Adolescent Coping with Depression

Study 1

Summary

Clark et al. (1999) used a randomized controlled trial to examine 123 Oregon youths ages 14-18 with a current diagnosis of a major depressive disorder. Participants were randomly assigned to two intervention groups, one with and one without parent-group sessions, or a wait-list control group. In addition, a random selection of intervention participants received booster sessions after the initial treatment. Measures of depression were obtained at 12 and 24 months after the initial phase.

Clark et al. (1999) found that, relative to the control group, the intervention group (either with or without the parent sessions) had significantly greater:

• depression recovery rates at posttest
• reductions in self-reported depression at posttest
• improvements in global functioning at posttest

Evaluation Methodology

The randomized control trial included an acute phase and follow-up phase. The acute phase followed the program and design of a previous 1990 study (see study 1 below) but lasted a week longer. The follow-up phase and booster sessions were unique to this study.

Design: The project recruited individuals in Eugene and Portland, Oregon, via announcements to health professionals, school counselors, television and newspaper stories, and advertisements. The population of interest was narrowly defined: Only adolescents ages 14 to 18 and with a current DSM-III-R diagnosis of major depressive disorder or dysthymia were eligible. Volunteers were excluded if they exhibited various anxiety disorders or substance abuse/dependence, mental retardation, or schizophrenia; would not agree to discontinue other therapy; or needed immediate, acute treatment. Screening interviews of 331 consenting adolescents and parents led to selection of 123 subjects who met the study requirements. Compared to excluded recruits, eligible youth were more likely to be female and older but did not differ by race, living situation, or parental education.

For the acute phase, eligible participants were randomly assigned to one of three conditions:

1) A 16-session cognitive-behavioral therapy group for adolescents only (n=45);

2) An identical group for adolescents supplemented with a separate nine-session parent group (n=42); and

3) A waitlist control group (n=36).

Twenty-seven (22%) of the 123 randomized adolescents failed to complete the acute phase by attending fewer than 7 sessions, not completing the assessments, or violating the study protocol.

Immediately after the acute phase, the 64 adolescents who were in the active treatments and completed the phase were randomly assigned to one of three conditions:

1) Booster sessions and independent assessments every 4 months (n =24);

2) Assessments every 4 months (n =16) ; and

3) Assessments every 12 months (n =24).

The first two conditions compared the impact of the booster sessions, while the last two conditions compared the impact of additional assessments. For the booster session condition, adolescents met 1 to 2 times with a therapist to discuss how skills learned earlier in the program could be applied to specific, problematic situations that had come up. Less than 50% of those assigned completed the booster sessions.

The study began in 1991, the acute (or intervention) phase lasted eight weeks, and the follow-up phase lasted 24 months after the intervention.

Sample Characteristics: Among the 96 participants completing the acute phase, females made up 70.8% of the sample. The mean age was 16.2 years, 95.8% were in school, 43.8% lived in 2-parent families, and 27.7% had 1 or 2 parents with graduate or postgraduate education. The majority (n=73) had pure major depressive disorder, 12 had pure dysthymia, and 11 had both.

Measures:

Diagnostic Interviews: Adolescents were interviewed at intake with the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Epidemiologic version (K-SADS-E). At the posttest and follow-up assessments, participants were interviewed regarding psychiatric symptoms and disorders since the previous interview using the Longitudinal Interval Follow-up Evaluation (LIFE), which used rigorous criteria for recovery (i.e., symptom-free for at least 8 weeks). Raters were blind to the subject condition, and interrater agreement for unipolar mood disorder was .75, indicative of good to excellent agreement.

Interviewer Ratings: Interviewers completed a 14-item version of the Hamilton Depression Rating Scale (HAM-D) for current and worst past episode of depression based on responses to the K-SADS-E. They also rated the 1) current level of functioning and 2) highest level of functioning during the past year using the DSM-III Global Assessment of Functioning scale.

Adolescent Report Measures: Adolescents completed the Beck Depression Inventory, a 21-item self-report measure of depressive symptoms. Internal consistency (alpha) at intake was .85.

Parent Report Measures: One or both parents completed the Child Behavior Checklist (CBCL), which assesses 118 adolescent/child behavior problems. CBCL subscales were computed for the Externalizing and Internalizing categories, as well as for depression. Reported CBCL scores were from mothers (90%) or from fathers or other guardians (10%).

