Family-Based Interventions for Youth Depression: Meta-Analysis of Randomized Clinical Trials.

Youth depression is an impairing pediatric condition for which psychotherapy effects are modest. Can outcomes be improved by treatments that address the family context, as proposed in practice parameters of the American Academy of Child and Adolescent Psychiatry? To find out, we searched five decades of research for randomized controlled trials testing family-based interventions; 11 trials were found for ages 4-18 years. Using robust variance estimation, we obtained estimates of effect size (ES) and tested candidate moderators that might explain variation in ES. Overall pooled ES of the studies was 0.33 at posttreatment, similar to that reported for all youth depression treatments in three prior meta-analyses (i.e., 0.36, 0.30, and 0.29), but higher for adolescents (ages ≥ 13, 0.50) than children (0.04). Taken together, our findings do not show superior outcomes for family-based interventions, and raise questions about how much confidence can be placed in the evidence base to date. The small number of relevant studies in more than five decades, together with the publication bias and risk of bias concerns, highlights the need for more trials testing family-based treatment, and for pre-registered reports, publicly-available preprints, and other mechanisms for improving the dissemination of completed research.

Psychotherapy for Depression Across Different Age Groups: A Systematic Review and Meta-analysis.

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, 16 756 records were screened and 2608 full-text articles were screened. Of these, 366 trials (36 702 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.

Meta-Analysis: 13-Year Follow-up of Psychotherapy Effects on Youth Depression.

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.

Latent Profiles of Cognitive and Interpersonal Risk Factors for Adolescent Depression and Implications for Personalized Treatment.

A personalized approach to treatment with patients being matched to the best-fit treatment has been proposed as one possible solution to the currently modest treatment response rates for adolescent depression. Personalized treatment involves identifying and characterizing subgroups likely to respond differently to different treatments. We investigated the feasibility of this approach, by focusing on two key risk factors that are the purported treatment targets of cognitive behavioral therapy (CBT) and interpersonal psychotherapy for depressed adolescents (IPT-A): negative unrealistic cognitions and interpersonal relationship difficulties, respectively. We sought to learn whether subgroups high and low on the two risk factors, respectively, might be identified in a large sample of depressed, treatment-seeking adolescents. Latent class analysis (LCA) was conducted on measures of the two risk factors among 431 adolescents (age 12-17) in the Treatment for Adolescents with Depression Study. LCA identified three classes: (1) adolescents with high levels of problems in both family relationships and cognitions (21.6% of sample), (2) adolescents with moderate levels of problems in both domains (52.4%), and (3) adolescents with low levels of problems in both domains (26.0%). These subgroups did not predict treatment outcome with CBT or CBT + fluoxetine (COMB). The results challenge a current assumption about how treatments could be personalized, and they support a multi-causal model of depression rather than a risk-factor-specific model. Strategies other than risk factor-based personalizing for case assignment to CBT vs. IPT-A are discussed.

Editorial: Making Sense of Youth Psychotherapy Dropout From Depression Treatment.

Adolescent depression is a prevalent disorder that increases risk for significant functional impairment and suicidality.1-3 Several psychotherapies are available, and it has been widely assumed that failure to complete these therapies will undermine benefit. The important study by O'Keeffe et al. raises questions about that assumption.4.

Parental Depressive Symptoms as a Predictor of Outcome in the Treatment of Child Internalizing and Externalizing Problems.

Child internalizing and externalizing problems have been identified as high priority intervention targets by the World Health Organization. Parental depression is a risk factor for development of these childhood problems and may negatively influence intervention outcomes; however, studies have rarely assessed its influence on these outcomes. The present study assessed whether baseline parental depressive symptoms predicted psychotherapy outcomes among children treated for clinically significant internalizing and externalizing problems. The sample included 142 children (79 with primary internalizing problems, 63 with primary externalizing problems). Children were aged 7-13, 67.6% boys, and race included Caucasian (46.5%), African-American (9.9%), Latino (5.6%), Asian (1.4%), and multi-racial (32.4%). Analyses focused on child- and parent-reported weekly trajectories of change and post-treatment symptoms among children treated for internalizing and externalizing problems whose parents did (N = 28 and 25) and did not (N = 51 and 38) have elevated depressive symptoms. For children with internalizing problems, growth curve analyses showed markedly different trajectories, by child- and parent-report: children with less depressed parents showed significantly steeper symptom declines than did children with more depressed parents, who showed an increase in symptoms. ANCOVAs showed marginally lower post-treatment symptoms for children of less depressed versus more depressed parents (p = 0.064 by child-report). For children with externalizing problems, growth curve analyses showed trajectories in the opposite direction, by child- and parent-report; however, ANCOVAs showed no group differences at post-treatment. These findings suggest that it may be important to consider the impact of parental depressive symptoms when treating child internalizing and externalizing problems.

Are Psychotherapies for Young People Growing Stronger? Tracking Trends Over Time for Youth Anxiety, Depression, Attention-Deficit/Hyperactivity Disorder, and Conduct Problems.

