How effective are treatments for child and adolescent depression? A meta-analytic review.

We located a comprehensive sample of studies (1980-1999) on the psychosocial and pharmacological treatment of child and adolescent depression through an extensive literature search. Articles that met the inclusionary criteria were subsequently analyzed. The outcome data from 38 studies were extracted and converted into effect sizes (ESs). Comparisons of main effects, demographic, and quality of study variables were conducted. The overall findings of this meta-analysis indicate that several different psychosocial interventions for child and adolescent depression produced moderate to large treatment gains that were clinically meaningful for many afflicted youth. However, in general, the vast majority of pharmacological interventions were not effective in treating depressed children and adolescents. Nonetheless, there is recent evidence that selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine are efficacious, and will likely play an increased role in the management of affective illness in youngsters. The clinical implications and limitations of these data are discussed and suggestions for future research are provided.     

Applying the criteria for empirically supported treatments to studies of psychosocial interventions for child and adolescent depression

Reviews the psychosocial treatment outcome studies for depressed children and adolescents and concludes that psychosocial interventions are effective at posttreatment and follow-up in reducing depressive symptoms/disorders in clinical and nonclinical samples of youth, regardless of treatment modality or extent of parental involvement. The article then examines the extent to which each study conforms to the guidelines set forth by the Task Force on Promotion and Dissemination of Psychological Procedures (1996) for well-established and probably efficacious interventions. Results of this analysis indicate only 2 series of studies that meet criteria for probably efficacious interventions and no studies that meet criteria for well-established treatments. Finally, the advantages and disadvantages of applying criteria for empirically supported treatments to identify good treatments for depressed youth are discussed, the importance of devising developmentally and culturally sensitive interventions targeted to the unique needs of each child is highlighted, and recommendations for future research that is informed by clinical practice and empirical findings are offered.     

Self-administered treatments for depression: a review

Although there are numerous self-help books for depression, relatively few have been empirically tested. However, those that have been used in clinical trials have fared well, with an average effect size roughly equivalent to the average effect size obtained in psychotherapy studies. Computer-based treatments are being developed and appear promising as an alternative to bibliotherapy for those interested in self-administered treatments. This article provides a summary of the depression bibliotherapy literature and discusses several remaining questions such as effectiveness versus efficacy, practice applications, ethics, and future research.     

A meta-analysis of treatments for perinatal depression

This meta-analysis assessed efficacy of pharmacologic and psychological interventions for treatment of perinatal depression. A systematic review identified 27 studies, including open trials (n = 9), quasi-randomized trials (n = 2), and randomized controlled trials (n = 16) assessing change from pretreatment to posttreatment or comparing these interventions to a control group. Uncontrolled and controlled effect sizes were assessed in separate meta-analyses. There was significant improvement in depressive symptoms from pretreatment to posttreatment, with an uncontrolled overall effect size (Hedges' g) of 1.61 after removal of outliers and correction for publication bias. Symptom levels at posttreatment were below cutoff levels indicative of clinically significant symptoms. At posttreatment, intervention groups demonstrated significantly greater reductions in depressive symptoms compared to control groups, with an overall controlled effect size (Hedges' g) of 0.65 after removal of outliers. Individual psychotherapy was superior to group psychotherapy with regard to changes in symptoms from pretreatment to posttreatment. Interventions including an interpersonal therapy component were found to have greater effect sizes, compared to control conditions, than interventions including a cognitive-behavioral component. Implications of the findings for clinical practice and future research are discussed.     

Mode-specific effects among three treatments for depression

In the NIMH Treatment of Depression Collaborative Research Program (TDCRP), 250 depressed outpatients were randomly assigned to interpersonal psychotherapy, cognitive-behavioral therapy, imipramine plus clinical management, or pill placebo plus clinical management treatments. Although all treatments demonstrated significant symptom reduction with few differences in general outcomes, an important question concerned possible effects specific to each treatment. The therapies differ in rationale and procedures, suggesting that mode-specific effects may differ among treatments, each of which was precisely specified, applied appropriately, and shown to be discriminable. Outcome measures were selected for presumed sensitivity to the different treatments. Findings provided only scattered and relatively insubstantial support for mode-specific differences. None of the therapies produced consistent effects on measures related to its theoretical origins.     

Marital adjustment and outcome following treatments for depression

Marital adjustment and treatment outcome were evaluated in the Treatment of Depression Collaborative Research Program, a multicenter clinical trial evaluating interpersonal psychotherapy, cognitive therapy, imipramine, and placebo. Marital adjustment and depression were assessed pre- and posttreatment, and depression was assessed at 6, 12, and 18 months after treatment. Results indicate that (a) there was a significant improvement in marital adjustment after treatment, (b) this effect was not moderated by treatment type, and (c) this effect was mediated by change in depression. Poor pretreatment marital adjustment was modestly associated with negative outcome, whereas poor posttreatment marital adjustment was strongly associated with negative outcome during follow-up. The findings suggest that poor marital adjustment at the end of active treatment is a risk factor for increases in depression severity during follow-up.     

