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Original Investigation |

Effect of a Cognitive-Behavioral Prevention Program on Depression 6 Years After Implementation Among At-Risk Adolescents A Randomized Clinical Trial

David A. Brent, MD1,2; Steven M. Brunwasser, PhD3; Steven D. Hollon, PhD4; V. Robin Weersing, PhD5; Gregory N. Clarke, PhD6; John F. Dickerson, PhD6; William R. Beardslee, MD7; Tracy R. G. Gladstone, PhD8; Giovanna Porta, MS2; Frances L. Lynch, PhD6; Satish Iyengar, PhD9; Judy Garber, PhD3
[+] Author Affiliations
1Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
2Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
3Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee
4Department of Psychology, Vanderbilt University, Nashville, Tennessee
5Joint Doctoral Program in Clinical Psychology, San Diego State University, San Diego, California, and University of California, San Diego, San Diego
6Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
7Department of Psychiatry, Boston Children’s Hospital, Boston, Massachusetts
8Wellesley Centers for Women, Wellesley College, Wellesley, Massachusetts
9Department of Statistics, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA Psychiatry. 2015;72(11):1110-1118. doi:10.1001/jamapsychiatry.2015.1559.
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Importance  Adolescents whose parents have a history of depression are at risk for developing depression and functional impairment. The long-term effects of prevention programs on adolescent depression and functioning are not known.

Objective  To determine whether a cognitive-behavioral prevention (CBP) program reduced the incidence of depressive episodes, increased depression-free days, and improved developmental competence 6 years after implementation.

Design, Setting, and Participants  A 4-site randomized clinical trial compared the effect of CBP plus usual care vs usual care, through follow-up 75 months after the intervention (88% retention), with recruitment from August 2003 through February 2006 at a health maintenance organization, university medical centers, and a community mental health center. A total of 316 participants were 13 to 17 years of age at enrollment and had at least 1 parent with current or prior depressive episodes. Participants could not be in a current depressive episode but had to have subsyndromal depressive symptoms or a prior depressive episode currently in remission. Analysis was conducted between August 2014 and June 2015.

Interventions  The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Usual care consisted of any family-initiated mental health treatment.

Main Outcomes and Measures  The Depression Symptoms Rating scale was used to assess the primary outcome, new onsets of depressive episodes, and to calculate depression-free days. A modified Status Questionnaire assessed developmental competence (eg, academic or interpersonal) in young adulthood.

Results  Over the 75-month follow-up, youths assigned to CBP had a lower incidence of depression, adjusting for current parental depression at enrollment, site, and all interactions (hazard ratio, 0.71 [95% CI, 0.53-0.96]). The CBP program’s overall significant effect was driven by a lower incidence of depressive episodes during the first 9 months after enrollment. The CBP program’s benefit was seen in youths whose index parent was not depressed at enrollment, on depression incidence (hazard ratio, 0.54 [95% CI, 0.36-0.81]), depression-free days (d = 0.34, P = .01), and developmental competence (d = 0.36, P = .04); these effects on developmental competence were mediated via the CBP program’s effect on depression-free days.

Conclusions and Relevance  The effect of CBP on new onsets of depression was strongest early and was maintained throughout the follow-up period; developmental competence was positively affected 6 years later. The effectiveness of CBP may be enhanced by additional booster sessions and concomitant treatment of parental depression.

Trial Registration  clinicaltrials.gov Identifier:NCT00073671

Figures in this Article


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Figure 1.
Consolidated Standards of Reporting Trials Diagram of Flow of Participants From Screening to Analysis

CES-D indicates Center for Epidemiological Studies of Depression Scale.

aOf these 16 adolescents, 13 completed the 75-month (6-year) follow-up.

bOf these 23 adolescents, 16 completed the 75-month (6-year) follow-up.

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Figure 2.
Parental Depression at Baseline Evaluation as Moderator of Primary Outcome (Time to Onset of a Depressive Episode)
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Figure 3.
Moderation/Moderated-Mediation Analysis of Developmental Competence

Solid lines indicate statistically significant paths, and dashed lines represent nonstatistically significant paths.

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Instituting mental health education in secondary schools
Posted on December 18, 2015
Hans Oh
University of California, Berkeley
Conflict of Interest: None Declared
Brent and colleagues employed a Cognitive Behavioral Prevention program using an indicated approach to prevention, targeting vulnerable students that screen positive for (a) subsyndromal symptoms or a prior depressive episode, and (b) at least one parent with current or prior depressive episodes. But historically we have struggled to identify and engage at-risk individuals in the US, where the majority of psychiatric disorders begin to surface in childhood and adolescence, and yet it can be years before these disorders are ever treated. An indicated approach will require ramping up school-based early detection efforts.

Alternatively we could cast a wider net. By using a selective approach, we can administer a modified version of CBP to every student within a given school or school district, under the belief that CBP will promote student health and wellness to an extent that outweighs any costs or consequences. Even wider still, we can use a universal approach and administer CBP to every student across the country. Students would learn how to catch their automatic thoughts, how to check those thoughts for any inaccuracies or distortions, and how to change those thoughts to enhance goal-directed feelings and behaviors. This is beneficial for addressing a broad range of psychological problems and is arguably something that students ought to learn regardless of risk-level. Further, students would not feel stigmatized since everyone would be required to participate.

CBP can be nested within a mandated mental health class for all students, which could also cover topics on how to cope with stress, how to recognize symptoms, how to solve problems, and how to seek help. Instituting a mandated mental health class may seem controversial, but recently schools have been making headway. In California and New York, some schools have scheduled a time of meditation for students in an effort to alleviate stress, enhance academic performance, and reduce behavioral problems. We can garner public support by pointing out that for decades we have been requiring all students to take physical education because we believe that they need to learn how to exercise in order to avoid health problems and lead healthy and productive lives. By applying this same rationale, we can argue that students should devote equal attention to mental wellness, establishing a parity of esteem between the mind and body.
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