Cognitive–Behavioral Therapy Versus Usual Clinical Care for Youth Depression:
An Initial Test of Transportability to Community Clinics and Clinicians
John R. Weisz
Harvard University and Judge Baker Children’s Center
Michael A. Southam-Gerow
Virginia Commonwealth University
Elana B. Gordis
University at Albany, State University of New York
Jennifer K. Connor-Smith
Oregon State University
Brian C. Chu
Rutgers, The State University of New Jersey
David A. Langer
University of California, Los Angeles
Bryce D. McLeod
Virginia Commonwealth University
Texas A&M University
Akron Children’s Hospital
Community clinic therapists were randomized to (a) brief training and supervision in cognitive–
behavioral therapy (CBT) for youth depression or (b) usual care (UC). The therapists treated 57 youths
(56% girls), ages 8–15, of whom 33% were Caucasian, 26% were African American, and 26% were
Latino/Latina. Most youths were from low-income families and all had Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) depressive disorders
(plus multiple comorbidities). All youths were randomized to CBT or UC and treated until normal
termination. Session coding showed more use of CBT by CBT therapists and more psychodynamic and
family approaches by UC therapists. At posttreatment, depression symptom measures were at subclinical
levels, and 75% of youths had no remaining depressive disorder, but CBT and UC groups did not differ
on these outcomes. However, compared with UC, CBT was (a) briefer (24 vs. 39 weeks), (b) superior
in parent-rated therapeutic alliance, (c) less likely to require additional services (including all psycho-
tropics combined and depression medication in particular), and (d) less costly. The findings showed
advantages for CBT in parent engagement, reduced use of medication and other services, overall cost,
and possibly speed of improvement—a hypothesis that warrants testing in future research.
Keywords: depression, children, adolescents, youth, cognitive–behavioral therapy
John R. Weisz, Department of Psychology, Harvard University and Judge
Baker Children’s Center; Michael A. Southam-Gerow and Bryce D. McLeod,
Department of Psychology, Virginia Commonwealth University; Elana B.
Gordis, Department of Psychology, University at Albany, State University of
New York; Jennifer K. Connor-Smith, Department of Psychology, Oregon
State University; Brian C. Chu, Graduate School of Applied and Professional
Psychology, Rutgers, The State University of New Jersey; David A. Langer,
Department of Psychology, University of California, Los Angeles; Amanda
Jensen-Doss, Department of Educational Psychology and Department of Psy-
chology, Texas A&M University; Alanna Updegraff, Oak Adoptive Health
Center, Akron Children’s Hospital; Bahr Weiss, Department of Psychology
and Human Development, Vanderbilt University.
This study was funded by National Institute of Mental Health (NIMH)
Grant R01-MH57347 (John R. Weisz, principal investigator), and the authors
were supported by additional grants from NIMH (R21-MH63302 [John R.
Weisz], R01-MH068806 [John R. Weisz], K23-MH069421 [Michael A.
Southam-Gerow], F31-MH64993 [Bryce D. McLeod], F31-MH079631
[David A. Langer]) and the John D. and Catherine T. MacArthur Foundation
(Research Network on Youth Mental Health [John R. Weisz]).
We thank our clinic administrative colleagues for their help, in many
forms, throughout the study. These include Herb Blaufarb, Thomas Ciesla,
Kita Curry, Carol Falender, Anita Feltes, Susan Hall-Marley, Joseph Ho,
Amy Hulberg, Cynthia Kelly, Jill Morgan, Philip Pannell, Robert Parsons,
Allison Pinto, Terry Rattray, Rebecca Refuerzo, David Slay, and Marian
Williams. We also thank the therapists, parents, and youths who partici-
pated in the study, as well as our project administrative and graduate
student colleagues, including Amie Bettencourt, Ashley Borders, Jen
Durham, Aileen Echiverri, Samantha Fordwood, Sarah Francis, Andrea
Kasimian, May Lim, Tamara Sharpe, and Irina Tauber.
Correspondence concerning this article should be addressed to John R.
