Subsyndromal depression in adolescents after a brief psychotherapy trial: course and outcome.

INTRODUCTION: Subsyndromal depression has been associated with an increased risk of the development of major depressive disorder (MDD). Since treatment trials of adolescent MDD often result in subsyndromal depression as the outcome, the long-term course of these youth would be useful to understand. METHODS: 107 adolescents with MDD participated in a clinical psychotherapy trial, of whom 99 were followed up for two years after acute treatment. Those with subsyndromal depression (2-3 symptoms) at the end of acute treatment were compared to those who were well (< or =1 symptom) and those who were still depressed (> or =4 symptoms) on presentation at intake, the end of treatment, and over the two-year follow-up. RESULTS: Of the 99 youth, at the end of acute treatment 26 were well, 18 were subsyndromal, and 55 were still depressed. A substantial proportion of the subsyndromally depressed youth were functionally impaired (38%), and showed a protracted time to recovery. The risk of recurrence was similar to those who were without depression at the end of acute treatment (46% vs. 44%). Recurrence was predicted by depressive symptom severity and family difficulties at the end of acute treatment. LIMITATIONS: A large proportion of the subsyndromal groups received open treatment that may have altered their course. Also, this was a referred sample, rather than an epidemiological one. CONCLUSIONS: In clinical samples treated with psychotherapy, subsyndromal depression poses a significant risk for functional impairment and protracted recovery. Depressive recurrence may be prevented by targeting reduction of symptom severity and of family difficulties.

Predictors of parent-rated credibility in a clinical psychotherapy trial for adolescent depression.

The authors have reported that adolescents with major depressive disorder had a higher remission rate with cognitive-behavioral therapy (CBT) than with systemic behavioral family therapy (SBFT) or nondirective supportive therapy (NST). Parent-rated treatment credibility deteriorated from baseline to end of treatment if patients were treated with SBFT or NST, compared with CBT. The present study evaluated the following variables as predictors of change in parent- rated credibility over time across the three treatment cells: severity of child's and parents' depression at baseline; parent-rated family climate at baseline; clinician age, gender, and years of clinical experience; and change in severity of child's depression and in family climate. The greater the baseline depression of children treated with CBT and NST, but not SBFT, the more favorable the change in parent-rated credibility at the end of treatment. Findings suggest that any improvement (for CBT) or a supportive therapeutic contact (for NST) may appeal to parents of severely depressed children.

Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression.

OBJECTIVE: To assess the rate and correlates of compliance with clinicians' recommendations to remove firearms from the homes of depressed adolescents participating in a clinical trial. METHOD: The parents of 106 adolescents with major depression who participated in a randomized psychotherapy clinical trial were asked systematically about firearms in the home. Those who answered affirmatively were given information about the suicide risk conveyed by guns in the home and urged to remove them. The rates of gun removal and acquisition were assessed at the end of the treatment and over the subsequent 2-year naturalistic follow-up. RESULTS: Of those who had guns at intake, 26.9% reported removing them by the end of the acute trial. Retention was associated with urban origin, marital dissatisfaction, and paternal psychopathology. Of those who did not have guns at intake, 17.1% reported acquiring them over 2-year follow-up. Living in a 2-parent household and marital dissatisfaction were associated with gun acquisition. CONCLUSIONS: Families of depressed adolescents may frequently be noncompliant with recommendations to remove guns from the home despite compliance with other aspects of treatment. More efficacious interventions to reduce access to guns in the homes of at-risk youths are needed.

Cognitive and family therapies for adolescent depression: treatment specificity, mediation, and moderation.

The specificity of cognitive and family therapies, and potential treatment mediators and moderators, was examined in a randomized clinical trial for adolescent depression. After acute treatment, cognitive-behavioral therapy (CBT) exerted specific effects on cognitive distortions relative to either systemic-behavioral family therapy (SBFT) or nondirective supportive therapy (NST). At 2-year follow-up, SBFT was found to impact family conflict and parent-child relationship problems more than CBT; NST and CBT tended to show a greater reduction in anxiety symptoms than SBFT. Nonspecific therapist variables qualified few outcome analyses. No measures of cognitive distortion or family dysfunction mediated or moderated treatment outcome. As in adult studies, relatively few areas of treatment specificity or mediation were identified. The implications of these findings for clinical treatment and research in adolescent depression are discussed.

Psychosis in a pediatric mood and anxiety disorders clinic: phenomenology and correlates.

