A semistructured cognitive behavioral (CB) program that teaches cognitive reappraisal and problem-solving skills helps prevent depression in high-risk adolescents, according to a new study.
The study found that the incidence of depression was more than 11% less among teens who participated in the CB program than among those who did not receive this intervention.
If teachers, nurses, and others learned how to provide this intervention, it could help the substantial number of teens whose parents are prone to depression and who are themselves at high risk of developing this disorder, said Judy Garber, PhD, from Vanderbilt University, in Nashville, Tennessee.
"We know that depression is a common and serious problem, that it often starts during adolescence, and that we can prevent onsets by teaching teens how to manage stress and how to view things differently," Dr. Garber toldMedscape Psychiatry. "This is a relatively straightforward intervention, and if it were adopted by schools or doctors' offices, etc, it might have an important impact."
The study was published in the June 3 issue of the Journal of the American Medical Association.
Teens Learned Problem-Solving Skills
The study involved 316 adolescents, aged 13 to 17 years, who had at least 1 parent or caretaker with a history of depression and/or current depression. The teens themselves were not depressed at the start of the study, but they had a history of depression and/or current elevated but subdiagnostic depressive symptoms.
The children were enrolled in the multicenter study, conducted at 4 sites in 4 states, between August 2003 and February 2008. After screening, 159 adolescents were randomized to the CB program and 157 were randomized to usual care.
The program consisted of 8 weekly 90-minute CB sessions, followed by 6 monthly sessions, with mixed-sex groups of 3 to 10 individuals. The teens initially learned problem-solving skills and techniques to identify and manage unrealistic and negative thoughts. During the 6-month continuation phase, they reviewed these skills and learned new behavioral, relaxation, and assertiveness skills.
Usual care encompassed any services that the teen received while in the study. Because these teens were not currently depressed, in many cases usual care meant little or no intervention, said Dr. Garber
Consistent Results for All Study Sites
Researchers used a number of clinical tests to evaluate the teens at baseline, after the intervention phase, and at the end of the 6-month continuation phase. The primary outcome was a score of 4 or more on the Depression Symptom Rating (DSR) scale for at least 2 weeks, which indicates a probable or definite episode of depression.
Researchers also used the self-report Center for Epidemiological Studies Depression (CES-D) rating scale, and the clinician-rated 17-item Children's Depression Rating Scale-Revised (CDRS-R).
The study found that children in the CB program had 11.3% fewer episodes of depression than those assigned to usual care (21.4% vs 32.7%, respectively).
The CB program also resulted in fewer self-reported depressive symptoms in adolescents than usual care.
The results did not vary significantly across locations. "All 4 sites showed effects, and there were no site differences in the effects of the intervention," said Dr. Garber.
Depressed Parents
The CB program was significantly better than usual care at preventing depression in teens if a parent did not have current depression (11.7% vs 40.5%). However, when a parent was depressed, the rates of depression among the youth did not differ significantly (31.2% for the CB program and 24.3% for usual care).
Within the CB program, if a parent had current depression, the child was almost 3 times more likely to develop depression than if the parent was not currently depressed (31.2% vs 11.7%).
"If the parents of adolescents who went through the program were currently depressed, then the teens did not reap the benefits of the program the way that the teens whose parents were not currently depressed did," said Dr. Garber.
There are several possible explanations for this, she said. It could be that there is more stress in the family, that the parent's depression is more chronic or severe, or that the teens are more genetically vulnerable, or it could be a combination of all of these factors. "It also could be that the parent is not as good at helping the child use the skills that we're trying to teach them," said Dr. Garber "So children may go home and try out these skills, and if the parent is not receptive, the teen may be less likely to use them."
Having a parent with depression did not seem to make a difference to the incidence of depression among teens in the usual-care group.
Cost Effective
Dr. Garber said this CB program could be offered across the country if school counselors, nurse practitioners, and other groups learned to administer it. Of course, she added, the matter of who would pay for it would have to be resolved, although there is some evidence that the program may be cost-effective.
Each of the 33 sets of siblings who participated in the study received the same intervention, an approach that anecdotal evidence showed had some merit, said Dr. Garber. "Parents would tell us that if 1 of their teens was upset, the other teen was able to talk to her [or him] about it and say, 'remember what we learned in that group,' so they would help each other."
Research shows that the offspring of parents with a history of depression are at a 2- to 3-fold increased risk of developing depression themselves. Both genes and the environment likely play a role in this familial transmission, said Dr. Garber.
However, only about 23% of depressed youth receive treatment and at least 20% of them develop recurrent, persistent, and chronic depression that is difficult to treat.
A Big "Hats Off"
Asked by Medscape Psychiatry to comment on the study, David Shaffer, MD, from Columbia University and the New York State Psychiatric Institute, in New York City, was full of praise: "Hats off to a group who has studied with great care a difficult problem in an imaginative and appropriate way and found that [the CB program] works."
Including teens that had a family history of depression and a number of depressive symptoms but did not meet criteria for major depression "allowed the investigators to see that the effects of having a parent who was currently depressed were more influential in determining outcome than the adolescent's level of depression," said Dr. Shaffer.
The CB program used in the study was "very sensible and rather innovative," in that it was given in a group setting rather than 1 on 1.
"The fact that they borrow from an approach developed for social anxiety is exciting because the comorbidity between anxiety and depression is considerable," said Dr. Shaffer.
He added that the group setting might carry more impact for teens than just recounting their own examples and hearing advice from their own therapist. "Social examples are a powerful vector for learning at all ages, but especially among teens."
Dr. Shaffer cautioned, however, that the study findings might not apply to teens at lower risk. "One shouldn't be too surprised or put off if future studies on kids carrying a lower level of risk don't respond as well."
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