Weisz, Department of Psychology, Harvard University, William James
Hall, 33 Kirkland Street, Cambridge, MA 02138. E-mail: jweisz@
Journal of Consulting and Clinical Psychology
2009, Vol. 77, No. 3, 383–396
© 2009 American Psychological Association
Advocates for evidence-based treatments (EBTs; e.g., National
Advisory Mental Health Council Workgroup on Child and Ado-
lescent Mental Health Intervention and Deployment, 2001; Office
of the Surgeon General, 1999, 2004; President’s New Freedom
Commission on Mental Health, 2003) have made a case for trans-
porting these treatments to a broad array of everyday practice
contexts. This perspective may make sense, in principle. However,
before major resources are devoted to large-scale dissemination, it
may be wise to study the implementation process, to learn what
steps are needed to transport these treatments effectively.
As several researchers have suggested (e.g., Southam-Gerow,
Chorpita, Miller, & Gleacher, 2008; Southam-Gerow, Weisz, &
Kendall, 2003; Weisz, 2004; Weisz, Donenberg, Han, & Weiss,
1995), there are many differences between the contexts in which
EBTs are usually tested and the contexts of everyday clinical care.
Bridging all of these differences may not be a simple process. This
point is made clear in a recent review of research on the imple-
mentation of tested programs in practice settings (Fixsen, Naoom,
Blase, Friedman, & Wallace, 2005). Fixsen et al. reported that
many implementation efforts have not succeeded, despite evidence
that the programs have worked well within controlled trials; by
contrast, a few studies have shown successful implementation in
practice settings when extensive, multilevel procedures were used,
including careful selection of the “implementers,” thorough train-
ing, and active coaching or supervision.
The complex array of findings reviewed by Fixsen et al. (2005)
suggests that extensive research will be needed to understand what
implementation procedures work in any particular domain (see
also Southam-Gerow, Austin, & Marder, 2008). The present study
represents one step toward such a body of research, focused on a
specific form of treatment for depression in children and adoles-
cents (referred to as youths in this article), as implemented in
The need for this research is underscored by questions about
whether skilled and effective use of EBTs can be achieved in the
limited time available to many practitioners. Many of the most
skilled users of EBTs have built their skills over several years of
graduate or postdoctoral training. Such training often occurs in
specialized training clinics that focus on one treatment protocol, or
a few related ones, for a narrow range of clients, and with faculty
mentors and peers all concentrating on a similar skill set (see, e.g.,
Southam-Gerow & Kendall, 2006). Such extended, intensive, and
highly focused skill building is not likely to be feasible for most
practitioners, given their mandate to serve a broad array of clients
and given the time constraints, work demands, and productivity
pressures of everyday clinical care. Similarly, the procedures used
in many clinical trials—including selection of only the most tal-
ented therapists, extensive training, skill building through practice
cases, and assignment of study cases only after high skill levels are
achieved in practice cases—may not be feasible in practice con-
texts, given the service mandates and financial and time constraints
under which clinics and clinicians must now operate.
These implementation challenges are quite relevant to
cognitive–behavioral therapy (CBT) for depression. CBT is
widely recommended for youth depression by professional groups
(e.g., American Academy of Child & Adolescent Psychiatry Work
Group on Quality Issues, 1998) and has the most extensively
replicated success in clinical trials for youth depression (see
Weisz, McCarty, & Valeri, 2006). However, preparing for a CBT
trial often involves extensive therapist preparation. For example,
CBT therapists in a randomized control trial (RCT) by Brent et al.
(1997) were required (a) to have 6 months of intensive training on
the specific CBT treatment manual, (b) to “treat two cases in
adherence to the treatment model before becoming a therapist for
the study” (p. 878), and (c) after passing requirements a and b, to
receive 1 hr of group and 1 hr of individual supervision per week
throughout their work as therapists. Because such an extensive
time commitment would not be feasible for most clinicians em-
ployed in everyday practice, an important implementation question
arises: Can clinicians employed in practice settings learn sufficient
skills in CBT, in the time that is available to them, to be successful
in treating youth depression?
Two recent studies suggest that it may be difficult to train
practitioners to use CBT in ways that outperform the usual inter-
ventions provided in everyday youth mental health care. In one
study, Clarke et al. (2002) compared usual care (UC) for youth
depression in the Kaiser Permanente health maintenance organi-
zation (HMO) (e.g., outpatient visits plus psychotropic medica-
tion) with UC plus CBT. The depressed offspring of depressed
parents were treated with the Coping With Depression Course for
Adolescents (CWD-A), a CBT protocol that had shown beneficial
effects in two previous efficacy trials. Therapists received initial
training in the CWD-A followed by supervision every other week.