OBJECTIVES: To examine the demographics and phenomenology of psychosis in a sample of children and adolescents referred to a mood and anxiety disorders clinic. METHOD: Patients (N = 2,031) were assessed with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present Episode version and classified as definite, probable, or nonpsychotic. Clinical and demographic characteristics of the groups were compared,and symptoms of psychosis were analyzed using factor analysis. RESULTS: Definite psychotic symptoms were seen in approximately 90 (4.5%) patients: 80% of these reported hallucinations (mainly auditory), 22% delusions, and 3.3% thought disorder. Of the patients with definite psychotic symptoms, 24% had bipolar disorder, 41% had major depression, 21% had subsyndromal depression, and 14% had schizophrenia spectrum disorders (schizophrenia and schizoaffective disorders). Factor analysis of the definite psychotic symptoms yielded 4 factors: hallucinations, thought disorder, delusions, and manic thought disorder. Psychotic patients had a higher frequency of comorbid disorders and suicidal ideation than nonpsychotic patients. CONCLUSIONS: Outpatient youngsters with mood disorders frequently present with psychotic symptoms, in particular auditory hallucinations. These patients commonly have comorbid psychiatric disorders and suicidal ideation.

Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder.

BACKGROUND: Cognitive behavioral therapy has been shown to be more efficacious than alternative psychosocial interventions for the acute treatment of adolescents with major depressive disorder. However, the long-term impact of brief psychosocial interventions on the course of adolescent depression is not well established. METHODS: One hundred seven adolescents with major depressive disorder randomly assigned to 12 to 16 weeks of cognitive behavioral therapy, systemic behavioral family therapy, or nondirective supportive therapy were evaluated for 2 years after the psychotherapy trial to document the subsequent course and predictors of major depressive disorder. RESULTS: There were no long-term differential effects of the 3 psychotherapies. Most participants (80%) recovered (median time, 8.2 months from baseline), and 30% had a recurrence (median time, 4.2 months from recovery). Twenty-one percent were depressed during at least 80% of the follow-up period. Severity of depression (at baseline) and presence of self-reported parent-child conflict (at baseline and during the follow-up period) predicted lack of recovery, chronicity, and recurrence. Despite the similarity to clinically referred patients at baseline, patients recruited via advertisement were less likely to experience a recurrence. CONCLUSIONS: There were no significant differences in long-term outcome among cognitive behavioral therapy, systematic behavioral family therapy, and nondirective supportive therapy. While most participants in this study eventually recovered, those with severe depression and self-perceived parent-child conflict are at greater risk for chronic depression and recurrences.

Age- and sex-related risk factors for adolescent suicide.

OBJECTIVE: To examine the impact of age and sex on adolescent suicide risk. METHOD: A standard psychological autopsy protocol was used to compare 140 suicide victims with 131 community controls. The risk factors for older (> or = 16 years) and younger, and for male and female suicide were compared. RESULTS: Mood disorders, parental psychopathology, lifetime history of abuse, availability of a gun, and past suicide attempt conveyed significant risk for suicide across all 4 demographic groups. Psychopathology, particularly substance abuse (alone and comorbid with mood disorder), was more common and conveyed a much higher risk for suicide in the older versus younger adolescents. Younger suicide victims showed lower suicidal intent. Males chose more irreversible methods, and conduct disorder was both more prevalent and a more significant risk factor in males. CONCLUSIONS: The increased rate of suicide in older versus younger adolescents is due in part to greater prevalence of psychopathology, namely substance abuse, and greater suicidal intent in the older population. The increased rate in males is less easily explained, but it may stem from method choice and the greater prevalence of and risk conveyed by conduct disorder in males.

Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study.

OBJECTIVE: To replicate and extend work on the psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED), a child and parent self-report instrument used to screen for children with anxiety disorders. METHOD: The 41-item version of the SCARED was administered to a new sample of 190 outpatient children and adolescents and 166 parents. The internal consistency, discriminant, and convergent validity were assessed. In addition, using discriminant function analysis, a briefer version of the SCARED was developed. RESULTS: Using item analyses and factor analyses on the 41-item version, 5 factors were obtained: panic/somatic, generalized anxiety, separation anxiety, social phobia, and school phobia. In general, the total score and each of the 5 factors for both the child and parent SCARED demonstrated good internal consistency and discriminant validity (both between anxiety and depressive and disruptive disorders and within anxiety disorders). A reduced version of the SCARED yielded 5 items and showed similar psychometrics to the full SCARED. CONCLUSIONS: In a new sample, the authors replicated their initial psychometric findings that the SCARED is a reliable and valid instrument to screen for childhood anxiety disorders in clinical settings. Furthermore, pending future research, the 5-item SCARED appears to be a promising brief screening inventory for anxiety disorders in epidemiological studies.

