Therapist competence, homework engagement, and client characteristics in CBT for youth depression: A study of mediation and moderation in a community-based trial.

OBJECTIVE: Prior studies of Cognitive Behavioral Therapy (CBT) have focused on the quantity and quality of clients' homework completion and only rarely have considered the role of therapist competence. METHODS: The present study examined (a) therapist competence across the entire process of integrating homework into CBT, including the review, design, and planning of tasks; (b) homework engagement, including client appraisals of the difficulty and obstacles encountered in task completion using the Homework Rating Scale - Revised (HRS-II); (c) pre-post symptom reduction as the index of outcome; and (d) considered client factors such as suicide risk in a community-based trial for adolescent depression. Trained independent observers assessed therapist competence and engagement with homework at two consecutive sessions of CBT for N = 80 young people (Mage = 19.61, SD = 2.60). RESULTS: Significant complementary mediation effects were obtained; there was an indirect mediation effect of HRS-II Beliefs (b = 1.03, SE B = 0.42, 95% BCa CI [0.35, 2.03]) and HRS-II Perceived Consequences on the Competence-Engagement relationship (b = 0.85, SE B = 0.31, 95% BCa CI [0.39, 1.61]). High levels of suicidal ideation were also shown to moderate this relationship. CONCLUSIONS: The present findings contribute to the growing body of CBT process research designed to examine the complex interrelationships of client and therapist variables, in a manner that reflects the actual process of therapy, and advances beyond studies of isolated predictors of symptom change.

The addition of fluoxetine to cognitive behavioural therapy for youth depression (YoDA-C): a randomised, double-blind, placebo-controlled, multicentre clinical trial.

BACKGROUND: Medication is commonly used to treat youth depression, but whether medication should be added to cognitive behavioural therapy (CBT) as first-line treatment is unclear. We aimed to examine whether combined treatment with CBT and fluoxetine was more effective than CBT and placebo in youth with moderate-to-severe major depressive disorder. METHODS: The Youth Depression Alleviation-Combined Treatment (YoDA-C) trial was a randomised, double-blind, placebo-controlled, multicentre clinical trial. Participants were aged 15-25 years with moderate-to-severe MDD and had sought care at one of four clinical centres in metropolitan Melbourne, Australia. Patients were randomly assigned (1:1) to receive CBT for 12 weeks, plus either fluoxetine or placebo. Participants began on one 20 mg capsule of fluoxetine or one placebo pill per day. All participants received CBT, delivered by therapists in weekly 50-minute sessions and attended interviews at baseline, and at weeks 4, 8, and 12, during which they completed assessments with research assistants. Participants saw a psychiatrist or psychiatry trainee to complete medical assessments at the same timepoints. The primary outcome was change in the interviewer-rated Montgomery-Åsberg Depression Rating Scale (MADRS) score at 12 weeks. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612001281886). FINDINGS: 153 participants (mean age 19·6 years [SD 2·7]) were enrolled from Feb 20, 2013, to Dec 13, 2016. 77 (50%) patients were allocated to CBT and placebo and 76 (50%) to CBT and fluoxetine. Participants had severe depression at baseline (mean MADRS score 33·6 [SD 5·1] in the CBT and placebo group and 32·2 [5·6] in the CBT and fluoxetine group), with high proportions of participants with anxiety disorder comorbidity (47 [61%] in the CBT and placebo group and 49 [64%] in the CBT and fluoxetine group) and past-month suicidal ideation (55 [71%] in the CBT and placebo group and 59 [78%] in the CBT and fluoxetine group). 59 (77%) participants in the CBT and placebo group and 64 (84%) in the CBT and fluoxetine group completed follow-up at week 12. After 12 weeks of treatment both groups showed a reduction in MADRS scores (-13·7, 95% CI -16·0 to -11·4, in the CBT and placebo group and -15·1, -17·4 to -12·9, in the CBT and fluoxetine group). There was no significant between-group difference in MADRS scores (-1·4, -4·7 to 1·8; p=0·39). There were five suicide attempts in the CBT and placebo group and one suicide attempt in the CBT and fluoxetine group (odds ratio 0·2, 0·0-1·8; p=0·21), and no significant between-group differences for other suicidal behaviours. INTERPRETATION: We did not find evidence that the addition of fluoxetine (rather than placebo) to CBT further reduced depressive symptoms in young people with moderate-to-severe MDD. Exploratory analyses showed that the addition of medication might be helpful for patients with comorbid anxiety symptoms and for older youth. FUNDING: Australian National Health and Medical Research Council.

A randomized controlled trial of bibliotherapy for carers of young people with first-episode psychosis.