At the end of the study, “the authors were unable to detect any
significant advantage of the CBT program over usual care” (Clarke
et al., 2002, p. 305).
In another study, Kerfoot, Harrington, Rogers, and Verduyn
(2004) randomly assigned social workers and other community
support workers to receive training and supervision in CBT or to
continue their UC procedures, with both groups treating depressed
adolescents. At the end of treatment, the adolescents in both
groups had shown similar reductions on depression symptom
self-report measures, with no significant difference evident be-
tween CBT and UC. Kerfoot et al. (2004) concluded from these
findings that “training community-based social workers in [CBT]
is neither practical nor effective in improving the outcomes of their
clients” (p. 92).
These important studies highlight the challenge of moving CBT
into community service settings, particularly when the task in-
cludes training professionals in their first-time use of CBT and
when CBT is pitted against UC in which professionals use familiar
procedures and do their best to help their young clients improve.
The research to date has taken valuable steps toward investigating
whether there are training and supervision procedures through
which CBT might produce more beneficial effects than UC. As a
next step, we set out (a) to use a more complete effectiveness
design than has been tried thus far, (b) to use a fully randomized
experimental procedure, and (c) to avoid built-in dose differences
that might favor CBT. Given these goals, our study design differed
from Clarke et al.’s (2002) and Kerfoot et al.’s (2004) studies in
More Complete Effectiveness Design
Our study involved clinically representative treatment settings,
youths, and therapists. All sessions took place within routine
WEISZ ET AL.
outpatient care in public mental health clinics; we included only
youths who had been referred through normal pathways, contact-
ing them only after their families had called the clinics to seek
services; and we included only clinicians who were already em-
ployed as therapists in those clinics. By contrast, the setting for
CBT in the Clarke et al. (2002) study was a research center, with
UC conducted in HMO offices, and in Kerfoot et al. (2004), both
CBT and UC were performed in various community social service
settings. Youths in the Clarke et al. study were recruited from an
HMO database, and in the Kerfoot et al. investigation, study
therapists recruited their own cases. Clinicians in Clarke et al. were
research center staff for CBT and HMO clinical staff for UC;
clinicians in Kerfoot et al. were social workers and community
Balanced Comparison, With Double Randomization
Our experimental design was structured to create as fair and
balanced a comparison as possible between CBT and UC; we
randomized therapists to CBT or UC, then randomized youths to
CBT or UC. By contrast, Clarke et al. (2002) randomized youths
but not therapists, and Kerfoot et al. (2004) randomized social
workers to CBT or UC, but youths were then recruited by the
therapists, precluding youth randomization.
No Built-in Dose Differences
We also sought to avoid built-in dose differences that would
favor CBT over UC (we tracked treatment duration but left it free
to vary). By contrast, the CBT condition in Clarke et al. (2002)
consisted of CBT plus usual HMO services (including medica-
tion), a design that offers advantages but does create a built-in dose
difference favoring CBT over UC.
Practice-Oriented Skill-Building Model
To minimize conflict with clinic productivity rules, we limited
initial CBT training to 1 day and stressed learning through weekly
case supervision. By contrast, Clarke et al. (2002) and Kerfoot et
al. (2004) mainly emphasized initial training: 30 hr in Clarke et al.,
3 days in Kerfoot et al. After training, Clarke et al. provided
supervision every other week for 30 min in Year 1 and 15 min in
Year 2, with most supervision focused on attendance issues (per-
sonal communication, G. Clarke, March 23, 2007). After their
training period, Kerfoot et al. offered voluntary supervision but
had poor clinician participation (median number of supervision
meetings attended was three; almost a third of therapists attended
none or one).
The CBT program in the present study consisted of Primary and
Secondary Control Enhancement Training (PASCET; Weisz,
Thurber, Sweeney, Proffitt, & LeGagnoux, 1997). A previous RCT
(Weisz et al., 1997) had shown beneficial effects of PASCET with
elementary to middle school youths who had elevated depression
symptoms, and PASCET was especially appropriate for this study
because (a) it included the most common core elements of CBT
[e.g., activity selection, cognitive restructuring, relaxation train-
ing], (b) it was designed to fit the relatively broad age range
needed in this study, (c) it was designed to accommodate the
variations in pace and session attendance often seen in outpatient
care, and (d) its focus on surveying multiple depression coping
skills and then identifying and practicing a few “best fit” skills
appeared to fit the array of different forms of youth depression
seen in outpatient settings (see, e.g., Weiss et al., 1991).