A clinical trial for adolescent depression: predictors of additional treatment in the acute and follow-up phases of the trial.

OBJECTIVE: To examine the predictors of additional service use among participants in a clinical trial for depression. METHOD: 107 adolescents with DSM-III-R depression were randomly assigned to receive either cognitive-behavioral therapy, systemic behavioral family therapy, or nondirective supportive therapy for 12 to 16 weeks of acute treatment and followed up periodically for 24 months after the termination of acute treatment. RESULTS: More than half (53.3%) of the 107 randomized adolescents received additional treatment beyond that provided in the clinical trial, with a median time to additional treatment from intake of 7.2 months. The rates and times to additional treatment were similar in the 3 treatment groups, despite the superior efficacy of cognitive-behavioral therapy in the acute phase. The severity of the index depressive episode and comorbid dysthymia were a predictor of additional treatment in the acute phase, whereas in the follow-up period the severity of depressive symptomatology, the presence of disruptive disorders, and family problems predicted additional treatment. CONCLUSIONS: Subsequent clinical trials for early-onset depression must focus on the entire depressive episode, rather than just the acute phase, to prevent depressive relapse. In addition, attendant family difficulties and comorbid behavioral problems must be addressed.

Rapid response to psychosocial treatment for adolescent depression: a two-year follow-up.

OBJECTIVE: To examine the differential course and treatment outcome of patients who participated in a randomized clinical trial, comparing cognitive, family, and supportive psychotherapies for adolescent major depressive disorder. METHOD: In a sample of 100 depressed adolescents, remission, clinical recovery, recurrence, and functional improvement were examined at the end of acute treatment and at 1- and 2-year follow-up, according to their type of response to treatment. Rapid response was defined as a decline of > or = 50% in the Beck Depression Inventory (BDI) score from pretreatment until the beginning of the second session of psychotherapy, intermediate as a decline of < 50% but > 0%, and initial nonresponse as a BDI score that stayed the same or increased. RESULTS: Rapid responders showed a better outcome at acute treatment, 1-year, and in some measures, 2-year follow-up. For those who had recurrences over time, rapid responders showed a longer period before recurrence. Subjects were most likely to respond rapidly, or not at all, in the supportive cell. CONCLUSIONS: These findings suggest that milder forms of depression may benefit from initial supportive therapy or short trials of more specialized types of psychotherapy. The use of a placebo run-in period might help to "wash out" nonspecific responders.

Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression.

OBJECTIVE: To assess the predictors of treatment outcome across treatments, as well as those associated with differential treatment response. METHOD: One hundred seven adolescent outpatients, aged 13 to 18 years, with DSM-III-R major depression were randomly assigned to one of three manual-based, brief (12 to 16 sessions) psychosocial treatments: cognitive-behavioral therapy (CBT), systemic-behavioral family therapy, or nondirective supportive therapy. Those with good and poor outcomes were compared. RESULTS: Continued depression was predicted by clinical referral (versus via advertisement) and was in part mediated by hopelessness. Other predictors of depression were comorbid anxiety disorder and higher levels of cognitive distortion and hopelessness at intake. Achievement of clinical remission was predicted by a higher level of self-reported depression. Poorer functional status was predicted by a higher level of initial interviewer-rated depression. Comorbid anxiety and maternal depressive symptoms predicted differential treatment efficacy. CBT's performance continued to be robust with respect to nondirective supportive therapy, even in the presence of the above-noted adverse predictors. CONCLUSION: Predictors of poor outcome may give clues as to how to boost treatment response. Subjects who come to treatment for clinical trials via advertisement (versus clinical referral) may show more favorable treatment responses. CBT is likely to be a robust intervention even in more complex and difficult-to-treat patients.

A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy.