Analysis: Outcome depression measures were analyzed at the individual level with random effects regression, which estimates an intercept and slope across time points for each participant (but is augmented by data from the entire sample). Using an intent-to-treat approach, the random effects regression included all 123 participants randomly assigned to conditions and all data available for each subject. For example, subjects having data through the 24-month assessment contribute more data than those dropping out after the posttest. The models include group-by-time interactions that isolate differential change from the baseline outcomes.

The planned comparisons (one-tailed, .05) for the acute phase involved group-by-time interactions that contrasted the two active conditions with the waitlist condition and contrasted the adolescent intervention condition with adolescent and parent intervention condition. The planned comparisons for the follow-up or maintenance phase again involved group-by-time interactions but contrasted the booster sessions condition with the annual and 4-month assessment conditions and contrasted the annual assessment condition with the 4-month assessment condition.

Outcomes

Baseline Equivalence and Attrition: The 3 experimental groups were statistically equivalent at baseline. Among the 123 volunteers who met the criteria for the study, 96 completed the acute phase (22% attrition). Of the 64 in the follow-up phase, 46 completed all assessments (28% attrition). Acute phase attrition was not significantly related to the experimental condition or baseline measures of gender, age, living with 1 versus 2 parents, parental education, depression diagnosis, or depression self-reports. It did vary across the two sites, but since the two sites did not differ on any of the sociodemographic variables, baseline depression measures, or recovery, the data from the two sites were pooled for the analysis.

Attrition during the follow-up assessments was not associated with adolescent gender, age, living with both biological parents, level of parent education, study site, or diagnostic or self-reported depression at intake. Dropouts had higher scores on the Beck Depression Inventory at posttreatment, however. Completion of the booster sessions was estimated at less than 50%, largely because some subjects had recovered and were uninterested in additional treatment, some were seeing a non-study therapist, some were unable to schedule or attend appointments, and some moved out of the area.

Posttest: In the acute phase, outcomes studied first included a dichotomous measure of recovery from depression (i.e., no longer meeting DSM-III-R criteria for either major depression or dysthymia for the two weeks preceding the posttreatment assessment). The results showed higher recovery rates in the intervention conditions (65% for adolescents and 69% for adolescents and parents) versus 48% in the waitlist condition. The significantly (one-tailed test, p<.05) better outcomes for the treatment groups compared to the waitlist group translate to an effect size (d) of .38 (small to medium) and an odds ratio of 2.15 (i.e., intervention groups had odds of recovery that were more than twice as high as the control group).

One of the continuous measures (the Beck Depression Inventory) showed significantly better improvement for the intervention groups (p < .01, two-tailed), while another (Global Assessment of Functioning scale) showed significantly better improvement at p < .05, one-tailed test. Four others (the Hamilton Depression Rating Scale, CBCL depression, CBCL internalizing, CBCL externalizing) did not. No significant differences emerged from comparisons of the adolescent only with the adolescent/parent conditions. The change score effect sizes were medium for the Global Assessment of Functioning scale (d = .54) and Beck Depression Inventory (d = .61). Overall, 1 of the 12 planned comparisons reached significance with two-tailed tests.

The dose-response analysis examined the influence of treatment attendance and recovery. About 48% of the waitlist group recovered, 57% of the intervention group attending 9-12 sessions recovered, and 69% of those attending 13-16 sessions recovered. The linear association indicates a significant trend toward greater recovery at higher levels of attendance.

Long-Term: Results for assessments at 12 and 24 months again examined recovery in binary form and six continuous measures of depression. Recovery in binary form was measured as 8 weeks or more of minimal or absent depression symptoms.

For the analysis of recovery, the 12-month follow-up showed that 100% (5/5) of depressed adolescents randomly assigned to the booster condition had recovered, versus 50% (6/12) of the participants in the two assessment-only conditions. The difference was significant. At the 24-month assessment, however, rates had converged, with 100% (5/5) of the booster-only condition recovered versus 90% (9/10) of the participants in the two assessment-only conditions. The difference between the two different periods of follow-up indicates that, despite ending up with similar rates of recovery, those in the booster condition recovered at a significantly faster rate than the assessment-only conditions.