To encompass outcomes across a relatively broad spectrum, we
built on the assessment model of Hoagwood, Jensen, Petti, and
Burns (1996), examining CBT versus UC group differences on
clinical outcomes, consumer response (i.e., therapeutic alliance),
treatment duration, use of additional clinical services beyond psy-
chotherapy, and cost. Our study appears to be the first trial of CBT
for youth depression to encompass all three major effectiveness
trial dimensions (i.e., clinically representative treatment setting,
referred youths, and psychotherapists); the rigor of a fully random-
ized design (i.e., with both therapists and youths randomized to
CBT or UC); and broad assessment encompassing clinical process,
clinical outcome, and cost. We tested the hypotheses that CBT
would prove superior to UC on clinical outcomes and therapeutic
alliance, with lower cost and less need for additional services than
UC. The primary study outcome was depression symptomatology,
assessed with youth- and parent-report measures.
Participants: Youths and Therapists
8–15 years (M ? 11.77, SD ? 2.14); 33% were Caucasian, 26%
African American, 26% Latino/Latina, 11% “mixed/other,” and
4% not reporting ethnicity. Some 34% of the families in our
sample reported yearly income at or below $15,000; 32% between
$15,000 and $30,000; 14% between $30,000 and $45,000; 12%
between $45,000 and $60,000; and 8% above $60,000 (seven
families did not report income). Primary diagnoses (based on the
Diagnostic Interview Schedule for Children Version 4 [DISC 4.0],
combined parent and youth report; Shaffer, Fisher, Lucas, Dulcan,
& Schwab-Stone, 2000) were 56% major depressive disorder
(MDD), 12% dysthymic disorder (DD), and 32% minor depressive
disorder (MinDD; American Psychiatric Association, 1994). Co-
morbidity with other disorders was high (see Table 1). For exam-
ple, 14% of the sample met criteria for conduct disorder, 60% for
oppositional defiant disorder, 47% for attention deficit hyperactiv-
ity disorder, 19% for generalized anxiety disorder, and 39% for
separation anxiety disorder. There were no significant condition
differences on any of these variables or on number of disruptive,
anxiety, or total comorbid disorders (all ps ? .48).
Therapists (n ? 26 in CBT, n ? 28
in UC) averaged 32.0 years of age (SD ? 7.02, range ? 25–55
years), and 75% were female; among the therapists, 43% were
Caucasian, 34% were Latino/Latina, 13% were Asian/Pacific, 6%
were of mixed ethnicity, and 4% were African American. Some
22% were social workers, 14% were doctoral-level psychologists,
56% had a master’s degree in psychology, and 8% were other
master’s-level professionals (e.g., marriage and family). Therapists
averaged 4.30 (SD ? 1.70) years of training and 2.40 (SD ? 3.50)
years of additional professional experience prior to the study.
Previous research in community samples (e.g., Weersing, Weisz,
& Donenberg, 2002) has reported similar clinician professional
and demographic characteristics. CBT and UC therapists did not
differ significantly on any of these characteristics, suggesting
The sample included 57 youths, 56% girls, ages
SPECIAL SECTION: COGNITIVE–BEHAVIORAL THERAPY FOR YOUTH DEPRESSION
Settings and Participant Contact Procedures
Participants were routine referrals to seven public urban
community mental health clinics within the most populous U.S.
county (U.S. Department of Commerce, 2003). Enrollment be-
gan in 1998 and ended in 2003, with assessments ending in
2005. If families’ initial request for services included any
mention of internalizing symptoms, and youth age was 8–15
years, families were told about the study. Given permission, a
phone screen followed. Those who passed the phone screen
(i.e., positive for any relevant symptom, no signs of psychotic
or developmental disorders) were invited to a project interview
(see below). If the interview identified a diagnosis of MDD,
DD, or MinDD, we then assessed treatment priority (see below)
to determine whether to invite the family to participate.1Figure
1 shows the flow of enrollment following the Consort format.