BACKGROUND: Previous studies in nonclinical samples have shown psychosocial treatments to be efficacious in the treatment of adolescent depression, but few psychotherapy treatment studies have been conducted in clinically referred, depressed adolescents. METHODS: One hundred seven adolescent patients with DSM-III-R major depressive disorder (MDD) were randomly assigned to 1 of 3 treatments: individual cognitive behavior therapy, systemic behavior family therapy (SBFT), or individual nondirective supportive therapy (NST). Treatments were 12 to 16 sessions provided in as many weeks. Intent-to-treat analyses were conducted using all follow-up data. RESULTS: Of the 107 patients enrolled in the study, 78 (72.9%) completed the study, 4 (3.7%) never initiated treatment, 10 (9.3%) had exclusionary criteria that were undetected at entry, 8 (7.5%) dropped out, and 7 (6.5%) were removed for clinical reasons. Cognitive behavior therapy showed a lower rate of MDD at the end of treatment compared with NST (17.1% vs 42.4%; P = .02), and resulted in a higher rate of remission (64.7%, defined as absence of MDD and at least 3 consecutive Beck Depression Inventory scores < 9) than SBFT (37.9%; P = .03) or NST (39.4%; p = .04). Cognitive behavior therapy resulted in more rapid relief in interviewer-rated (vs both treatments, P = .03) and self-reported depression (vs SBFT, P = .02). All 3 treatments showed significant and similar reductions in suicidality and functional impairment. Parents' views of the credibility of cognitive behavior therapy improved compared with parents' views of both SBFT (P = .01) and NST (P = .05). CONCLUSIONS: Cognitive behavior therapy is more efficacious than SBFT or NST for adolescent MDD in clinical settings, resulting in more rapid and complete treatment response.

Suicide in affectively ill adolescents: a case-control study.

Sixty-three adolescent suicide victims with a history of affective illness were compared to 23 adolescent community controls with a lifetime history of affective illness, using a case-control design. Suicide victims were more likely to have had major depression, comorbid substance abuse, a past suicide attempt, family history of major depression, treatment with a tricyclic antidepressant, history of legal problems, and a handgun available in the home. There was a non-significant trend for bipolar depression to convey a higher risk for completed suicide than unipolar depression. Recommendations for the prevention of suicide among those with early onset affective illness are discussed in light of these findings.

Risk factors for completed suicide among adolescents with a lifetime history of substance abuse: a case-control study.

The risk factors for suicide in adolescents with substance abuse were assessed by comparing 23 adolescent suicide victims and 12 community controls with a lifetime history of definite or probable DSM-III substance abuse. Suicide victims were more likely than controls to show the following risk factors: active substance abuse, comorbid major depression, suicidal ideation within the past week, family history of depression and substance abuse, legal problems and presence of a handgun in the home. Recommendations for the identification and prevention of suicide among substance-abusing youth on the basis of these findings are presented.

Firearms and adolescent suicide. A community case-control study.

OBJECTIVE: To assess the association between firearms in the home and adolescent suicide. RESEARCH DESIGN: Matched, case-control. SETTING: Population-based community sample. SUBJECTS: Sixty-seven adolescent suicide victims and a demographically matched group of 67 living community controls. SELECTION PROCEDURE: The series of adolescent suicide victims was consecutive, with an overall participation rate of 74% (67/91). MEASUREMENTS AND RESULTS: The presence, type (hand-gun vs long-gun), number, and method of storage (locked vs unlocked, loaded vs unloaded) of firearms in the home were compared between the suicide victims and controls. Even after adjusting for differences in rates of psychiatric disorders between suicide victims and controls, the association between suicide and both any gun (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 1.1 to 17.5) and handguns (OR = 9.4, 95% CI = 1.7 to 53.9) in the home were both highly significant. Long-guns in the home were associated with suicide only in rural areas, whereas handguns were more closely associated with suicide in urban areas. Handguns (OR = 12.9, 95% CI = 1.5 to 110.9) and loaded guns (OR = 32.3, 95% CI = 2.5 to 413.4) in the home were particularly significant risk factors for suicide in those with no apparent psychiatric disorder. CONCLUSIONS: When pediatricians are faced with a suicidal adolescent, they should insist on the removal of firearms from the home. Pediatricians should also inform parents that the presence of firearms may be associated with adolescent suicide even in the absence of clear psychiatric illness.

A psychoeducational program for families of affectively ill children and adolescents.

OBJECTIVE: The objective of this study was to evaluate the acceptability, feasibility, and efficacy of a family psychoeducational program for the parents of affectively ill adolescents. METHODS: Sixty-two parents of 34 affectively ill adolescents received one 2-hour psychoeducational session that covered information about the diagnosis, course, and treatment of affective illness. Methods of coping with an affectively ill family member also were discussed. The view of depression as a chronic and recurrent illness was strongly emphasized. RESULTS: Participants showed improvement in knowledge about depression and in modification of dysfunctional beliefs about depression and its treatment. Almost all participants found the program both useful and interesting. CONCLUSIONS: These findings support the feasibility, acceptability, and to a modest degree, the efficacy of a family psychoeducational program for parents of affectively ill adolescents. Additional studies should address the impact of such programs on compliance with treatment, clinical outcome, and family life.