Caring for young people with first-episode psychosis (FEP) is challenging and can adversely affect carer well-being, with limited evidence-based support materials available. We aimed to examine whether completion of a self-directed problem-solving bibliotherapy among carers of young people with FEP led to a better experience of caring, less distress and expressed emotion, and better general health than carers who only received treatment as usual (TAU). A randomized controlled trial was conducted across two early-intervention psychosis services in Melbourne, Australia. A total of 124 carers were randomized to problem-solving bibliotherapy intervention (PSBI) or TAU and assessed at baseline, 6-week and 16-week follow-up. Intent-to-treat analyses were carried out and indicated that recipients of PSBI had a more favorable experience of caring than those receiving TAU, and these effects were sustained at both follow-up time points. Across the other measures, both groups demonstrated improvements by week 16, although the PBSI group tended to improve earlier. The PSBI group experienced a greater reduction in negative emotional evaluations of the need to provide additional support to young people with FEP than the TAU group by week 6, while the level of psychological distress decreased at a greater rate from baseline to 6 weeks in the PSBI compared with the TAU group. These findings support the use of problem-solving bibliotherapy for first-time carers, particularly as a cost-effective adjunct to TAU.

Outcomes of an integrated cognitive behaviour therapy (CBT) treatment program for co-occurring depression and substance misuse in young people.

BACKGROUND: There are high rates of co-occurring depression among young people with substance use disorders. While there is preliminary evidence for the effectiveness of integrated cognitive behaviour therapy (CBT) in combination with antidepressants among alcohol and substance dependent adolescents and adults with co-existing depression, no studies have examined the effectiveness of integrated CBT interventions in the absence of pharmacotherapy. The aim of the current study was to determine the outcomes of an integrated CBT intervention for co-occurring depression and substance misuse in young people presenting to a mental health setting. METHODS: Sixty young people (aged 15 to 25), with a DSM-IV diagnosis of Major Depressive Disorder and concurrent substance misuse (at least weekly use in the past month) or disorder were recruited from a public youth mental health service in Melbourne, Australia. Participants received 10 sessions of individual integrated CBT treatment delivered with case management over a 20-week period. RESULTS: The intervention was associated with significant improvements in depression, anxiety, substance use, coping skills, depressive and substance use cognitions and functioning at mid- (10 weeks) and post- (20 weeks) treatment. These changes were maintained at 6 months follow-up (44 weeks). CONCLUSIONS: These results provide preliminary evidence for the effectiveness of the integrated CBT intervention in young people with co-occurring depression and substance misuse. Further studies using randomised controlled designs are required to determine its efficacy.

Integrated cognitive behaviour therapy for co-occurring substance misuse and major depression: lessons from a youth mental health service.

OBJECTIVE: The aim of this paper is to describe a 20-week integrated cognitive behavioural therapy (CBT) program addressing co-occurring substance misuse and major depression in young people. METHOD: Participants were aged between 15 and 25 years, met DSM-IV criteria for major depressive disorder and had at least weekly illicit drug use and/or weekly alcohol use exceeding the Australian national guidelines on alcohol. RESULTS: Between December 2004 and January 2007, an integrated CBT program was offered to 60 young people with co-occurring depression and substance misuse who presented to a youth-specific mental health service. Young people attended for a median of 10.5 sessions. CONCLUSIONS: We describe the components of a 20-week integrated CBT program for young people with co-occurring depression and comorbid substance misuse, as well as the challenges associated with providing such treatment. While integrated treatment approaches are recommended as best practice for this population, further evaluation is necessary to determine their effectiveness within routine clinical settings.

Feasibility and acceptability of a mental health screening tool and training programme in the youth alcohol and other drug (AOD) sector.

The high prevalence of co-occurring mental health and substance use disorders in young people is well established. Despite this, there are low rates of detection of co-occurring disorders across alcohol and other drug (AOD) services within Australia. This paper describes the development, implementation and evaluation of a mental health screening tool and training programme within the youth AOD sector. Thirty youth AOD workers received training in mental health screening, and the screening tool was subsequently piloted on 84 young people accessing two youth AOD services. Training was evaluated using measures of the trainee's mental health knowledge, attitudes, skills and confidence in mental health screening at baseline and 12-month follow-up. Feedback from young people supported the feasibility, acceptability and relevance of the screening tool. Evaluation of the associated training programme indicated improvements in AOD workers' mental health knowledge, skills and confidence in mental health screening. These findings provide preliminary evidence of the feasibility and acceptability of the mental health screening tool to young people and the effectiveness of the training package within the youth AOD sector.

Feasibility and outcomes of an innovative cognitive-behavioural skill training programme for co-occurring disorders in the youth alcohol and other drug (AOD) sector.

There are limited treatment options available for young drug users with comorbid mental health problems who present to alcohol and other drug (AOD) services within Australia. While there is some evidence for the use of cognitive-behaviour therapy (CBT) in the treatment of co-occurring disorders, CBT is rarely used to address comorbidity in the AOD sector. This paper describes the development, implementation and evaluation of a brief cognitive-behavioural skills (BCBS) training programme for addressing comorbidity within two youth AOD services in Australia. Ten youth AOD workers completed a 2-day training programme in the BCBS. Training was evaluated using measures of trainees' cognitive-behavioural knowledge, attitudes towards mental health interventions and level of skills and confidence in each of the BCBS pre- and 6 months post-training. The BCBS training had a positive impact on the knowledge, skills and confidence of trainees and was perceived to be highly relevant and appropriate. These findings provide preliminary support for the feasibility and effectiveness of the BCBS training programme for workers within the youth AOD sector.