Of the 268 youths assessed for eligibility, 185 did not meet
study criteria2; 26 who were eligible did not enroll, most often
because the family decided not to start therapy at the clinic.
Determining treatment priority/study eligibility.
treatment priority, we obtained DISC 4.0 (Shaffer et al., 2000)
DSM-IV (American Psychiatric Association, 1994) diagnoses, dis-
order symptom counts, and symptom-report measures (described
below) separately from parents and youths. Parents and youths also
reported their top three reasons for seeking services (parent exam-
ples: “she is unhappy all the time,” “dark clouds that she goes
through”; youth examples: “bad mood,” “I’m sad”) and gave a
severity rating (0–10 scale) associated with each of these. These
diagnostic, symptom, referral problem, and severity data were
discussed by project staff, senior clinic staff, and family; if it was
agreed that the depressive disorder had treatment priority, the
youth was invited to enroll in the trial.3
Medication decisions followed usual clinic
procedures, guided by clinic staff psychiatrists. This fit our goal of
adhering to usual clinic procedures wherever possible, and, in any
event, clinic staff members were unwilling to relinquish control
over medication. We recorded medication use and included the
data in analyses (as discussed later).
Assessment Personnel and Schedule
Interviews and assessors.
assessments were conducted before and after treatment (Time 1
[T1] and Time 2 [T2]). Assessments were carried out by inter-
viewer pairs, including one clinical psychology graduate student
and one post-bachelor’s research assistant, both blind to condition.
Assessments were highly standardized, so instead of assessing
inter-interviewer reliability, we focused on ensuring that standard-
ized procedures were followed strictly. Interviewer training by
postdoctoral staff included didactics, modeling, and individually
supervised practice interviews; videotapes of full completed inter-
By agreement with clinics, project
1We complied with American Psychological Association ethical stan-
dards in the treatment of our sample.
2Why were 185 youths excluded? Note that we tried to assess all whose
referral concerns included any depression or anxiety symptom; most either
did not meet criteria for a depressive disorder or met criteria for another
disorder that had treatment priority (see Settings and Participant Contact
Procedures section of the text). Youths for whom anxiety disorders had
priority (n ? 48) were invited to enroll in an anxiety trial. Youths for whom
neither a depressive nor an anxiety disorder was primary (n ? 137) were
offered regular treatment in their clinic. Because we lacked detailed infor-
mation on youths at the time of their initial clinic contact, we had to
interview many who ultimately did not qualify for the study.
3In any situation where decisions were influenced by parent, youth, or
staff judgment as well as standardized measures, bias of various kinds
could enter the process. Thus, it is important to note that randomization to
PASCET versus usual care occurred after study eligibility was determined.
Pretreatment Characteristics of Primary and Secondary Control Enhancement Training (PASCET) and Usual Care (UC) Groups
Cohen’s dM SDnM SDn
DISC-C MDD symptom count
Depression factor score
DISC-P MDD symptom count
Depression factor score
DISC-P comorbid disruptive
DISC total diagnoses
2.761.7125 2.661.43 320.25 55 0.800.07
?0.4554 0.66 0.12
disorder; CDI-P ? Children’s Depression Inventory—Parent Report; CBCL ? Child Behavior Checklist Anxious/Depressed Scale; DISC-P ? Diagnostic
Interview Schedule for Children—Parent Report; ETOS ? Expectations of Therapy Outcome Scale; DISC ? Diagnostic Interview Schedule for Children.
CDI ? Children’s Depression Inventory; DISC-C ? Diagnostic Interview Schedule for Children—Child Report; MDD ? major depressive
WEISZ ET AL.
views were reviewed throughout the study to prevent drift and
ensure adherence to standardized protocols.
T1 assessments were done prior to the
start of therapy. Timing of T2 assessments reflected the fact that
the study was a hybrid of efficacy and effectiveness research (e.g.,
Southam-Gerow, Austin, & Marder, 2008). Because treatment
duration was free to vary in UC and in CBT, posttreatment
assessment could not be set at the same time points for all partic-
ipants (as in an efficacy trial with fixed treatment duration).