Subjects having recovered in the acute phase could experience a recurrence in the follow-up phase. Of the 46 adolescents in the 2 active treatments who had recovered at posttreatment, 12-month recurrence rates were 14% (2/14) in the annual assessment conditions, 0% (0/11) in the frequent assessment condition, and 27% (4/15) in the booster condition. These differences were not significant. Also, differences across planned comparisons at 24 months were not significant.

For the continuous measures, the group-by-time interactions indicated significant benefits of the booster session relative to the two assessment-only conditions for one measure - the CBCL externalizing. The group-by-time interactions indicated significant benefits of the frequent assessment relative to the annual assessment only for the CBCL depression and CBCL internalizing outcomes. Overall, 3 of the 12 planned comparisons reached significance.

Study 2

This study applied the Coping with Depression course to a different population than previous studies - depressed adolescents with comorbid conduct disorders. Whereas previous studies of depression excluded subjects with comorbid conditions, this study focuses on youth from a real-world setting and with multiple problems. The study also differs from previous ones in that subjects could continue therapy outside the experimental study. This means the study combines components of both efficacy (in random assignment) and effectiveness (in the possible influence of other real-world activities). The study examined gender differences in more detail than previous ones. Otherwise, the course work for those in the treatment group was the same as in previous studies.

Summary

Rohde et al. (2004, 2006) and Kaufman et al. (2005) used a randomized controlled trial to examine 93 Oregon youths ages 13-17 with both a major depressive disorder and a conduct disorder. Participants were randomly assigned to the program intervention group or a life-skills control group. Measures of depression, conduct disorder, and social functioning were obtained at posttest and at six- and 12-month follow-ups. Rohde et al. (2006) extended the sample by including an additional 21 participants with a major depressive disorder but no conduct disorder.

Rohde et al. (2004, 2006) and Kaufman et al. (2005) found that, relative to the control group, the intervention group had significantly:

• greater depression recovery rates at posttest but not follow-up
• lower scores on measures of depression symptoms at posttest but not follow-up
• higher scores on social adjustment at posttest but not follow-up

Evaluation Methodology

Design: Individuals aged 13 to 17 were referred to the study by staff from the Department of Youth Services of Lane County, Oregon. All were under the supervision of an intake, probation, or parole officer but not incarcerated. After screening for both major depressive disorder and conduct disorder, 93 adolescents were randomly assigned to one of two conditions: the Coping with Depression therapy (n = 45) or a life-skills control (n = 48).

The two treatments were made similar in the number of sessions, interventionist contact time, and non-specific therapeutic factors. Mixed gender groups of approximately 10 adolescents were treated in 16 2-hour sessions conducted over an 8-week period. The Adolescent Coping with Depression course was modified to address conduct disorder but still used cognitive-behavioral skill-based training. The life-skills course emphasized activities such as filling out a job application and renting an apartment, and it offered academic tutoring. It attempted to educate participants on basic life skills in a supportive and non-judgmental manner.

The study began between 1998 and 2001. Posttest assessment occurred after completion of the 8-week intervention, and 6-month and 12-month assessments followed.

Sample: The subjects were referred from the Department of Youth Services (n = 281), provided consent (n = 205), completed the intake evaluation (n = 187), and met the inclusion criteria (n =98). Subjects had to be able to converse in English and expect to stay in the county over the next 12 months. Those charged with first-degree assault, robbery, homicide, or rape were excluded (and sent to special programs), and those with psychotic symptoms were excluded. The 93 of the 98 who agreed to continue and were randomly assigned then completed the posttest, the 6-month follow-up, and the 12-month follow-up.

The assigned sample had a mean age of 15.1 years, consisted of 48% female and 81% white, 15% resided with both parents, 75% were attending school, 18% had repeated a grade, and 15% had a parent with a bachelor's degree or higher. The mean duration of major depressive disorder was 81.3 weeks, the mean duration of conduct disorder was 185.3 weeks, and 40% had attempted suicide.

Measures:

Psychiatric Outcomes: Adolescents and a parent were interviewed at intake to assess adolescent past and current episodes of DSM-IV disorders using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version (K-SADS-E). At the follow-up assessments, participants were interviewed regarding psychiatric symptoms and disorders since the previous interview with the Longitudinal Interval Follow-up Evaluation (LIFE), which used rigorous criteria for recovery (i.e., symptom-free for at least 8 weeks). Recovery from conduct disorder required 6 months of nearly absent symptoms. Interrater agreement for a 10% sample was .88 for depression and 1.00 for conduct disorder.

