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Original Article |

A Randomized Effectiveness Trial of Interpersonal Psychotherapy forDepressed Adolescents FREE

Laura Mufson, PhD; Kristen Pollack Dorta, PhD; Priya Wickramaratne, PhD; Yoko Nomura, PhD; Mark Olfson, MD; Myrna M. Weissman, PhD
[+] Author Affiliations

From the Department of Clinical and Genetic Epidemiology, New YorkState Psychiatric Institute (Drs Mufson, Wickramaratne, Nomura, Olfson, andWeissman), and the Department of Psychiatry, Columbia University College ofPhysicians and Surgeons (Drs Mufson, Dorta, Wickramaratne, Nomura, Olfson,and Weissman), New York. Drs Mufson and Weissman have received royalties fromthe sale of the manual used in this study.


Arch Gen Psychiatry. 2004;61(6):577-584. doi:10.1001/archpsyc.61.6.577.
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Context  Adolescent depression is highly prevalent and has substantial morbidity, including suicide attempts, school dropout, and substance abuse, but many depressed adolescents are untreated. The school-based health clinic offers the potential for accessible and efficient treatment, although it is unknown whether school-based clinicians can be trained to implement evidence-based psychotherapies for depression in routine care.

Objective  To assess the effectiveness of interpersonal psychotherapy modified for depressed adolescents (IPT-A) compared with treatment as usual (TAU) in school-based mental health clinics.

Design  A 16-week randomized clinical trial was conducted from April 1, 1999, through July 31, 2002.

Setting  Five school-based mental health clinics in New York City, NY.

Patients  Sixty-three adolescents referred for a mental health intake visit who met eligibility criteria. Eligible patients had a mean Hamilton Depression Rating Scale score of 18.6 (SD, 5.5) and a mean Children's Global Assessment Scale score of 52.6 (SD, 5.5) and met DSM-IV criteria for major depressive disorder, dysthymia, depression disorder not otherwise specified, or adjustment disorder with depressed mood. Mean age was 15.1 years (SD, 1.9 years). The sample was predominantly female (n = 53 [84%]), Hispanic (n = 45 [71%]), and of low socioeconomic status.

Intervention  Patients were randomly assigned to receive IPT-A (n = 34) or TAU (n = 29) from school-based health clinic clinicians.

Main Outcome Measures  The Hamilton Depression Rating Scale, Beck Depression Inventory, Children's Global Assessment Scale, Clinical Global Impressions scale, and the Social Adjustment Scale–Self-Report.

Results  Adolescents treated with IPT-A compared with TAU showed greater symptom reduction and improvement in overall functioning. Analysis of covariance showed that compared with the TAU group, the IPT-A group showed significantly fewer clinician-reported depression symptoms on the Hamilton Depression Rating Scale (P = .04), significantly better functioning on the Children's Global Assessment Scale (P = .04), significantly better overall social functioning on the Social Adjustment Scale–Self-Report (P = .01), significantly greater clinical improvement (P = .03), and significantly greater decrease in clinical severity (P = .03) on the Clinical Global Impressions scale.

Conclusions  Interpersonal psychotherapy delivered in school-based health clinics is an effective therapy for adolescent depression. This effort is a significant step toward closing the gap between treatment conducted in the laboratory and community clinic.

Figures in this Article

Adolescent depression is a highly prevalent disorder (1.6%-8.9% in ayear).1 Untreated adolescent depression isassociated with substantial morbidity, including school dropout, teenage pregnancy,suicide, and substance abuse,2,3 aswell as considerable health expenditure.4 Adolescentswith mental health problems, including depression, are largely undertreated.Fewer than 3 of 10 adolescents with mental health problems in the United Statesreceive mental health services.57 Thereis a large gap between the use of and need for mental health services.8 In recent years, school-based health clinics haveemerged as an important treatment setting for adolescents with mental healthand general medical problems.912

Several efficacious treatments are available for depression, includingserotonin reuptake inhibitors,1315 cognitivebehavior therapy, interpersonal psychotherapy, and various group therapies.1622 Mostof these treatments have been assessed in university hospitals under controlledconditions. Even then, the general response rate for cognitive behavior therapy,the most widely tested psychotherapy, is approximately 60%, leaving room forimprovement.23 It is not known whether evidence-basedpsychotherapy can be effectively delivered in community mental health settingsby professionals with little formal training to broadly representative patientsamples.

This report describes the results of an effectiveness study of interpersonalpsychotherapy for depressed adolescents (IPT-A) in school-based health clinics.The goal was to assess the feasibility, acceptability, and efficacy of deliveringIPT-A under prevailing resource constraints of urban public school–basedclinics.

PARTICIPANTS

The sample consisted of adolescents aged 12 to 18 years who were referredto mental health clinicians in 1 of 5 school-based health clinics (3 middleschools and 2 high schools). The sample had a mean age of 15.1 years (SD,1.9 years), and was 84% female and 71% Hispanic (Table 1). The schools are located in urban, impoverished areas ofNew York City, NY.

Table Graphic Jump LocationTable 1. Demographics and Sample Characterisitics*
DETERMINING ELIGIBILITY

All adolescents referred for a mental health intake in the school-basedhealth clinic were eligible to undergo screening to participate in the study.To be eligible for enrollment, adolescents needed a Hamilton Depression RatingScale (HAMD)24 score of 10 or higher and aChildren's Global Assessment Scale (C-GAS) score of 65 or lower25 atinitial clinical intake and again at study baseline. In addition, eligibilityrequirements included parental consent and a DSM-IV diagnosisof major depression, dysthymia, adjustment disorder with depressed mood, ordepressive disorder not otherwise specified. Adolescents were not eligibleif they were actively suicidal or mentally retarded; had a life-threateningmedical illness or a current diagnosis of substance abuse disorder, psychosis,or schizophrenia; were currently in treatment for depression; or were takingantidepressant medication. English-speaking students were accepted at all5 schools. In 2 schools, monolingual Spanish-speaking students were acceptedas well. A child psychologist (K.P.D.) determined whether students met eligibilitycriteria using the Schedule for Affective Disorders and Schizophrenia forSchool-aged Children lifetime depression module–child report26 and the baseline clinical interview.

If at any time an adolescent's symptoms or functioning appeared to beworsening (HAMD score, >25), they underwent evaluation by a child psychologistor psychiatrist masked to the treatment condition. If possible, adolescentswere offered an adjunctive treatment such as medication. Adolescents who receivedantidepressants during the course of the study could remain in the study.They were removed from the treatment protocol if it was clinically necessaryto refer them for a more restrictive level of care such as hospitalizationor partial hospitalization.