Assessment at any fixed point (e.g., 16 weeks) would have in-
cluded some youths who had terminated and others who had not;
moreover, some administrators and clinicians objected to assess-
ments during treatment, believing they would alter the therapy
process or relationship. Thus, T2 assessments were set at the end
of treatment for all participants. This did not control for duration,
but it did ensure that assessment would come after the treat-
ment—be it CBT or UC—had been given a full opportunity to
The median lag between the date of the last session and the date
of the T2 assessment was 59 days (32 for CBT, 63 for UC),
reflecting the fact that termination decisions were often not an-
nounced by families (only becoming evident after several weeks of
nonattendance) and the fact that scheduling was difficult for our
low-income sample, often requiring substantial advance planning
(e.g., to arrange time off from work).
Measurement Model for the Study
Treatment research has been criticized for relying on too narrow
a range of outcomes (especially diagnoses and symptoms; see
Hoagwood et al., 1996; Kazdin & Weisz, 1998). To address this
concern, we built on the Hoagwood et al. (1996) model, assessing
three outcome dimensions: (a) symptoms and diagnoses; (b) con-
sumer perspectives, including youth and parent ratings of thera-
peutic alliance; and (c) treatment process and systems impact,
including duration, cost, and use of other clinical services. Fol-
lowing Consort principles, we identified depression symptom re-
duction as the primary outcome of interest in the study, with the
other measures regarded as secondary.
Measurement of Symptom–Diagnosis Domain
Diagnostic Interview Schedule for Children.
noses and symptoms, we used the DISC 4.0 (Shaffer et al., 2000).
Earlier versions generated extensive reliability and validity data (e.g.,
Rubio-Stipec et al., 1996; Schwab-Stone et al., 1996; Shaffer et al.,
1996), and the DISC team has continued to assess psychometrics of
the DISC 4.0 (e.g., Shaffer et al., 2000). We used the DISC 4.0 to
obtain (a) youth-report diagnoses and symptom counts (DISC-C),
(b) parent-report diagnoses and symptom counts (DISC-P), and (c)
combined diagnoses and symptom counts. To obtain combined
values, we counted a symptom as positive if either the youth or the
parent endorsed it. To reduce youth burden and focus their reports
on the categories thought to be most validly reported by youths (as
per consultation with DISC authors), we used only parent-report
modules for oppositional defiant disorder, conduct disorder, and
attention deficit hyperactivity disorder. Other DISC modules were
administered to both parents and youths.
Children’s Depression Inventory (CDI).
(Kovacs, 2003) is a widely used youth self-report measure of
To assess diag-
The 27-item CDI
program; UC ? usual care; N/A ? not applicable.
Consort flowchart for the study. PASCET ? Primary and Secondary Control Enhancement Training
SPECIAL SECTION: COGNITIVE–BEHAVIORAL THERAPY FOR YOUTH DEPRESSION
depressive symptoms. In clinical samples, Cronbach’s alphas for
the CDI have ranged from .71 to .89, and test–retest reliability
coefficients have ranged from .50 to .87 (see Kovacs, 2003). The
CDI and several other measures of youth depression have been
found to correlate at .5 and higher (e.g., McCauley, Mitchell,
Burke, & Moss, 1988; see Kovacs, 1992, for review). We used the
CDI Total Depression scale for this study.
Children’s Depression Inventory—Parent Form (CDI-P).
parallel the youth-report CDI, we used the parent-report CDI-P.
This measure has shown good test–retest reliability and internal
consistency (Kazdin, French, & Unis, 1983; Wierzbicki, 1987) and
has distinguished children with depressive disorders from children
with other diagnoses (Kazdin et al., 1983). Some research has
shown substantial correlations between parent and youth versions
of the CDI in nonclinical populations (e.g., Slotkin, Forehand,
Fauber, McCombs, & Long, 1988; Wierzbicki, 1987), but the
relation between parent and youth reports of youth depression is
often weak (Kazdin et al., 1983), which argues for assessing both
Child Behavior Checklist (CBCL).
118-item scale that obtains parent ratings for an array of behavioral
and emotional problems. Extensive reliability and validity evi-
dence has been reported (see Achenbach, 1991). We focused
mainly on the broadband Internalizing scale and two narrow-band
scales: Anxious–Depressed and Withdrawn–Depressed, all of
which reported as T scores with a mean of 50 and a standard
deviation of 10.