Psychosocial treatments for ADHD in teens and adults: a practice-friendly review

Although stimulant medication is a cornerstone of treatment for attention deficit hyperactivity disorder (ADHD), numerous nonpharmacological treatments can be employed in combination with medication to assist in the lifelong management of the disorder. A multimodal treatment combining psychoeducation, medication, psychotherapy, compensatory behavioral/self-management skills, technological tools and devices, coaching, advocacy, and reasonable school or workplace accommodations is probably the most comprehensive and effective. This article describes a variety of psychosocial treatments that are commonly used for adolescents and adults suffering from ADHD.     

Psychosocial factors and episode number in depression

We studied the relationship between 2 types of psychosocial factors, life events and chronic stress, and the numerical order of the depressive episodes. The population studied consisted of 97 subjects suffering from major depressive disorder and 65 controls. Life events occurred with the first 2 depressive episodes with significantly higher frequency than with later episodes or with the control group. Patients in the third or later episode had no more life events than controls. No significant differences were apparent in the incidence of chronic stress in the different depressive episodes of the patient group or in the comparison of this group with controls. No second order interaction between life events and chronic stress was found.     

Psychosocial factors in outcome in two opiate addiction treatments

Thirty naltrexone and 30 methadone patients in outpatient opiate addiction treatment were compared on pretreatment somatization, stress, and family support. Also, the relationship between these pretreatment variables and outcome in terms of drug abuse and retention was examined. In the methadone group, drug abuse was correlated significantly with somatization, stress, and family support. In the naltrexone group, retention was correlated significantly with somatization and stress. Treatment and research considerations were discussed.     

Psychosocial treatments in pain management of sickle cell disease

The principal symptom of sickle cell disease (SCD) is pain. Many studies have been conducted on pain management strategies for this illness. There is recognition that psychosocial factors influence clinical disease outcomes; therefore, more attention is being provided to behavioral interventions that address psychosocial problems. This review examines the psychosocial interventions that have been researched for children and adults with SCD, the limitations of these studies, and barriers to implementing the treatments. The intervention receiving the most empirical support was cognitive-behavioral therapy. Additional research is needed to define the efficacy and effectiveness of the other psychosocial treatments. Suggestions for future investigations include conducting research that has better methodology, and providing more education for health care providers about psychosocial treatments and the importance of considering cultural factors in health care delivery. In addition, individuals with SCD need to have more information about their illness and better access to psychosocial interventions.     

Psychosocial treatments of suicidal behaviors: a practice-friendly review

Worldwide, almost a million people die by suicide each year. Intentional, nonfatal, self-inflicted injury, including both suicide attempts and acts without suicide intent, also has very high prevalence. This article provides a practice-friendly review of controlled studies of psychosocial treatments aiming to prevent suicide, attempted suicide, and nonsuicidal self-inflicted injuries. Despite relatively small sample sizes for a low-base-rate outcome such as self-inflicted injury, several psychotherapies have been found effective, including cognitive therapy, dialectical behavior therapy, problem-solving therapy, and interpersonal psychotherapy, as well as outreach interventions, such as sending caring letters. The clinical implications of the review are discussed with the goal of translating the science to service-particularly the importance of outreach and treatment of non-compliance, the assessment and management of suicide risk, and competency in effective psychotherapies. These are critical steps for clinical psychology and psychotherapists to take in their role in suicide prevention.     

Validation of Edinburgh postnatal depression scale for adolescent mothers

The Edinburgh Postnatal Depression Scale has widespread use internationally with adult women, but few psychometric properties have been described for samples of adolescent mothers. The purpose of this paper is to validate the psychometric properties of the EPDS in a sample of adolescent mothers (n = 149) in a southern, urban area of the United States. Internal consistency reliability was .88. Principal components analysis supported a two factor structure accounting for 60% of variance. Results of item response theory analysis suggest that the EPDS and the Center for Epidemiologic Studies of Depression Scale have similar psychometric properties. This data can be used to provide evidence of construct validity of the EPDS. The study provides a foundation for further psychometric testing of the instrument.     

Psychosocial treatments for multiple unexplained physical symptoms: a review of the literature

OBJECTIVE: Patients presenting with multiple medically unexplained physical symptoms, termed polysymptomatic somatizers, often incur excessive healthcare charges and fail to respond to standard medical treatment. The present article reviews the literature assessing the efficacy of psychosocial treatments for polysymptomatic somatizers. METHODS: Relevant articles were identified by scanning Medline and PsychLit. Thirty-four randomized, controlled studies were located. Whenever possible results from each study were transformed into effect sizes. An analysis of the efficacy of the psychotherapeutic approaches is provided. RESULTS: Various psychosocial interventions have been investigated with polysymptomatic somatizers. Although the majority of studies suggest psychosocial treatments benefit this population, the literature is tarnished by methodological shortcomings. Effect sizes are modest at best. Long-term improvement has been demonstrated in fewer than one-quarter of the trials. CONCLUSIONS: Although seemingly beneficial, psychosocial treatments have not yet been shown to have a lasting and clinically meaningful influence on the physical complaints of polysymptomatic somatizers.     