The study was approved by the institutional review boards for the 3hospitals that sponsored the 5 school-based mental health clinics and by theNew York City Board of Education. Informed consent was received from parentsor legal guardians, and assent was received from the adolescents.

DESIGN OVERVIEW
Randomization

Randomization occurred at clinician and student levels. With the useof a table of random numbers, mental health clinicians in the school clinicswere randomized to provide IPT-A or treatment as usual (TAU). Half of thetherapists at each of the 5 schools received IPT-A training. Adolescents wererandomized to IPT-A or TAU within schools. In 1 school, clinicians were routinelyrestricted to treating students on a particular floor of the school; therefore,randomization occurred at the level of the clinician, but not the student(n = 7).

Treatment

Interpersonal psychotherapy is a time-limited psychotherapy that focuseson current problems. The procedures are specified in a manual.27 Thegoals of IPT-A are to reduce depressive symptoms and improve interpersonalfunctioning by relating the symptoms to 1 or more of 4 problem areas (grief,role disputes, role transitions, and interpersonal deficits) and by developingstrategies for dealing with these problems.28 Twoindependent studies have demonstrated the efficacy of IPT-A.17,18 TheIPT-A intervention was delivered as 12 sessions during a 12- to 16-week period.Therapists provided 8 consecutive 35-minute weekly sessions followed by 4sessions scheduled at any frequency during the ensuing 8 weeks.

The TAU condition was whatever psychological treatment the adolescentswould have received in the school-based clinic if the study had not been inplace. The psychotherapy varied but closely resembled supportive counseling.Most adolescents in the TAU group received individual psychotherapy. Eightadolescents received 1 to 3 additional family/parent sessions, and 5 participatedin group therapy.

Clinician Training

Participating school clinicians included 11 social workers and 2 doctoral-levelclinical psychologists. Before participating, the clinicians had little formalspecialized training in screening and identifying depression in adolescentsand no training in evidence-based psychotherapy. Training in the screeningbattery was provided to all clinicians. A subset of 6 social workers and 1psychologist were trained in IPT-A. The training included reading the IPT-Amanual, 2 half days of didactic training, and weekly supervision throughoutthe project by 2 of us (L.M. or K.P.D.). Treatment adherence and competencewere measured by checklists completed by therapists and supervisors. Overallcompetence in IPT-A was rated as satisfactory (mean, 3.3; SD, 0.87) on a scaleof 1 (poor) to 5 (excellent). One of the 7 IPT-A therapists who treated asignificant number of cases was a low outlier on the competency scale. Themean competence score without him was 3.6 (SD, 0.55). A future report willexamine therapist adherence and competence in detail.

ASSESSMENTS

The primary domains assessed included (1) depression symptoms as measuredby the clinician-rated HAMD and self-reported Beck Depression Inventory (BDI)29; (2) global functioning as measured by the clinician-ratedClinical Global Impressions scale (CGI)30 andC-GAS; and (3) social functioning as measured by the Social Adjustment Scale–Self-Report(SAS-SR).31 Higher scores on the HAMD and BDIindicate a greater number of symptoms; on the CGI and C-GAS, better functioning;and on the SAS-SR, worse functioning. Scores on the HAMD can range from 0to 74; on the BDI, from 0 to 39; on the C-GAS, from 0 to 100; and on the SAS-SR,from 1 to 5.

All patient assessments were performed in both treatment conditionsby a psychologist or a social worker masked to the patient's treatment conditionand were not shared with the treating clinicians. The assessments were conductedat baseline and weeks 4, 8, 12, and 16, or at early termination from the protocol.At week 12, the mask was accidentally broken in 2 cases for one evaluator.After week 12, a second evaluator completed the assessments of these cases.

Three independent evaluators were trained in the assessments beforethe onset of the study and participated in a reliability study to establishcomparability between their ratings. School-based clinicians also participatedin the reliability study on the screening instruments (HAMD and C-GAS). Reliabilityfor the Schedule for Affective Disorders and Schizophrenia for School-agedChildren was obtained by the 3 independent evaluators rating 7 audiotapedinterviews (κ = 0.76). Reliability of the HAMD was obtained from 21clinicians (including school clinicians and independent evaluators) rating20 audiotaped HAMD interviews (intraclass correlation coefficient, 0.84).To obtain reliability for the C-GAS, the 21 clinicians rated 20 case vignettes(intraclass correlation coefficient, 0.83).

STATISTICAL METHODS

The comparability of the patients in the IPT-A and TAU groups was examinedfor demographic characteristics, including sex, ethnicity, living in a single-parenthome, receiving public assistance, and diagnoses, using the χ2 test.Mean age and paternal and maternal education were analyzed using an unpaired t test. Between-group differences for major outcome measures(ie, BDI, HAMD, C-GAS, and CGI) at baseline were calculated using unpaired t tests.

Analyses were conducted for the intent-to-treat sample (n = 63). Overallefficacy of treatment was assessed by conducting an analysis of covariancecontrolling for pretreatment scores on all major outcome measures by treatmentcondition at termination. Clinical recovery was defined as a HAMD score of6 or less and a BDI score of 9 or greater. Data were analyzed using a χ2 test for the percentage of patients who reached these cutoff scoresat the point of termination. The α level was .05 (2 sided).

Post hoc analyses examined differential treatment effects by severityof depressive symptoms and age. Those who were in the highest HAMD quartilescore (≥22) and in the lower half of a median split of the C-GAS were consideredto be the most severely ill. Age was stratified as 12 to 14 years and 15 to18 years. A separate stratified analysis by each of these 3 baseline measureswas conducted to evaluate the treatment effect.

Two statistical approaches were used to examine changes over time inthe outcome measures. A repeated-measures analysis of variance (ANOVA) wasconducted on each of the outcome measures of interest32 with2 treatment groups; the number of time categories varied, with the outcomemeasure ranging from 4 (weeks 0, 4, 8, and 12) for HAMD to 2 for C-GAS (weeks0 and 12). For the 6 cases in which attrition occurred, the end point wascarried forward. Although this approach is easily interpretable, it assumesthat variances and covariances of observations across time points are homogeneous(assumption of compound symmetry). Violation of this assumption will frequentlyresult in type I errors greater than the nominal values, therefore a randomcoefficients regression analysis33 was performedto complement the repeated-measures ANOVA. This method accommodates attritionof subjects by using available data without carrying over end points and isnot restricted to the assumption of compound symmetry. The primary parametersthat were estimated by the random coefficients regression are overall slopesfor each treatment supplemented by tests of differences among slopes.