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.

Parental Depressive Symptoms as a Predictor of Outcome in the Treatment of Child Depression.

Child depression is an impairing condition for which psychotherapies have shown modest effects. Parental depression is a risk factor for development of child depression and might also be negatively associated with child depression treatment outcomes. To explore this possibility, we analyzed data from a study in which children were treated for depression after parental depressive symptoms had been assessed at baseline. Among children treated for depression in a randomized controlled trial, we identified 31 who had child- and parent-report pre- and post-treatment data on child symptoms and parent-report of pre-treatment parental depressive symptoms. Children were aged 8-13, 77% boys, and 52% Caucasian, 13% African-American, 6% Latino, and 29% multi-racial. Analyses focused on differences in trajectories of change (across weekly measurements), and post-treatment symptoms among children whose parents did (n = 12) versus did not (n = 19) have elevated depressive symptoms at baseline. Growth curve analyses showed markedly different trajectories of change for the two groups, by both child-report (p = 0.03) and parent-report (p = 0.03) measures: children of parents with less severe depression showed steep symptom declines, but children of parents with more severe depression showed flat trajectories with little change in symptoms over time. ANCOVAs showed lower post-treatment child symptoms for children of parents with less severe depression versus parents with more severe depression (p = 0.05 by child report, p = 0.01 by parent report). Parental depressive symptoms predict child symptom trajectories and poorer child treatment response, and may need to be addressed in treatment.

What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice.

Across 5 decades, hundreds of randomized trials have tested psychological therapies for youth internalizing (anxiety, depression) and externalizing (misconduct, attention deficit and hyperactivity disorder) disorders and problems. Since the last broad-based youth meta-analysis in 1995, the number of trials has almost tripled and data-analytic methods have been refined. We applied these methods to the expanded study pool (447 studies; 30,431 youths), synthesizing 50 years of findings and identifying implications for research and practice. We assessed overall effect size (ES) and moderator effects using multilevel modeling to address ES dependency that is common, but typically not modeled, in meta-analyses. Mean posttreatment ES was 0.46; the probability that a youth in the treatment condition would fare better than a youth in the control condition was 63%. Effects varied according to multiple moderators, including the problem targeted in treatment: Mean ES at posttreatment was strongest for anxiety (0.61), weakest for depression (0.29), and nonsignificant for multiproblem treatment (0.15). ESs differed across control conditions, with "usual care" emerging as a potent comparison condition, and across informants, highlighting the need to obtain and integrate multiple perspectives on outcome. Effects of therapy type varied by informant; only youth-focused behavioral therapies (including cognitive-behavioral therapy) showed similar and robust effects across youth, parent, and teacher reports. Effects did not differ for Caucasian versus minority samples, but more diverse samples are needed. The findings underscore the benefits of psychological treatments as well as the need for improved therapies and more representative, informative, and rigorous intervention science. (PsycINFO Database Record

Amelioration of Child Depression Through Behavioral Parent Training: A Preliminary Study.

Child depression is an impairing condition for which tested treatments have shown relatively modest mean effects. One possible explanation is that the treatments have generally adopted an individual child focus, without addressing the dysfunctional parent-child interactions that often accompany child depression. The present study provides preliminary evidence bearing on this hypothesis, using data from a treatment outcome study in which clinically referred children with a depression diagnosis could receive individual cognitive behavioral therapy (CBT) focusing on the depression or behavioral parent training (BPT) focusing on comorbid conduct problems. Among children in the study who met criteria for Diagnostic and Statistical Manual of Mental Disorders (4th ed.) depressive disorders, we identified two groups, matched on gender and age: 15 who received only CBT focused on child depression and 15 who received only BPT focused on child conduct problems. Children were 7 to 13, 20 of whom were male, and race included Caucasian (17), Latino (5), African American (2), and multirace (6). Measures assessed depressive diagnoses and symptoms, as well as parenting stress. Analyses focused on whether BPT alone might lead to reduced depression, and if so how that reduction would compare to the depression reduction achieved through CBT that focused on depression. Both groups showed significant reductions from pre- to post-treatment in depressive diagnoses and depression symptoms, and there were no BPT versus CBT group differences at post-treatment. BPT that focuses on child conduct problems, with no emphasis on depression treatment, may produce significant depression reduction in comorbid children who meet criteria for depressive disorders.

Assessing Fit Between Evidence-Based Psychotherapies for Youth Depression and Real-Life Coping in Early Adolescence.

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

Combined Individual Cognitive Behavior Therapy and Parent Training for Childhood Depression: 2-3-Year Follow-Up.

Fourteen children with significant depressive symptoms from an open clinical trial of Primary and Secondary Control Enhancement Training augmented with Caregiver-Child Relationship Enhancement Training, participated in a 2-3-year follow-up assessment. The results suggested that the significant decreases in depressive symptoms observed at post-treatment were maintained at 2-3-year follow-up. Mothers' reports of significant improvement of child psychosocial functioning were also maintained, providing social validation of the effects. Pre-treatment child-rated mother-child relations predicted depressive symptoms at 2-3-year follow-up. These long-term data support the use of the combined intervention and suggest the need for further research on caregiver involvement in treatment.