Dimensional Measures: Interviewers completed a 17-item version of the Hamilton Depression Rating Scale, and adolescents completed the 21-item Beck Depression Inventory.

Conduct Disorder: Parent or adult informants completed the Child Behavior Checklist (CBCL), and the externalizing subscale was computed to measure disruptive behavior.

Psychosocial functioning: Interviewers rated current functioning using the Children's Global Adjustment scale and adolescents completed the Social Adjustment Scale - Self Report for Youth.

Nonresearch treatment: Subjects were permitted to receive external mental health treatment during the course of the study. Based on parent/adult reports, three variables related to such treatment were created: pharmacotherapy, residential treatment, and number of hours of nonresearch outpatient treatment.

Criminal records: Participants granted researchers access to criminal arrest records for the 12 months preceding and 12 months after treatment.

Analysis: The individual-level analysis used contingency tables and logistic regression for dichotomous outcomes, and random effects regression for dimensional measures. Random effects regression was done for the full assignment sample of 93 in an intent-to-treat analysis and for the subsample with complete data on the follow-up assessments. Because attrition was low (6%) and both analyses produced the same pattern of results, the paper presents only the results for the complete follow-up sample. The analyses included group-by-time interaction terms that control for baseline differences in the outcomes.

Outcomes:

Baseline Equivalence and Attrition: The two treatment groups differed at baseline on gender, which the investigators then included as a covariate, but not on the outcome variables or other measured determinants. No formal attrition analysis of group differences in attrition was presented but, as noted above, attrition was low and the pattern of results proved similar when including and not including drop-outs in the analysis.

Posttest: Major depressive disorder recovery rates at posttreatment were significantly greater in the treatment condition (39%) than in the life-skills control condition (19%) and the odds ratio equaled 2.66. Recovery rates for conduct disorder were not significantly different across the groups. Interactions by gender were not significant.

For the five dimensional measures, group-by-time interactions were significant for three of the five outcomes - the Beck Depression Index, the Hamilton Depression Rating Scale, and the Social Adjustment Scale - Self-Report. The tables report the variance explained by group-by-time interactions; for the significant relationships, the variance explained ranged from .047 to .064 (equivalent to correlations ranging from .22 to .25). No measures of mediators were available for analysis.

Mediation Analyses. Kaufman et al. (2005) examined how measures of social skills, increased engagement in pleasant activities, the use of relaxation techniques, identification of negative irrational thoughts and creation of positive counter-thoughts, and improved problem-solving or conflict resolution skills mediated the impact of the intervention on depression outcomes at posttest. The mediators were measured at posttest rather than at a time point between baseline and posttest. The automatic thoughts measure appeared to mediate treatment effects on depressive symptoms, which suggested that reducing negative thinking may be the primary mechanism through which the intervention reduced depression.

Long-term: Differences in major depressive disorder recovery rates were not significant at 6 and 12 months. Survival analysis and Cox proportional hazard models showed no difference on the 12-month recovery function. With only one exception among the 10 tests, dimensional measures did not differ significantly at 6 and 12 months. Among the 25 adolescents who recovered at posttest, the reoccurrence was higher for the treatment group (25%) than the life-skills group (11%). The authors interpret the convergence as the result of the late effectiveness of the life-skills condition rather than the loss of gains from the therapeutic treatment.

Moderation Analyses. Rohde et al. (2006) expanded the sample from 93 to 114 by including youths with a major depressive disorder but not a conduct disorder. The analysis did not examine the main effects of the program but in a multivariate model found two significant moderators on time to recovery from a major depressive disorder: the program was most effective for participants with a history of two or more episodes of a major depressive disorder at baseline and for participants with high coping skills at baseline.

Study 3

Summary

Clarke et al. (2002) used a randomized controlled trial to examine 88 youths ages 13-18 from an Oregon HMO who were diagnosed as depressed and had a parent diagnosed as depressed. Participants were randomly assigned to the program intervention group or a usual-care control group. Measures of depression, behavior problems, and global functioning were obtained at posttest and at 12- and 24-month follow-ups.