PATIENT RECRUITMENT

Of the 509 adolescents who underwent screening from April 1, 1999, throughJanuary 31, 2002, 183 (35.9%) were initially eligible for baseline assessment,but 23 (12.6%) of the 183 were determined to be ineligible by the baselineassessment. Thus, 160 (31.4%) of those undergoing screening were eligiblefor the study. Of the 160 eligible, 96 (60.0%) refused to participate (Figure 1). Refusal to participate was notrelated to adolescent sex. The most common reasons for refusal were relatedto the requirements intrinsic to a research protocol, including not wantingto be randomized (n = 25 [13.7%]) and not wanting a parent contacted (n =26 [14.2%]). Other reasons for exclusion each represented less than 5% ofthe sample. No adolescents were excluded at screening or baseline becauseof current medication treatment.

Place holder to copy figure label and caption
Figure 1.

Flow diagram for the study. ADHDindicates attention-deficit/hyperactivity disorder; ED, emergency department;IPT-A, interpersonal psychotherapy modified for depressed adolescents; TAU,treatment as usual.

Graphic Jump Location
BASELINE PATIENT CHARACTERISTICS

The treatment groups did not significantly differ in background demographiccharacteristics (Table 1). Otherdiagnoses regarded as possible or probable by results of the clinical interviewat baseline were 20 patients (32%) with anxiety disorders, 5 (8%) with oppositionaldefiant disorder, 10 (16%) with substance use, and 4 (6%) with attention-deficit/hyperactivitydisorder.

SIGNIFICANT EVENTS DURING CLINICAL TRIAL

Of the 64 participants initially enrolled in the study, 57 completedthe full protocol. Reasons for attrition are displayed in Figure 1. In the IPT-A condition, 1 adolescent was referred to theemergency department for suicidality and hospitalized for 1 week. In the TAUcondition, 1 adolescent was referred to the emergency department, hospitalizedovernight, and withdrawn from the study. Four adolescents were referred formedication treatment during the protocol, including 2 in IPT-A and 2 in TAU.One of the 2 adolescents in IPT-A was prescribed medication during her weeklonghospitalization, but discontinued its use after 1 to 2 weeks. The second IPT-Apatient received medication for attention-deficit/hyperactivity disorder,but discontinued its use after 2 weeks. One TAU patient was referred for butnever received medication, and the second received the medication during anovernight hospitalization but was nonadherent after several days.

MAIN OUTCOMES
Depression Symptoms

At baseline, there were no significant group differences in depressionsymptoms on the HAMD or BDI. Mean baseline score was 18.6 on the 24-item HAMD,whereas the mean BDI score was 21.4. On the HAMD, adolescents who receivedIPT-A compared with those who received TAU reported significantly greaterdecreases in depressive symptoms (week 12, 8.7 vs 12.8; P = .04) (Table 2). Onthe BDI, adolescents who received IPT-A reported fewer depressive symptomsthan those who received TAU (8.4 vs 12.3; P = .14)at week 12 (Table 3).

Table Graphic Jump LocationTable 2. Clinician-Related Depression Symptoms and Functioning at Baselineand Week 12 or Termination by Treatment
Table Graphic Jump LocationTable 3. Self-reported Depression Symptoms and Functioning at Baselineand Week 12 or Termination by Treatment

At termination, 17 (50%) of the adolescents in IPT-A and 10 (34%) ofthose in TAU met the HAMD recovery criterion (score, ≤6). On the BDI, 25(74%) of the adolescents in IPT-A compared with 15 (52%) of adolescents inTAU met the recovery criterion (score, ≤9) (χ21 =3.9; P = .048). Effect sizes for the difference intreatment outcomes are shown in Table 2 and Table 3.

The repeated-measures ANOVA showed a statistically significant interactionbetween treatment and time (F3,169 = 3.79; P = .01). Post hoc pairwise contrasts of the treatment means at individualtime points revealed significant differences between mean scores that emergedat week 8, with IPT-A reducing the mean score by a difference of 4.1 pointsgreater than TAU (t = −3.18; P = .003) (Figure 2). TheBDI analysis similarly showed a statistically significant interaction betweentreatment and time (F3,169 = 2.88; P =.04) and significant differences between mean scores also at week 8, whenIPT-A reduced the mean score by a difference of 5.42 compared with that ofTAU (t = −3.34; P =.001).

Place holder to copy figure label and caption
Figure 2.

Repeated-measures analysis forthe Hamilton Depression Rating Scale (HAMD). IPT-A indicates interpersonalpsychotherapy for depressed adolescents; TAU, treatment as usual (treatment× time interaction, P = .01).

Graphic Jump Location

In the random regression analysis to linearize change in HAMD scores,the time scale was transformed by using the natural logarithm of week + 1.Thus, slope estimates approximate change in HAMD score per unit of changein logarithm of week after baseline. Significantly different slopes over timewere found between the 2 treatment groups (treatment × time interaction,F1,114 = 8.85; P = .004). The IPT-A grouphad a significantly faster rate of improvement relative to the TAU group duringthe 12 weeks. Slope estimates (per natural logarithm of week in treatment)for the 2 treatments ±SE were −4.55 ± 0.54 for IPT-A and−2.29 ± 0.53 for TAU. The rate of improvement for the IPT-A groupon the HAMD was 1.99 U per time more rapid than in the TAU group. The averagedifference between treatments was 4.10 points at week 8 and 5.21 points atweek 12.

General Functioning

Adolescents receiving IPT-A compared with those receiving TAU reportedsignificantly greater improvement in overall functioning on the C-GAS (F2,60 = 5.03; P = .04) at week 12 (Table 2). A repeated-measures analysisto determine changing patterns with time was not performed because there wasonly a single assessment made after baseline, at week 12.

At week 12, adolescents who received IPT-A as compared with those whoreceived TAU were rated as significantly less ill (F2,60 = 4.89; P = .03) (Table 2).At week 12, adolescents who received IPT-A compared with those who receivedTAU had significantly greater improvement in their symptoms (F1,60 =5.3; P = .03). The effect size for CGI severity ofillness was 0.48 (95% confidence interval [CI], 0.15-0.81) and for improvementwas 0.59 (95% CI, 0.24-0.94).

