapies for depression with control conditions in all age groups were included. Data Extraction and Synthesis: Effect sizes (Hedges g) were calculated for all comparisons and pooled with random-effects models. Differences in effects between age groups were examined with mixed-effects subgroup analyses and in meta-regression analyses. Main Outcomes and Measures: Depressive symptoms were the primary outcome. Results: After removing duplicates, 16â¯756 records were screened and 2608 full-text articles were screened. Of these, 366 trials (36â¯702 patients) with 453 comparisons between a therapy and a control condition were included in the qualitative analysis, including 13 (3.6%) in children (13 years and younger), 24 (6.6%) in adolescents (≥13 to 18 years), 19 (5.2%) in young adults (≥18 to 24 years), 242 (66.1%) in middle-aged adults (≥24 to 55 years), 58 (15.8%) in older adults (≥55 to 75 years), and 10 (2.7%) in older old adults (75 years and older). The overall effect size of all comparisons across all age groups was g = 0.75 (95% CI, 0.67-0.82), with very high heterogeneity (I2 = 80%; 95% CI: 78-82). Mean effect sizes for depressive symptoms in children (g = 0.35; 95% CI, 0.15-0.55) and adolescents (g = 0.55; 95% CI, 0.34-0.75) were significantly lower than those in middle-aged adults (g = 0.77; 95% CI, 0.67-0.87). The effect sizes in young adults (g = 0.98; 95% CI, 0.79-1.16) were significantly larger than those in middle-aged adults. No significant difference was found between older adults (g = 0.66; 95% CI, 0.51-0.82) and those in older old adults (g = 0.97; 95% CI, 0.42-1.52). The outcomes should be considered with caution because of the suboptimal quality of most of the studies and the high levels of heterogeneity. However, most primary findings proved robust across sensitivity analyses, addressing risk of bias, target populations included, type of therapy, diagnosis of mood disorder, and method of data analysis. Conclusions and Relevance: Trials included in this meta-analysis reported effect sizes of psychotherapies that were smaller in children than in adults, probably also smaller in adolescents, that the effects may be somewhat larger in young adults, and without meaningful differences between middle-aged adults, older adults, and older old adults.
Assuntos
Depressão/terapia , Transtorno Depressivo/terapia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Psicoterapia/estatística & dados numéricos , Adolescente , Adulto , Idoso , Criança , Humanos , Pessoa de Meia-Idade , Adulto JovemRESUMO
OBJECTIVE: Youth depression is a debilitating condition that constitutes a major public health concern. A 2006 meta-analysis found modest benefits for psychotherapy versus control. Has 13 more years of research improved that picture? We sought to find out. METHOD: We searched PubMed, PsychINFO, and Dissertation Abstracts International for 1960 to 2017, identifying 655 randomized, English-language psychotherapy trials for individuals aged 4 to 18 years. Of these, 55 assessed psychotherapy versus control for youth depression with outcome measures administered to both treatment and control conditions at post (κ = 53) and/or follow-up (κ = 32). Twelve study and outcome characteristics were extracted, and effect sizes were calculated for all psychotherapy versus control comparisons. Using a three-level random-effects model, we obtained an overall estimate of the psychotherapy versus control difference while accounting for the dependency among effect sizes. We then fitted a three-level mixed-effects model to identify moderators that might explain variation in effect size within and between studies. RESULTS: The overall effect size (g) was 0.36 at posttreatment and 0.21 at follow-up (averaging 42 weeks after posttreatment). Three moderator effects were identified: effects were significantly larger for interpersonal therapy than for cognitive behavioral therapy, for youth self-reported outcomes than parent-reports, and for comparisons with inactive control conditions (eg, waitlist) than active controls (eg, usual care). Effects showed specificity, with significantly smaller effects for anxiety and externalizing behavior outcomes than for depression measures. CONCLUSION: Youth depression psychotherapy effects are modest, with no significant change over the past 13 years. The findings highlight the need for treatment development and research to improve both immediate and longer-term benefits.
Assuntos
Depressão/psicologia , Depressão/terapia , Psicoterapia , Adolescente , Ansiedade/psicologia , Ansiedade/terapia , Criança , Pré-Escolar , Terapia Cognitivo-Comportamental , Seguimentos , HumanosRESUMO
With the development of empirically supported treatments over the decades, have youth psychotherapies grown stronger? To investigate, we examined changes over time in treatment effects for four frequently treated youth mental-health problems: anxiety, depression, attention-deficit hyperactivity disorder (ADHD), and conduct disorders. We used PubMed and PsycINFO to search for randomized controlled trials (RCTs) that were published between January 1960 and May 2017 involving youths between the ages of 4 and 18 years. We also searched reviews and meta-analyses of youth psychotherapy research, followed reference trails in the reports we identified, and obtained additional studies identified by therapy researchers whom we contacted. We identified 453 RCTs (31,933 participants) spanning 53 years (1963-2016). Effect sizes for the problem-relevant outcome measures were synthesized via multilevel meta-analysis. We tracked temporal trends for each problem domain and then examined multiple study characteristics that might moderate those trends. Mean effect size increased nonsignificantly for anxiety, decreased nonsignificantly for ADHD, and decreased significantly for depression and conduct problems. Moderator analyses involving multiple study subgroups showed only a few exceptions to these surprising patterns. The findings suggest that new approaches to treatment design and intervention science may be needed, especially for depression and conduct problems. We suggest intensifying the search for mechanisms of change, making treatments more transdiagnostic and personalizable, embedding treatments within youth ecosystems, adapting treatments to the social and technological changes that alter youth dysfunction and treatment needs, and resisting old habits that can make treatments unduly skeuomorphic.