Clarke et al. (2002) found no significant effects of the program for the sample of teens diagnosed at baseline with major depression.

Evaluation Methodology

Design:

Recruitment: The study recruited two cohorts (1994-1996) of adolescent children whose parents had experienced a major depressive episode in the preceding year, based on HMO records. Adolescents were screened for depressive symptoms and those who received a diagnosis of major depressive disorder were invited to participate in the study. A total of 2,995 parents with children ages 13-18 were initially recruited. After selecting parents and youths who both participated in the screening interview and had a confirmed diagnosis of depression, 116 youths remained. Of the 116, 88 (76%) consented to participate in the study.

Assignment: The 88 adolescents were assigned to either the treatment group (n = 41) or control group (n = 47) using block randomization to balance for parent age or sex, youth sex, or youth baseline outcome scores.

Attrition: Assessments occurred at baseline, posttest (5 weeks), and approximately 1 year and 2 years after the program end. Of the 88 participants, two (2%), six (7%), and 13 (15%) did not complete the posttreatment, 12-month, and 24-month diagnostic interviews, respectively.

Sample: Participants had an average age of 15.3, were 68% female, and 9% minority. Parents of participants were mostly female (82%), mostly married 77%, and mostly employed 75%.

Measures: The study used four previously validated continuous measures of depression, one measure of suicide symptoms, and one measure of a follow-up depression diagnosis. The measures came from self-reports, parent reports, and diagnostic interviews (by interviewers who were unaware of subject condition) and reported reliabilities were good. In addition, the study used an interviewer-rated measure of global functioning and parent-rated measures of internalizing and externalizing.

Analysis: For continuous outcomes, the study used random-effect regression analyses, modeling an unstructured covariance matrix with slopes and intercepts as random effects. A time-trend measure included the baseline assessment. In addition, the study used survival analyses for the onset of major depression.

Intent-to-Treat: The study stated that an intent-to-treat protocol was employed, and it appears that the models included all 88 randomized participants.

Outcomes

Implementation Fidelity: Based on evaluations of videotaped intervention group sessions, blind raters used a 10-item structured rating scale. The study had an average of 90.8% compliance.

Baseline Equivalence: Tables 1 and 2 present condition means but without significance tests. The authors stated: "The two experimental conditions did not differ on rates of current and past psychiatric disorder, nor on any other key demographic, depression severity, functioning, or psychosocial measures."

Differential Attrition: The authors stated that they "found few baseline or treatment interaction differences between participating and nonparticipating subjects at any follow-up point on any of the key demographic, major affective, or psychopathological measures." Also, the "few differences were not consistent across time." They further re-ran primary outcome analyses including only participants who completed all four assessments, with no change in the pattern of results.

Posttest and Long-term follow-up:

The analysis found no significant intervention effects for any of the eight continuous outcomes or the survival analysis of the dichotomous outcome.

Study 4

Compared to Study 1 (Clarke et al., 1999), this study had a smaller sample and no follow-up booster sessions. It used 14 rather than 16 sessions of treatment over 7 rather than 8 weeks. Otherwise, it was similar in design and outcome to the previous study and provided additional evidence of the effectiveness of group-based cognitive-behavioral therapy for adolescents with depression.

Summary

Lewinsohn et al. (1990) used a randomized controlled trial to examine 59 youths ages 14-18 with a diagnosed major depressive disorder. Participants were randomly assigned to two program intervention groups, one with and one without a parallel parent group, or a waitlist control group. Measures of depression, behavior problems, and relationships with parents were obtained for all conditions at posttest.

Lewinsohn et al. (1990) found at posttest that the two intervention groups had significantly fewer depression diagnoses and self-reported depressive symptoms than the control group.

Evaluation Methodology

Design: Adolescent individuals with depression were recruited via letters and announcements. After screening, a total of 114 adolescents were interviewed and 69 were selected as meeting the inclusion criteria (ages 14-18, having a depressive disorder, and in grades 9-12) and exclusion criteria (having other disorders or needing immediate treatment). Ten withdrew before treatment but after assignment (5 from the wait list, 3 from one treatment condition, and 2 from the other treatment condition). The withdrawals were not studied, leaving 59 subjects for analysis.