Social Functioning

At week 12, adolescents who received IPT-A compared with those who receivedTAU reported significantly greater improvement in dating (F2,60 =4.7; P = .03) and overall social functioning (F2,60 = 7.0; P = .01) and a trend for greaterimprovement in family functioning (F2,60 = 2.8; P = .10) on the SAS-SR. The repeated-measures ANOVA showed that patternsin variation of mean overall social functioning during the 12 weeks of treatmentwere significantly different between the 2 conditions (treatment × timeinteraction, F3,167 = 4.40; P = .003)(Figure 3). Post hoc pairwise comparisonsof treatment means at individual time points showed that significant differencesemerged at week 8. The IPT-A condition reduced the mean score by a differenceof 0.24 points compared with that of the TAU condition (t = −2.24; P = .03).

Place holder to copy figure label and caption
Figure 3.

Repeated-measures analysis forSocial Adjustment Scale–Self-Report (SAS-SR) overall scores. Other abbreviationsare explained in the legend to Figure 2 (treatment × time interaction, P = .003).

Graphic Jump Location

The random regression analysis showed that rates of improvement overtime in the 2 treatment groups were significantly different (treatment ×time interaction, F1,114 = 9.80; P = .002).Although overall social functioning scores on average decreased linearly duringthe 12 weeks for IPT-A, these scores in TAU on average remained relativelyunchanged. Slope estimates for the 2 treatments ±SE were −0.06± 0.01 for the IPT-A and −0.02 ± 0.01 for TAU, which translatesinto an average difference between treatments of 0.27 points at week 8 and0.45 points at week 12.

POST HOC ANALYSIS OF TREATMENT ADHERENCE

Adolescents treated with IPT-A received a mean of 10.5 therapy sessionsin 16 weeks compared with a mean of 7.9 therapy sessions for those who receivedTAU (P = .01). Part of the beneficial effects ofIPT-A could be due to a greater dosage of therapy. Conventional methods foradjusting for covariates (number of sessions) were not appropriate for thisstudy, because only 3 IPT-A patients received fewer than 8 sessions comparedwith 12 TAU patients. The 3 IPT-A patients dropped out of treatment, whereasonly 2 of the 12 TAU patients with fewer than 8 sessions dropped out. Thissuggests that dropout status and number of sessions are confounded in IPT-A.To explore this volume further, we compared the subset of TAU patients whohad at least 8 sessions (n = 17) with the IPT-A patients with at least 8 sessions(n = 30). There was a significant reduction in HAMD scores among the IPT-Apatients compared with the TAU patients in this subgroup (week 12, t = 2.55; P = .01). Of the 29 TAU patients,17 had at least 8 sessions, whereas 12 had fewer than 8 sessions. We exploredthe possibility that among the TAU patients, those who had more than 8 sessionsmay be more severely ill than those with fewer sessions, a finding that wouldresult in the previous comparison being biased in favor of IPT-A. These 2subgroups of TAU were compared on their baseline, week 12, and week 16 HAMDscores. These analyses showed that there was no significant association betweennumber of sessions and baseline HAMD scores (18.47 vs 18.17; P = .87) for TAU patients. In addition, no statistically significantdifferences were found between the number of sessions and HAMD scores at weeks12 and 16 in these 2 TAU groups. In fact, those with at least 8 sessions showedsomewhat greater improvement than those with fewer than 8 sessions.

POST HOC ANALYSIS OF TREATMENT EFFECTS BY INITIAL SEVERITY

Differential treatment effects were found on the HAMD and C-GAS by ageat study entry (12-14 vs 15-18 years). A significant correlation was foundbetween age and severity of illness measured on the CGI (r = 0.33; P = .008) and age and global functioningmeasured on the C-GAS (r = 0.36; P = .004). Specifically in the older group, IPT-A compared with TAUwas more effective as demonstrated by a significantly lower HAMD score atweek 12, with an average difference of 7.6 points (P =.006), and a significantly higher C-GAS score at week 12, with an averagedifference of 6.6 points (P = .02), controlling forthe baseline scores. The difference between the 2 treatments was minimal andnonsignificant in the younger group. The interaction between age and treatment(IPT-A vs TAU) in the adolescents 15 years and older was marginally significantto predict HAMD scores (P = .055) and statisticallysignificant to predict C-GAS score (P = .03) at week12.

When baseline severity of illness was measured by the HAMD (using ≥22as the top quartile of severity), IPT-A patients compared with TAU patientswithin the high-severity subgroup had significantly lower HAMD scores (differenceof −9.3; P = .04) and higher C-GAS scores (differenceof 13.6; P = .04) at week 12. The group differencewas statistically nonsignificant in the low-severity HAMD subgroup. Baselineseverity of impairment was measured by C-GAS using a median split rather thanquartiles because of the limited variance in the C-GAS scores. Patients treatedwith IPT-A compared with those treated with TAU within the high-impairmentC-GAS subgroup had significantly lower HAMD scores (difference, 7.8; P = .02) and higher C-GAS scores (−13.8; P = .006) at week 12. The difference between the 2 groups was statisticallynonsignificant in the low-impairment subgroup.

TELEPHONE FOLLOW-UP AT WEEK 16

At week 16, a telephone follow-up interview was conducted with all patients(n = 62) after completion of any remaining sessions between weeks 12 and 16.No attempt was made to contact 1 patient who did not attend any therapy sessions,and this patient was not included in the analysis. Assessments administeredby telephone by the independent evaluators included the HAMD and C-GAS. Thestudy findings were maintained at week 16. On the HAMD, the IPT-A patientscompared with the TAU patients reported significantly greater decreases indepressive symptoms (6.9 vs 10.6; P = .04), an effectsize of 0.51 (95% CI, 0.003-1.02), and a trend toward greater improvementin overall functioning on the C-GAS (F2,59 = 3.72; P = .06).

Much has been written about the gap between clinical practice and clinicalresearch. As Weisz and colleagues34 have stated,the crucial question is whether community clinicians can actually benefitfrom the findings of outcome research, and an important task is to study theapplication of research therapy to community settings. The present study helpsto bridge the gap by successfully applying modified research therapy proceduresfor the training of school-based clinicians to deliver an evidence-based therapy.Specifically, the results demonstrate the effectiveness of IPT-A comparedwith TAU for the treatment of adolescent depression in school-based healthclinics in impoverished urban communities in New York City.