Psychosocial processes underlying the maintenance and persistence of depression: implications for understanding chronic depression.

The three major theoretical perspectives on the maintenance and persistence of depression in the psychological literature are reviewed. Cognitive theorists, such as Teasdale and Nolen-Hoeksema, focus on how a reciprocal relationship between depressed mood and the individual's processing of, and response to, their symptoms maintains and prolongs the duration of depressive episodes. Interpersonal theorists, such as Lewinsohn and Coyne, hypothesize that the depressed person's interpersonal behavior elicits negative reactions from the social environment, leading to a downward spiral of persistent depression. Finally, recent studies have indicated that individuals who experienced childhood adversity are more susceptible to a chronic course of depression. Although these three perspectives vary somewhat in the degree of support they have accumulated, each exhibits some promise for helping to elucidate the maintenance and persistence of depression. However, much of the available empirical literature suffers from a number of critical limitations, including the lack of clinical samples, longitudinal studies, and adequate attention to confounding variables, such as the severity and duration of depression at baseline and comorbid psychopathology. We conclude by suggesting a number of ways in which cognitive and interpersonal factors and early adversity may interact to maintain and prolong depressive episodes.     

Psychosocial treatments for negative symptoms in schizophrenia: Current practices and future directions

Schizophrenia can be a chronic and debilitating psychiatric disorder. Though advancements have been made in the psychosocial treatment of some symptoms of schizophrenia, people with schizophrenia often continue to experience some level of symptoms, particularly negative symptoms, throughout their lives. Because negative symptoms are associated with poor functioning and quality of life, the treatment of negative symptoms is a high priority for intervention development. However, current psychosocial treatments primarily focus on the reduction of positive symptoms with comparatively few studies investigating the efficacy of psychosocial treatments for negative symptoms. In this article, we review and evaluate the existing literature on three categories of psychosocial treatments — cognitive behavioral therapy (CBT), social skills training (SST), and combined treatment interventions — and their impact on the negative symptoms of schizophrenia. Of the interventions reviewed, CBT and SST appear to have the most empirical support, with some evidence suggesting that CBT is associated with maintenance of negative symptom improvement beyond six months after treatment. It remains unclear if a combined treatment approach provides improvements above and beyond those associated with each individual treatment modality. Although psychosocial treatments show promise for the treatment of negative symptoms, there are many unanswered questions about how best to intervene. We conclude with a general discussion of these unanswered questions, future directions and methodological considerations, and suggestions for the further development of negative symptom interventions.     

Double depression in adolescent substance users

One hundred adolescent substance users were interviewed in a youth drop-in counseling center. The results indicated that 16% of the sample suffered from a nontransitory type of depression with a duration of at least one year with a superimposed major depressive disorder. The group with such double-depression was found to include significantly more alcohol dependent individuals as well as amphetamine abusers. The study gives further support to the DSM-III notion that depression is associated with substance use in adolescents.     

Evidence of cost-effective treatments for depression: a systematic review

BACKGROUND: High levels of public spending, rising costs of treatments and scarcity of mental health resources have intensified the need for information on the cost-effectiveness of interventions for depression. There have been few reviews that consider the cost-effectiveness of all treatments for depression together. METHODS: Systematic review of published economic evaluations of interventions for depression to identify where evidence of cost-effectiveness exists and where ambiguity remains. RESULTS: Fifty-eight papers met the criteria and were included in the review. The quality of the evaluations varied greatly. Evidence establishing the cost-effectiveness of interventions for depression is accumulating; selective serotonin reuptake inhibitors (SSRI) and the newer antidepressants venlafaxine, mirtazepine and nefazodone appear cost-effective compared with older drugs. Despite the availability of high quality economic evaluations of psychological therapies compared to usual care, there is limited evidence of their cost-effectiveness particularly when compared directly to pharmacotherapies. Changes to health systems have been found to be cost-effective in some patient groups, but there is no evidence that screening in primary care populations is a cost-effective strategy. LIMITATIONS: Vastly different interventions, outcome measures and cost perspectives meant a meta-analysis of costs and effects was not considered possible. CONCLUSIONS: On the basis of available evidence, it is not possible to identify the most cost-effective strategy for alleviating the symptoms of depression, although the SSRIs and newer antidepressants consistently appear more cost-effective than tricyclic antidepressants in many patient groups. Better quality economic evidence is needed.