Subjects were randomly assigned to three conditions. The two treatment conditions consisted of 14 2-hour sessions of skill-based, group cognitive-behavioral therapy, one with the adolescent only (n = 21) and one with the adolescent and a parallel parent group (n = 19). A third waitlist group served as the control (n = 19).

Assessments were made at pretreatment (intake), at posttreatment (after the seven-week course), and at 1, 6, 12, and 24 months after posttreatment. However, given attrition, 10 of 21 and 13 of 19 remained in the two treatment groups at 24 months.

Sample: The 59 subjects assigned to the three groups differed little on demographic characteristics at baseline. The mean age was about 16, about 61% were female, and 58% lived with one parent. The control group had significantly more siblings.

Measures: The study used most of the same measures reported above.

Diagnostic Interviews: Adolescents were interviewed at intake with the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Epidemiologic version (K-SADS-E). This schedule was used with the DSM-III to make a summary clinical judgment about the presence of depression. Interrater agreement for a sample of the ratings at intake was .83.

Beck Depression Inventory: Adolescents completed a 21-item self-report measure of depressive symptoms. Other studies show this inventory has high concurrent validity, internal consistency, and test-retest reliability.

Center for Epidemiological Studies Depression Scale: Adolescents completed a 7-item abbreviated form of the full 20-item self-report measure of depressive symptoms over the past week. The alpha coefficient equaled .78.

Development of Abbreviated Measures for Adolescent Target Behaviors: In addition to self-report depression scales, adolescents completed instruments selected to assess psychosocial constructs known to be associated with depression in individuals: depressogenic cognitions, pleasant events, anxiety, social skills, and conflict resolution skills. These characteristics were targeted by the treatment.

Parent Report Measures: One or both parents completed the Child Behavior Checklist (CBCL), which assessed 118 adolescent/child behavior problems. Subscales were computed for the externalizing and internalizing categories, as well as for a depression scale. Also, an issues checklist identifies disagreement between adolescents and parents.

Analysis: For the dichotomous diagnostic measure of having depressive symptoms, the individual-level analysis compared groups with chi-square and ANOVA statistics. For the reported measures from adolescents and parents, group-by­-gender and group-by-time interactions were examined in MANOVA with repeated measures. However, neither the gender main effects nor gender interactions reached significance. The results therefore focused on the group-by-time interactions.

By excluding 10 dropouts after the initial assignment and 36 dropouts after the posttest, the analysis did not use an intent-to-treat approach. The attrition analysis reported below was used to justify the approach.

The study did not include a dose-response analysis. Nor did it report effect sizes.

Outcomes:

Baseline Equivalence and Attrition: The study mentions but did not analyze 10 subjects who dropped out after being assigned to a condition but before any treatments. About 75% of the intervention group eligible for follow-up completed the 6-month assessment and 50% completed the 24-month assessment. The analysis used only the subjects with completed data rather than an intent-to-treat sample. However, the authors note that a MANOVA comparing the posttreatment scores of those who participated in the follow-up assessment with those who did not participate revealed no significant differences on either adolescent or parent measures. Also, group-by-time (pretreatment versus 6-month follow-up) repeated measures MANOVAs showed a significant effect only for time, with both groups showing improvements on both adolescent and parent measures.

Posttest: Based on the K-SADS-E interview classification of depression, the difference in the effect of treatment versus waitlist was significant. At the end of treatment, 52% of the adolescent and parent group and 57% of the adolescent-only group met diagnostic criteria for depression, while 95% of the waitlist group met the criteria. The difference between the two treatment groups was not significant.

For the reported measures, the MANOVA indicated a significant interaction between group and time such that there were no significant differences between groups at baseline but there were significant differences at posttest. Planned comparisons at posttest showed significantly lower depression for the intervention groups versus the waitlist group on the Beck Depression Inventory and Center for Epidemiological Studies Depression scale but not for any of the other 5 measures obtained from the adolescent or parent. Comparing the adolescent-only with the adolescent-and-parent treatment showed significantly lower scores for the latter group on some parent-reported measures but not on adolescent-reported measures.

Analysis of mediating or targeted behaviors focused on changes over time across groups on measures of anxiety, pleasant activities, and depressogenic cognitions. Although time had significant effects (i.e., all groups improved over time), the group-by-time interactions for these mediating factors were not significant. The improved depression outcomes for the intervention groups did not correspond closely to similar improvements in the targeted behaviors.