Adolescents who receive IPT-A have significant reductions in depressionsymptoms and impairment by clinician report and self-report and significantimprovement in overall and specific domains of social functioning. Depressedadolescents treated with IPT-A rather than TAU improved faster and were significantlybetter after 8 consecutive weekly sessions of IPT-A, and this is not merelya dosage effect. The largest treatment effects occurred in the older and/ormore severely depressed adolescents, consistent with findings in the adultIPT literature.35 This finding suggests thatmilder depression in younger adolescents can be more easily treated with supportivepsychotherapy, whereas more severe depression is more effectively treatedwith a structured treatment specifically targeted for adolescent depression.The current findings extend treatment effects observed in carefully controlledclinical trials with depressed adolescents17,18 totreatment in school-based health clinics, and are an important first stepin the study of the transportability of treatments from the laboratory tothe clinic.

Although other research efforts have tried to disseminate treatmentson a larger scale36 and study their effectivenessin comparison with community care,37 this studyis one of the first to assess the effectiveness of an evidence-based treatmentfor adolescent depression as delivered by school-based clinicians. Concernsabout implementation have been expressed regarding necessary adaptations intraining and supervision, although little has been written about actual implementation.The results of this study are significant, despite the small sample size,in that they support the ability to implement evidence-based practices outsideof university settings. Although organizational factors such as patient volume,staffing patterns, referral sources, and resource availability influenceddelivery of the intervention and necessitated protocol modifications, it wasstill possible to implement IPT-A in a clinically effective manner. Modificationsincluded abbreviated therapist training, monitored treatment adherence withoutaudiotapes or videotapes, shortened session duration, flexibility in schedulingowing to school calendar constraints, acceptance of heterogeneous diagnosticprofiles, and parental notification of treatment when otherwise unnecessaryin the school clinics.38

The study involved training on-site clinicians rather than bringingin expert clinicians. A frequently asked question is what is needed to changeclinician practice. Training was abbreviated compared with efficacy studiesthat have extensive therapist training.39 Aftera brief didactic session, clinicians received 1 hour of supervision per 4to 5 cases per week without the use of videotapes or audiotapes. It may bepossible to streamline this training as graduate programs move toward trainingin evidence-based treatments and clinicians come to the job with greater knowledgeof the treatments.

Although medication is seen as a frontline treatment for adolescentdepression,40 it is not easily accessed inthe school clinics, and minority families are generally reluctant to acceptantidepressants.41 More recently, concernshave developed regarding the effects of antidepressant medications for childrenand adolescents.42 With little physician time,clinics are unable to offer medication and must refer adolescents to nearbyhospital centers. The 4 students who were prescribed antidepressant medicationshowed poor adherence with their regimens. An important future study wouldbe to assess the effectiveness of medication alone and combined with psychotherapyfor the treatment of more severely ill students.

This study has several limitations. The predominantly female sampledoes not permit the power to test for sex differences in treatment outcome.The size of the study sample also precludes analyses of treatment effectivenessin the middle vs high school students and other school or environmental effectsthat may facilitate or impede successful implementation of the intervention.At one school, therapists, but not students, were randomly assigned; however,this school contributed only 7 cases. Delivery of TAU may have been alteredby our observation of its practice, and this likely made TAU more effectivethan normal. Attempts to monitor the number of visits attended in the TAUcondition led to increased outreach and contact with the adolescents. Finally,the current study represents a relatively small-scale demonstration. An importantchallenge ahead is to expand this dissemination effort to a larger numberand wider range of school-based clinics.

Although there was little attrition of students randomized to treatment,there was a significant rate of refusal to participate (60.0%) before baselineassessment. The most common reasons for refusal were related to research requirements,particularly parental notification and consent rather than a refusal to receivepsychotherapy. At present, adolescents receive treatment in the clinics withoutparental knowledge. Many wish to retain this privacy and therefore declineto participate. Outside the study, we would expect better participation intreatment; however, such research requirements are likely to continue to hinderthe conduct of research in this setting. We have no reason to believe thatIPT-A is less effective with adolescents who declined participation for reasonsrelated to technical research demands, although we are unable to evaluatethe effectiveness of IPT-A with those who refused study participation.

The present study demonstrates a successful implementation of a briefpsychosocial intervention (IPT-A) delivered by community-based cliniciansin urban school-based health clinics serving minority students. The IPT-Aintervention is a viable and effective model for organizing treatment deliveryin this population and setting. The intervention can be learned and deliveredby social workers and psychologists who work in these clinics. We found consistentreduction of depression symptoms and improved social and general functioningwith IPT-A. This setting provided a rigorous test of the effectiveness ofIPT-A. Similar or more robust intervention effects would likely be achievedin school settings with more clinical resources. Given the critical role thatschool clinics play in the provision of care for adolescents,43 thesefindings are of public health importance for improving the delivery of mentalhealth care to underserved, depressed adolescents.

Corresponding author and reprints: Laura Mufson, PhD, New York StatePsychiatric Institute, 1051 Riverside Dr, Unit 24, New York, NY 10032 (e-mail: MufsonL@childpsych.columbia.edu).

Submitted for publication May 23, 2003; final revision received December24, 2003; accepted January 20, 2004.

This study was funded by grant 6 HS5 SM52671-02-1 from the SubstanceAbuse and Mental Health Administration, Rockville, Md, and grant 5 P30 MH60570-03from the Psychotherapy Core of the National Institute of Mental Health ChildPsychiatry Intervention Research Center, Rockville.

We thank Hector Bird, MD, and Jami F. Young, PhD, for their thoughtfulcontributions to the project and readings of earlier drafts; Cora de Leon,MSW, for her hard work; the patients and the school-based health clinics fortheir participation in this project; and Marilyn Camacho for her tirelessefforts on behalf of the project and manuscript preparation.

