JOURNAL ARTICLE REVIEW

School-Based Cognitive-Behavioral Therapy for Adolescent Depression S.R. Shirk, H. Kaplinski & G. Gudmundsen (2009)

Shawna Sjoquist
APSY 674

OUTLINE

Introduction Design Method (Sample, Measures, Treatment, Procedure) Results (Preliminary Analysis, Predictors of Outcomes) Strengths/ Limitations

Further Implications

DEPRESSION
Emotional/ Affective Symptoms
Cognitive Symptoms Motivational Symptoms Physical Symptoms
Dysphonic mood Inability to experience enjoyment

Negative Self Evaluation Feelings of Guild and/or Hopelessness

Social Withdrawal Suicidal Ideation

Chronic Fatigue/ Low Energy Levels Sleep Disturbances

K. Rice & T. F. McLaughlin, 2001

DEPRESSION

15% to 20% of adolescents will experience major depression, with annual incidence rate of 7.7%

Prevalence rate estimate ranges between 3% to 8%

Functional Impairments Future Concerns

Poor Academic Achievement Peer Problems Substance Abuse Suicide

Recurrence of Depressive Episodes Impaired Occupational Functioning Early Childbearing Lowered Life Satisfaction

COGNITIVE-BEHAVIORAL THERAPY (CBT)

Randomized control trials have revealed moderate to large treatment effects for adolescent depression.

Advancing as a promising evidence-based treatment for adolescent depression (Kazdin & Weisz, 2003)
Comparable results for CBT under clinically representative conditions (i.e. School mental health services).

CURRENT

STUDY

Referral Process Diagnostic Inclusion Criteria Relaxed Exclusion Criteria

Conduct Disorder Substance Use Trauma History

DESIGN

Benchmarking Strategy

Magnitude Predictors
Naturalistic Design

Evaluation

Treatment Response

METHOD: SAMPLE

50 adolescents Selected from 4 high schools in the Rocky Mountain West region.

Identified as by school based personnel as having symptoms of depression.

Symptoms were identified through routine academic or clinical assessments i.e. IEPs. Computerized Diagnostic Interview Scale for Children (C-DISC-IV).

METHOD: SAMPLE CHARACTERISTICS

Diversity

Ethnic Youth Minority 46%

European American 54%

Other Hispanic African American

Gender
Male 32%
Female 68%

METHOD: SAMPLE CO-MORBIDITY

Adolescents 32 21 22

14

Comorbid Disorders

3+ Disorders

History of Attempted Suicide

Prior Traumatic Event (PTSD)

11%
20% 40% GAD CD Social Phobia ADHD

29%

METHOD: MEASURES

C-DISC-IV (Mood, Anxiety, Disruptive Behavior Disorder Modules) (Shaffer et al., 2000).

Good reliability and Criterion validity Pre and post-treatment

Beck Depression Inventory (BDI) (Beck, Wardd, Mendelson, Mock &

Erbaugh, 1961)

Good psychometric properties and Research supports use with adolescents. Pre, mid and post-treatment

METHOD: MEASURES

Life Events Questionnaire (LEQ) (Newcomb, Huba & Bentler,

1981)

Evaluated exposure to stress and pre-treatment perception of stress Internal reliability set at .82

Trauma History
Self reported item added to the LEQ Indicated presence or absence of exposure to traumatic event.

Demographic Information
Gender, Age, Grade, Race-ethnicity Number of sessions attended.

METHOD: TREATMENT AND THERAPISTS

12 Session Manual Based CBT Culturally sensitive protocol was selected Slight cultural modifications made Delivered by 8 doctoral level psychologists Three Components:

Cognitive Module Behavioral Module Interpersonal Module

Treatment Fidelity

METHOD: TREATMENT BENCHMARKS

9 published trials of CBT for adolescent depression

Modality and dose varied

3 Studies of standard length were chosen

Treatments shared some but not all components Compared results and outcomes Outcome data from 9 studies used to generate benchmark z scores for CBT at pre and post-treatment.

METHOD: PROCEDURES

Identification Informed Consent Pre-treatment intake sessions Treatment occurred in school-based clinics C-DISC-IV and BDI at 2 weeks post completion or 14 weeks after treatment start date were termination occurred prior to week 12.

RESULTS: PRELIMINARY ANALYSES

Overall
Avg. of 8.8 sessions completed; 58% full completion Significant reduction in depressive symptoms on BDI pre and post-treatment No significant therapist or school effects of outcomes.

Current sample vs. Benchmark

slightly older, presentation with comorbid CD, increased diagnosis of MDD More severe depressive symptoms

Primary Outcomes Compared

2. 5 times as large

Response Rates Compared

Response rate comparable to prior efficacy studies. Depressive symptoms normalized by post-treatment 62% met criteria for clinically significant change.

RESULTS: PREDICTORS OF OUTCOMES

Stress Depressive symptoms

Increased depressive symptoms; increased likelihood of retained diagnosis

Reported trauma history

Severity and life stress marginally correlated

# of Sessions completed Age, CD symptoms and number of co-morbid disorders unrelated to outcomes. No significant difference for gender or ethnicity

STUDY STRENGTHS

High level of treatment fidelity and adherence

Ethnically diverse/ highly comorbid group of schoolreferred adolescents

STUDY LIMITATIONS

Relatively small sample

Missing outcome data for 9 participants

Follow-up data not available Outcome data derived from single source Change in depressive symptoms potentially inflated by regression effects.

IMPLICATIONS: FUTURE RESEARCH

Address long-term outcomes for CBT in school settings Impact of CBT on academic outcomes Potential impact of therapist training and supervision outcomes Evaluate outcomes of school based CBT delivered by school-based clinicians.

IMPLICATIONS: PRACTICE

Potential treatment approach for school based services Associated treatment costs

Training of school-based personnel

Consideration of Academic programming time Visibility of outcomes

FINAL THOUGHTS

Provides a treatment option Requires staff resources

REFERENCES

Kazdin, A., & Weisz, J. (Eds.). (2003). Evidence-based psychotherapies for children and adolescents. New York: Guilford.

Shirk, S. R., Kaplinski, H., & Gudmundsen, G. (2009). School-Based CognitiveBehavioral Therapy for Adolescent Depression: A Benchmarking Study. Journal Of Emotional & Behavioral Disorders, 17(2), 106-117.
Rice, K & McLaughlin, T. F. (2001). Childhood and Adolescent Depression: A Review with Suggestions for Special Educators. International Journal of Special Education, 16(2), 85-96 Shaffer, D., Fisher, P., Lucas, C., Dulcan, M., & Schwab-Stone, M. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): Description, differences from pre-vious versions, and reliability of some common diagnoses. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 2838.

Newcomb, M., Huba, G., & Bentler, P. (1981). A multidimensional assessment of stressful life events among adolescents: Derivation and correlates. Journal of Health and Social Behavior, 22, 400415.