Performance of evidence-based youth psychotherapies compared with usual clinical care: a multilevel meta-analysis.

IMPORTANCE: Research across more than 4 decades has produced numerous empirically tested evidence-based psychotherapies (EBPs) for psychopathology in children and adolescents. The EBPs were developed to improve on usual clinical interventions. Advocates argue that the EBPs should replace usual care, but this assumes that EBPs produce better outcomes than usual care. OBJECTIVE: To determine whether EBPs do in fact produce better outcomes than usual care in youth psychotherapy. We performed a meta-analysis of 52 randomized trials directly comparing EBPs with usual care. Analyses assessed the overall effect of EBPs vs usual care and candidate moderators; we used multilevel analysis to address the dependency among effect sizes (ES) that is common but typically unaddressed in psychotherapy syntheses. DATA SOURCES: We searched the PubMed, PsychINFO, and Dissertation Abstracts International databases for studies from January 1, 1960, through December 31, 2010. STUDY SELECTION: We identified 507 randomized youth psychotherapy trials. Of these, the 52 studies that compared EBPs with usual care were included in the meta-analysis. DATA EXTRACTION AND SYNTHESIS: Sixteen variables (participant, treatment, outcome, and study characteristics) were extracted from studies, and ESs were calculated for all comparisons of EBP vs usual care. We used an extension of the commonly used random-effects meta-analytic model to obtain an overall estimate of the difference between EBP and usual care while accounting for the dependency among ESs. We then fitted a 3-level mixed-effects model to identify moderators that might explain variation in ESs within and between studies by adding study or ES characteristics as fixed predictors. MAIN OUTCOMES AND MEASURES: Primary outcomes of our meta-analysis were mean ES estimates across all studies and for levels of candidate moderators. These ES values were based on measures of symptoms, functioning, and other outcomes assessed within the 52 randomized trials. RESULTS: Evidence-based psychotherapies outperformed usual care. Mean ES was 0.29; the probability was 58% that a randomly selected youth would have a better outcome after EBP than a randomly selected youth after receiving usual care. The following 3 variables moderated treatment benefit: ESs decreased for studies conducted outside North America, for studies in which all participants were impaired enough to qualify for diagnoses, and for outcomes reported by informants other than the youths and parents in therapy. For certain key groups (eg, studies of clinically referred samples and youths with diagnoses), significant EBP effects were not demonstrated. CONCLUSIONS AND RELEVANCE: Evidence-based psychotherapies outperform usual care, but the EBP advantage is modest and moderated by youth, location, and assessment characteristics. The EBPs have room for improvement in the magnitude and range of their benefit relative to usual clinical care.

Combining individual cognitive behaviour therapy and caregiver-child sessions for childhood depression: an open trial.

The objective was to obtain preliminary evidence on the feasibility and efficacy of combining individual cognitive behavior therapy (CBT) with complimentary caregiver-child sessions for depressed youths. Fifteen children participated in an open clinical trial. Treatment included 16 CBT sessions combined with seven caregiver/caregiver-child sessions over 12 weeks. Data were collected at pre-, mid-, and post-treatment and at one- and six-month follow-ups. Significant decreases in depressive symptoms were apparent, with the majority showing clinically meaningful improvement. Benchmarked against the literature, the combination equaled or outperformed CBT in other studies and was superior to control conditions. Mother and teacher reports of child functioning significantly improved, providing social validation of the effects. Mothers reported improved caregiver-child relationships and less parenting stress. Children did not report acute improvements in relations with their caregivers. However, when a father participated, improved father-child relations were reported in the follow-up period. Younger age and lower pretreatment severity predicted greater symptom change. The positive treatment effects provide support for the combined intervention and suggest a further research focus on the effects of caregiver involvement in the treatment of depressed youths.

The effects of parental depression and parenting practices on depressive symptoms and metabolic control in urban youth with insulin dependent diabetes.

OBJECTIVE: Examine relationships between parental depressive symptoms, affective and instrumental parenting practices, youth depressive symptoms and glycemic control in a diverse, urban sample of adolescents with diabetes. METHODS: Sixty-one parents and youth aged 10-17 completed self-report questionnaires. HbA1c assays were obtained to assess metabolic control. Path analysis was used to test a model where parenting variables mediated the relationship between parental and youth depressive symptoms and had effects on metabolic control. RESULTS: Parental depressive symptoms had a significant indirect effect on youth depressive symptoms through parental involvement. Youth depressive symptoms were significantly related to metabolic control. While instrumental aspects of parenting such as monitoring or discipline were unrelated to youth depressive symptoms, parental depression had a significant indirect effect on metabolic control through parental monitoring. CONCLUSIONS: The presence of parental depressive symptoms influences both youth depression and poor metabolic control through problematic parenting practices such as low involvement and monitoring.