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Greenberg  PEStiglin  LEFinkelstein  SNBerbdt  ER The economic burden of depression in 1990. J Clin Psychiatry. 1993;54405- 418
PubMed
Surgeon General US Public Health Service, Mental Health: A Report from the Surgeon General. Available athttp://www.surgeongeneral.gov/library/mentalhealth/home.htmlSeptember 232002;
Ialongo  NMcCreary  BKPearson  JLKoenig  ALWagner  BMSchmidt  NBPoduska  JKellam  SG Suicidal behavior among urban, African American young adults. Suicide Life Threat Behav. 2002;32256- 271
PubMed Link to Article
Lewinsohn  PMRohde  PSeeley  JR Treatment of adolescent depression. Depress Anxiety. 1998;747- 52
PubMed Link to Article
Flaherty  LTWeist  MDWarner  BS School-based mental health services in the United States. Community Ment Health J. 1996;32341- 352
PubMed Link to Article
Burns  BJCostello  EJAngold  ATweed  DStangl  DFarmer  EMErkanli  A Children's mental health service use across service sectors. Health Aff (Millwood). 1995;14147- 159
PubMed Link to Article
Leaf  PJAlegria  MCohen  PGoodman  SHHorwitz  SMHoven  CWNarrow  WEVaden-Kiernan  MRegier  DA Mental health service use in the community and schools. J Am Acad Child Adolesc Psychiatry. 1996;35889- 897
PubMed Link to Article
Staghezza-Jaramillo  BBird  HRGould  MSCanino  G Mental health service utilization among Puerto Rican children ages4 through 16. J Child Fam Stud. 1995;4399- 418
Link to Article
Hoagwood  KErwin  HD Effectiveness of school-based mental health services for children:a 10-year research review. J Child Fam Stud. 1997;6435- 454
Link to Article
Emslie  GJRush  AJWeinburg  WAKowatch  RAHughes  CWCarmody  TRintelmann  J A double-blind randomized, placebo-controlled trial of fluoxetine inchildren and adolescents with depression. Arch Gen Psychiatry. 1997;541031- 1037
PubMed Link to Article
Emslie  GJHeiligenstein  JHWagner  KDHoog  SLErnest  DEBrown  ENilsson  MJacobson  JG Fluoxetine for acute treatment of depression in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2002;411205- 1215
PubMed Link to Article
Keller  MBRyan  NDStrober  MKlein  RGKutcher  SPBirmaher  BHagino  ORKoplewicz  HCarlson  GAClarke  GNEmslie  GJFeinberg  DGeller  BKusumakar  VPapatheodorou  GSack  WHSweeney  MWagner  KDWeller  EBWinters  NCOakes  RMcCafferty  JP Efficacy of paroxetine in the treatment of adolescent major depression. J Am Acad Child Adolesc Psychiatry. 2001;40762- 772
PubMed Link to Article
Brent  DAHolder  DKolko  DBirmaher  BBaugher  MRoth  CIyengar  SJohnson  BA A clinical psychotherapy trial for adolescent depression comparingcognitive, family, and supportive therapy. Arch Gen Psychiatry. 1997;54877- 885
PubMed Link to Article
Mufson  LWeissman  MMMoreau  DGarfinkel  R Efficacy of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 1999;56573- 579
PubMed Link to Article
Rossello  JBernal  G The efficacy of cognitive-behavioral and interpersonal treatments fordepression in Puerto Rican adolescents. J Consult Clin Psychol. 1999;67734- 745
PubMed Link to Article
Reynolds  WMCoats  KI A comparison of cognitive-behavioral therapy and relaxation trainingfor the treatment of depression in adolescents. J Consult Clin Psychol. 1986;54653- 660
PubMed Link to Article
Lewinsohn  PMClarke  GNHops  HAndrews  JA Cognitive-behavioral treatment for depressed adolescents. Behav Ther. 1990;21385- 401
Link to Article
Kahn  JSKehle  TJJensen  WRClark  E Comparison of cognitive-behavioral, relaxation, and self-modeling interventionsfor depression among middle-school students. School Psych Rev. 1990;27146- 155
Wood  AHarrington  RMoore  A Controlled trial of a brief cognitive-behavioral intervention in adolescentpatients with depressive disorders. J Child Psychol Psychiatry. 1996;37737- 746
PubMed Link to Article
Harrington  RWhittaker  JShoebridge  P Psychological treatment of depression in children and adolescents. Br J Psychiatry. 1998;173291- 298
PubMed Link to Article
Williams  JB A structured interview guide for the Hamilton Depression Rating Scales. Arch Gen Psychiatry. 1988;45742- 747
PubMed Link to Article
Shaffer  DGould  MSBrasic  JAmbrosini  PFisher  PBird  HAluwahlia  S A Children's Global Assessment Scale (CGAS). Arch Gen Psychiatry. 1983;401228- 1231
PubMed Link to Article
Chaput  FFisher  PKlein  RGreenhill  LShaffer  D Columbia K-SADS (Schedule for Affective Disordersand Schizophrenia for School-aged Children).  New York Child Psychiatry Intervention Research Center, New YorkState Psychiatric Institute1999;