Suicide in adolescents with no apparent psychopathology.

OBJECTIVE: To delineate the characteristics of adolescent suicide victims with no apparent psychiatric disorder. METHOD: Seven adolescent suicide victims with no apparent disorder were compared with 60 suicide victims with definite or probable psychiatric disorder, and with 38 community controls with no psychiatric disorder. RESULTS: Suicide victims without psychiatric disorder, compared with the remainder of suicides showed lower rates of past psychiatric treatment, previous suicide attempt, family history of affective illness, total life stressors over the previous 12 months, and a greater prevalence of the availability of a loaded gun in the home. The seven suicide victims compared with the 38 psychiatrically normal community controls, showed a higher rate of familial psychiatric disorder, past suicidal ideation or behavior, legal or disciplinary problems in the past year, and firearms in the home, particularly those that were loaded. CONCLUSION: Even suicide victims without apparent psychiatric disorder still show some evidence of psychiatric risk factors compared with community controls. However, prevention of suicide in this group is probably best achieved by restriction of the availability of firearms, particularly loaded ones. The clinician should pay particular attention to suicidal risk in youth who are confronting legal or serious disciplinary crises and should take suicidal ideation seriously even in the absence of clear psychopathology.

Psychiatric risk factors for adolescent suicide: a case-control study.

OBJECTIVE: The objective of this study was to determine the psychiatric risk factors for adolescent suicide. METHOD: Sixty-seven adolescent suicide victims were compared with 67 demographically matched community controls. Psychiatric disorder was assessed in suicide victims using a psychological autopsy protocol and in controls using similar semistructured psychiatric interviews. Risk factors were quantified by use of the odds ratio (OR), that is, the relative frequency of the occurrence of a given condition in the suicides compared with the controls. RESULTS: The most significant psychiatric risk factors associated with adolescent suicide were major depression (OR = 27.0), bipolar mixed state (OR = 9.0), substance abuse (OR = 8.5), and conduct disorder (OR = 6.0). Substance abuse was a more significant risk factor when comorbid with affective illness than when alone (OR = 17.0 versus 3.3). The majority of depressed suicide victims had a primary affective disorder (82%). A significant minority (31%) of depressed suicide victims had been depressed less than 3 months. Previous suicide attempts, suicidal ideation, and homicidal ideation also were associated with adolescent suicide. CONCLUSIONS: The development of effective treatments for youth who fit the above-noted risk profiles should be given high priority.

Stressful life events, psychopathology, and adolescent suicide: a case control study.

The relationship between stressful life events and adolescent suicide was assessed in 67 adolescent suicide victims and 67 matched community controls. In the year before death, suicide completers were more likely to have experienced: (1) interpersonal conflict with parents and with boy/girlfriends, (2) disruption of a romantic attachment, (3) legal or disciplinary problems. Legal or disciplinary problems were more commonly associated with suicide in conduct and substance abuse disordered youth. Interpersonal loss was more commonly associated with suicide in substance abuse as well. Even after controlling for psychopathology, legal and disciplinary problems in the past year were associated with an increased risk of suicide.

Adolescent psychiatric inpatients' risk of suicide attempt at 6-month follow-up.

Adolescent inpatients (of whom 48 were admitted for a suicide attempt, 33 were admitted for suicidal ideation, and 53 had no history of clinically significant suicidal ideation or attempt), were interviewed while in the hospital and then followed up 6 months later. Of the 134 patients followed up, 13 (9.7%) had made a suicide attempt. The vast majority of those who attempted suicide had been suicidal while in the hospital (12/13 or 92.3%). Other risk factors for suicidal behavior include major depression at intake, affective disorder with nonaffective comorbidity, a depressive disorder that continued through follow-up, death of a relative, and family financial problems. Suicidal inpatients, particularly those with chronic and recurrent affective illness, are at substantial risk for making a suicide attempt within 6 months of discharge. At follow-up, an even higher proportion showed attempts or suicidal ideation with a plan (N = 36 or 26.8%), with risk factors similar to those noted above. More intense outpatient or partial hospital interventions as a transition from the inpatient environment may be necessary to reduce the rate of recidivism among suicidal adolescents.