Long-term: Follow-up data were not available for the control group, which was offered enrollment in the therapy after the posttreatment interview. The analysis examined those remaining in the two treatment groups after attrition to see if the improvements were maintained and if they differed by treatment type. None of the adolescent measures of depression showed significant time effects, group effects, or group-by-time effects, meaning gains were maintained. For most of the parent measures of depression, significant time effects showed better ratings in the follow-up, and significant group-by-time effects showed better improvement in the adolescent-only group. The advantages of the adolescent-and-parent group at posttest thus disappeared by 6 months and both groups did equally well. Overall, then, posttest improvements were maintained in follow-up, and the adolescent-only condition enjoyed additional gains in some measures.

Over the full 24-month period, diagnoses and depression scores for the intervention groups continued to decline and remained at very low levels. With 100% depressed at intake, the percentages fell to less than 60% at posttest, about 30% at 1 month, less than 20% at 6 months, less than 10% at 12 months, and about 15% at 24 months.

Study 5

The study evaluated a modified version of the program. Because the program was implemented in school, the parent component was not used. Also, the program was reduced to ten 50-minute sessions, one per week, from the original sixteen two-hour sessions, two per week.

Summary

McLaughlin (2010) used a randomized controlled trial to examine 22 students ages 10-15 from one rural Pennsylvania school district who were at risk of depression. The students were randomly assigned to the program intervention group or a treatment-as-usual control group and assessed after 10 weeks with several measures of depression.

McLaughlin (2010) found no significant posttest effects of the program relative to the control group.

Evaluation Methodology

Design:

Recruitment: Participants included 23 students enrolled in grades five through eight in one rural school district in Pennsylvania (one elementary school and one middle school building). Screening with several depression instruments identified eligible students who were at risk for depression.

Assignment: The 23 students were randomized by the implementation team to the intervention group (n = 11) that received a modified version of the program or to a treatment-as-usual control group that received a coping skills/problem solving group program with five sessions. Both programs lasted 10 weeks, with the intervention group meeting every week, and the control group meeting every other week. The school psychologist, school psychology intern, and a school counselor were the co-facilitators for both the intervention and control groups.

Assessments/Attrition: The posttest came 10 weeks after the pretest. One participant dropped out of the control group and was excluded from the analysis. The retention rate was therefore 96%.

Sample:

Participant ages ranged from ages 10-15, and 59% were male and 41% were female. About 46% of participants were considered of low socio-economic status. At the school district level, 94% of students were Caucasian, and 11% of students participated in free and reduced-price lunch services.

Measures:

The study examined four scales of depression symptoms: the Behavior Assessment System for Children-Teacher, the Behavior Assessment System for Children-Parent, the Beck Depression Inventory for Youth, and the Center for Epidemiology Scale for Depression. Only the depression components of the multi-trait scales were used. The Center for Epidemiology Scale for Depression was obtained at every session (10 times for the intervention group and five times for the control group).

The author reported from other studies that the measures had acceptable reliabilities but did not present figures from the study sample. The author also noted that the Center for Epidemiological Scale was developed for adults and had not been validated for youths.

Analysis:

The analysis of data at posttest used two-way analysis of covariance with terms for condition, time, and the interaction of condition-by-time. However, because the teacher-completed measure of depression violated assumptions of normality and homogeneity of variance, the analysis of this outcome used a non-parametric method based on a rank transformed analysis of covariance. Additional analyses of the time series available for one of the measures fit quadratic models separately for the two conditions.

Intent-to-Treat: The study dropped one student who declined to participate after the start of the control program without efforts to obtain any further data, but the exclusion comprised only 4% of the sample.

Outcomes

Implementation Fidelity:

No quantitative figures.

Baseline Equivalence:

The study reported only that age and enrollment in the free and reduced-price lunch program did not differ significantly across conditions at baseline.

Differential Attrition:

With only one dropout, attrition was minimal (4%).

Posttest:

The pretest-posttest analyses found no significant condition-by-time interaction terms for any of the four depression measures. The time series analysis for one of the measures, the Center for Epidemiology-Depression scale, showed improvement for the intervention group but not the control group. The trends nonetheless did not produce significant posttest differences.

Long-Term:

Not examined.