Weissman  MMMarkowitz  JCKlerman  GL Comprehensive Guide to Interpersonal Psychotherapy.  New York, NY Basic Books Inc Publishers2000;
Mufson  LMoreau  DWeissman  MMKlerman  GL Interpersonal Psychotherapy for Depressed Adolescents.  New York, NY Guilford Publications1993;
Beck  ATSteer  RAGarbin  MG Psychometric properties of the Beck Depression Inventory: twenty-fiveyears of evaluation. Clin Psychol Rev. 1988;877- 100
Link to Article
Beneke  MRasmus  W Clinical Global Impressions (ECDEU): some critical comments. Pharmacopsychiatry. 1992;25171- 176
PubMed Link to Article
Weissman  MMBothwell  S Assessment of social adjustment by patient self-report. Arch Gen Psychiatry. 1976;331111- 1115
PubMed Link to Article
Fleiss  JL The Design and Analysis of Clinical Experiments.  New York, NY John Wiley & Sons Inc1986;
Gibbons  RHedeker  DElkin  IWaternaux  CKraemer  HCGreenhouse  JBShea  MTImber  SDSotsky  SMWatkins  JT Some conceptual and statistical volumes in analysis of longitudinalpsychiatric data. Arch Gen Psychiatry. 1993;50739- 750
PubMed Link to Article
Weisz  JRDonnenberg  GRHan  SSWeiss  B Bridging the gap between laboratory and clinic in child and adolescentpsychotherapy. J Consult Clin Psychol. 1995;63688- 701
PubMed Link to Article
Elkin  IGibbons  RDShea  MTSotsky  SMWatkins  JTPilkonis  PAHedeker  D Initial severity and differential treatment outcome in the NationalInstitute of Mental Health Treatment of Depression Collaborative ResearchProgram. J Consult Clin Psychol. 1995;63841- 847
PubMed Link to Article
Munoz  RFYing  YUArmas  RChan  FGurza  R The San Francisco Depression Prevention Research Project: a randomizedtrial with medical outpatients. Munoz  RFedDepression Prevention ResearchDirections. New York, NY HarperCollins Publications Inc1987;199- 216
Clarke  GNHornbrook  MLynch  FPolen  MGale  JO'Connor  ESeeley  JRDebar  L Group cognitive-behavioral treatment for depressed adolescent offspringof depressed parents in a health maintenance organization. J Am Acad Child Adolesc Psychiatry. 2002;41305- 313
PubMed Link to Article
Mufson  L IPT-A: translating efficacy into effectiveness research.  Paper presented at: Cold Spring Harbor Laboratory Conference on ChildhoodDepression A Critical Review February 22, 2001 Cold Spring Harbor, NY
Weissman  MMRounsaville  BJChevron  E Training psychotherapists to participate in psychotherapy outcome studies. Am J Psychiatry. 1982;1391442- 1446
PubMed
Birmaher  BBrent  D Pharmacotherapy for depression in children and adolescents. Shaffer  DWaslick  BDeds.The Many Facesof Depression in Children and Adolescents. Washington, DC AmericanPsychiatric Publishing Inc2002;73- 103Oldham  JMRiba  MBeds Review ofPsychiatry Series 21
Cooper  LAGonzalez  JJGallo  JJRost  KMMeredith  LSRubenstein  LVWang  NYFord  DE The acceptability of treatment for depression among African-American,Hispanic, and white primary care patients. Med Care. 2003;41479- 489
PubMed
US Food and Drug Administration, Public health advisory: reports of suicidality in pediatric patientsbeing treated with antidepressant medication for major depressive disorder(MDD). Available at:http://www.fda.gov/cder/drug/advisory/mdd.htmNovember 14, 2003
Angold  AErkanli  AFarmer  EMFairbank  JABurns  BJKeeler  GCostello  EJ Psychiatric disorder, impairment, and service use in rural AfricanAmerican and white youth. Arch Gen Psychiatry. 2002;59893- 904
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Flow diagram for the study. ADHDindicates attention-deficit/hyperactivity disorder; ED, emergency department;IPT-A, interpersonal psychotherapy modified for depressed adolescents; TAU,treatment as usual.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Repeated-measures analysis forthe Hamilton Depression Rating Scale (HAMD). IPT-A indicates interpersonalpsychotherapy for depressed adolescents; TAU, treatment as usual (treatment× time interaction, P = .01).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Repeated-measures analysis forSocial Adjustment Scale–Self-Report (SAS-SR) overall scores. Other abbreviationsare explained in the legend to Figure 2 (treatment × time interaction, P = .003).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Demographics and Sample Characterisitics*
Table Graphic Jump LocationTable 2. Clinician-Related Depression Symptoms and Functioning at Baselineand Week 12 or Termination by Treatment
Table Graphic Jump LocationTable 3. Self-reported Depression Symptoms and Functioning at Baselineand Week 12 or Termination by Treatment

References

Angold  ACostello  EJ The epidemiology of depression in children and adolescents. Goodyer  IMedThe Depressed Child and Adolescent. 2nd New York, NY Cambridge University Press2001;143- 178
Lewinsohn  PMRohde  PKlein  DNSeely  JR Natural course of adolescent major depressive disorder, I: continuityinto young adulthood. J Am Acad Child Adolesc Psychiatry. 1999;3856- 63
PubMed Link to Article
Weissman  MMWolk  SGoldstein  RBMoreau  DAdams  PGreenwald  SKlier  CMRyan  NDDahl  REWickramaratne  P Depressed adolescents grown up. JAMA. 1999;2811707- 1713
PubMed Link to Article
Greenberg  PEStiglin  LEFinkelstein  SNBerbdt  ER The economic burden of depression in 1990. J Clin Psychiatry. 1993;54405- 418
PubMed
Surgeon General US Public Health Service, Mental Health: A Report from the Surgeon General. Available athttp://www.surgeongeneral.gov/library/mentalhealth/home.htmlSeptember 232002;
Ialongo  NMcCreary  BKPearson  JLKoenig  ALWagner  BMSchmidt  NBPoduska  JKellam  SG Suicidal behavior among urban, African American young adults. Suicide Life Threat Behav. 2002;32256- 271
PubMed Link to Article
Lewinsohn  PMRohde  PSeeley  JR Treatment of adolescent depression. Depress Anxiety. 1998;747- 52
PubMed Link to Article
Flaherty  LTWeist  MDWarner  BS School-based mental health services in the United States. Community Ment Health J. 1996;32341- 352
PubMed Link to Article
Burns  BJCostello  EJAngold  ATweed  DStangl  DFarmer  EMErkanli  A Children's mental health service use across service sectors. Health Aff (Millwood). 1995;14147- 159
PubMed Link to Article
Leaf  PJAlegria  MCohen  PGoodman  SHHorwitz  SMHoven  CWNarrow  WEVaden-Kiernan  MRegier  DA Mental health service use in the community and schools. J Am Acad Child Adolesc Psychiatry. 1996;35889- 897
PubMed Link to Article
Staghezza-Jaramillo  BBird  HRGould  MSCanino  G Mental health service utilization among Puerto Rican children ages4 through 16. J Child Fam Stud. 1995;4399- 418
Link to Article
Hoagwood  KErwin  HD Effectiveness of school-based mental health services for children:a 10-year research review. J Child Fam Stud. 1997;6435- 454
Link to Article
Emslie  GJRush  AJWeinburg  WAKowatch  RAHughes  CWCarmody  TRintelmann  J A double-blind randomized, placebo-controlled trial of fluoxetine inchildren and adolescents with depression. Arch Gen Psychiatry. 1997;541031- 1037
PubMed Link to Article
Emslie  GJHeiligenstein  JHWagner  KDHoog  SLErnest  DEBrown  ENilsson  MJacobson  JG Fluoxetine for acute treatment of depression in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2002;411205- 1215
PubMed Link to Article
Keller  MBRyan  NDStrober  MKlein  RGKutcher  SPBirmaher  BHagino  ORKoplewicz  HCarlson  GAClarke  GNEmslie  GJFeinberg  DGeller  BKusumakar  VPapatheodorou  GSack  WHSweeney  MWagner  KDWeller  EBWinters  NCOakes  RMcCafferty  JP Efficacy of paroxetine in the treatment of adolescent major depression. J Am Acad Child Adolesc Psychiatry. 2001;40762- 772
PubMed Link to Article
Brent  DAHolder  DKolko  DBirmaher  BBaugher  MRoth  CIyengar  SJohnson  BA A clinical psychotherapy trial for adolescent depression comparingcognitive, family, and supportive therapy. Arch Gen Psychiatry. 1997;54877- 885
PubMed Link to Article
Mufson  LWeissman  MMMoreau  DGarfinkel  R Efficacy of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 1999;56573- 579
PubMed Link to Article
Rossello  JBernal  G The efficacy of cognitive-behavioral and interpersonal treatments fordepression in Puerto Rican adolescents. J Consult Clin Psychol. 1999;67734- 745
PubMed Link to Article
Reynolds  WMCoats  KI A comparison of cognitive-behavioral therapy and relaxation trainingfor the treatment of depression in adolescents. J Consult Clin Psychol. 1986;54653- 660
PubMed Link to Article
Lewinsohn  PMClarke  GNHops  HAndrews  JA Cognitive-behavioral treatment for depressed adolescents. Behav Ther. 1990;21385- 401
Link to Article
Kahn  JSKehle  TJJensen  WRClark  E Comparison of cognitive-behavioral, relaxation, and self-modeling interventionsfor depression among middle-school students. School Psych Rev. 1990;27146- 155
Wood  AHarrington  RMoore  A Controlled trial of a brief cognitive-behavioral intervention in adolescentpatients with depressive disorders. J Child Psychol Psychiatry. 1996;37737- 746
PubMed Link to Article
Harrington  RWhittaker  JShoebridge  P Psychological treatment of depression in children and adolescents. Br J Psychiatry. 1998;173291- 298
PubMed Link to Article
Williams  JB A structured interview guide for the Hamilton Depression Rating Scales. Arch Gen Psychiatry. 1988;45742- 747
PubMed Link to Article
Shaffer  DGould  MSBrasic  JAmbrosini  PFisher  PBird  HAluwahlia  S A Children's Global Assessment Scale (CGAS). Arch Gen Psychiatry. 1983;401228- 1231
PubMed Link to Article
Chaput  FFisher  PKlein  RGreenhill  LShaffer  D Columbia K-SADS (Schedule for Affective Disordersand Schizophrenia for School-aged Children).  New York Child Psychiatry Intervention Research Center, New YorkState Psychiatric Institute1999;
Weissman  MMMarkowitz  JCKlerman  GL Comprehensive Guide to Interpersonal Psychotherapy.  New York, NY Basic Books Inc Publishers2000;
Mufson  LMoreau  DWeissman  MMKlerman  GL Interpersonal Psychotherapy for Depressed Adolescents.  New York, NY Guilford Publications1993;
Beck  ATSteer  RAGarbin  MG Psychometric properties of the Beck Depression Inventory: twenty-fiveyears of evaluation. Clin Psychol Rev. 1988;877- 100
Link to Article
Beneke  MRasmus  W Clinical Global Impressions (ECDEU): some critical comments. Pharmacopsychiatry. 1992;25171- 176
PubMed Link to Article
Weissman  MMBothwell  S Assessment of social adjustment by patient self-report. Arch Gen Psychiatry. 1976;331111- 1115
PubMed Link to Article
Fleiss  JL The Design and Analysis of Clinical Experiments.  New York, NY John Wiley & Sons Inc1986;
Gibbons  RHedeker  DElkin  IWaternaux  CKraemer  HCGreenhouse  JBShea  MTImber  SDSotsky  SMWatkins  JT Some conceptual and statistical volumes in analysis of longitudinalpsychiatric data. Arch Gen Psychiatry. 1993;50739- 750
PubMed Link to Article
Weisz  JRDonnenberg  GRHan  SSWeiss  B Bridging the gap between laboratory and clinic in child and adolescentpsychotherapy. J Consult Clin Psychol. 1995;63688- 701
PubMed Link to Article
Elkin  IGibbons  RDShea  MTSotsky  SMWatkins  JTPilkonis  PAHedeker  D Initial severity and differential treatment outcome in the NationalInstitute of Mental Health Treatment of Depression Collaborative ResearchProgram. J Consult Clin Psychol. 1995;63841- 847
PubMed Link to Article
Munoz  RFYing  YUArmas  RChan  FGurza  R The San Francisco Depression Prevention Research Project: a randomizedtrial with medical outpatients. Munoz  RFedDepression Prevention ResearchDirections. New York, NY HarperCollins Publications Inc1987;199- 216
Clarke  GNHornbrook  MLynch  FPolen  MGale  JO'Connor  ESeeley  JRDebar  L Group cognitive-behavioral treatment for depressed adolescent offspringof depressed parents in a health maintenance organization. J Am Acad Child Adolesc Psychiatry. 2002;41305- 313
PubMed Link to Article
Mufson  L IPT-A: translating efficacy into effectiveness research.  Paper presented at: Cold Spring Harbor Laboratory Conference on ChildhoodDepression A Critical Review February 22, 2001 Cold Spring Harbor, NY
Weissman  MMRounsaville  BJChevron  E Training psychotherapists to participate in psychotherapy outcome studies. Am J Psychiatry. 1982;1391442- 1446
PubMed
Birmaher  BBrent  D Pharmacotherapy for depression in children and adolescents. Shaffer  DWaslick  BDeds.The Many Facesof Depression in Children and Adolescents. Washington, DC AmericanPsychiatric Publishing Inc2002;73- 103Oldham  JMRiba  MBeds Review ofPsychiatry Series 21
Cooper  LAGonzalez  JJGallo  JJRost  KMMeredith  LSRubenstein  LVWang  NYFord  DE The acceptability of treatment for depression among African-American,Hispanic, and white primary care patients. Med Care. 2003;41479- 489
PubMed
US Food and Drug Administration, Public health advisory: reports of suicidality in pediatric patientsbeing treated with antidepressant medication for major depressive disorder(MDD). Available at:http://www.fda.gov/cder/drug/advisory/mdd.htmNovember 14, 2003
Angold  AErkanli  AFarmer  EMFairbank  JABurns  BJKeeler  GCostello  EJ Psychiatric disorder, impairment, and service use in rural AfricanAmerican and white youth. Arch Gen Psychiatry. 2002;59893- 904
PubMed Link to Article

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