The CBCL is a widely used
Measurement of Consumer Perspectives Domain
Expectations of Therapy Outcome Scale (ETOS).
parent forms of the ETOS were used to assess UC versus CBT
differences in pretreatment expectations (sample item: “How do
you expect to feel when therapy is over?” 1 ? much worse, 9 ?
much better). ETOS scores have been found to be significantly
related to (a) the information youngsters and parents receive prior
to treatment and (b) therapists’ expectations at therapy onset
(Bonner & Everett, 1982, 1986).
Therapeutic Alliance Scale for Children (TASC).
treatment assessment, we used the seven-item TASC (Shirk &
Saiz, 1992) youth-report (TASC-C) and parent-report (TASC-P)
forms to assess youth and parent therapeutic alliance with the
therapist. Hawley and Weisz (2005) have reported good internal
consistency and test–retest reliability for the TASC among clinic-
referred youths (alpha ? .93, r ? .79) and parents (alpha ? .81,
r ? .82).
In the post-
Measurement of Treatment Process and Systems Impact
Service Assessment for Children and Adolescents (SACA)—
A key question to ask about any treatment is
whether it reduces the need for other services. For this question,
we used the SACA (Horwitz et al., 2001), a standardized parent-
report interview assessing use of multiple mental health services
(outpatient, inpatient, and other). SACA reliability and validity are
well documented (Hoagwood et al., 2000; Horwitz et al., 2001;
Stiffman et al., 2000).
Clinic record review.
All of the clinics kept detailed records
on study clients, following standard protocol required for reporting
and billing. The records contained diverse information, including
treatment duration, session attendance, no-shows/cancellations,
and other data required for service and cost documentation. Three
reviewers recorded data from these records. Each record was
coded by two reviewers, with discrepancies resolved by consulting
the original record.
Random Assignment of Participants
We assigned youths to either UC or CBT, using block random-
ization (e.g., Friedman, Furberg, & DeMets, 1998), to support
balance on clinic, youth gender, and bilingual therapist require-
ment (i.e., parent-preferred Spanish). Youths’ identical status on
the three dimensions were blocked and assigned randomly within
blocks. As an illustration, the first bilingual requirement boy in
Clinic A was randomly assigned to either CBT or UC; the next
bilingual requirement boy in Clinic A was assigned to the other
condition. This procedure provided reasonable, but not perfect,
balance across conditions, because randomization occurred at the
clinic level, each clinic had four blocks, and some blocks were left
incomplete at the end of the study.
Random Assignment of Therapists
To ensure comparability of therapists in the two conditions, we
randomly assigned all therapists to either UC or CBT using a
randomized block procedure (see Friedman et al., 1998) to balance
the conditions on inclusion of bilingual therapists and on repre-
sentation of disciplines: psychologists, social workers/marriage,
family, and child counselors, and psychiatrists. Note that we ad-
hered strictly to therapist randomization, not excluding any CBT
therapists, regardless of their performance in training or compe-
tence with CBT during therapy.
Power was calculated for between- and within-group compari-
sons using actual sample sizes and assuming alpha ? .05 (Lenth,
2006). Between-group power was based on a two-group t-test
model with equal variances; power was .80 to detect an effect size
of d ? .76 difference. For within-group comparisons, we used a
paired-group t-test model with equal variances; power was .80 to
detect d ? .51 for the CBT condition and .80 to detect d ? .58 for
the UC condition. To detect a medium effect size of .50, power for
between-group comparisons was .45. Power for within-group com-
parisons was .67 for the UC condition and .78 for CBT.
Treatment Procedures Used in the Study: UC and CBT
UC therapists agreed to use the treatment procedures they used
regularly and believed to be effective in their clinic practice.
Therapy continued in UC until a normal client termination. CBT
therapists were trained to use the PASCET program (Weisz,
Thurber, Sweeney, Proffitt, & LeGagnoux, 1997). PASCET is
built on findings concerning cognitive and behavioral features of,
and beneficial treatments for, youth depression (e.g., Lewinsohn,
Clarke, Hops, & Andrews, 1990; Stark, Reynolds, & Kaslow,
1987) and on the two-process model of perceived control and
coping (see Rothbaum, Weisz, & Snyder, 1982; Weisz, Rothbaum,
WEISZ ET AL.
& Blackburn, 1984a, 1984b). In this model, primary control in-
volves coping by making objective conditions (e.g., school grades,
peer relationships) fit one’s wishes. Secondary control involves
coping by adjusting oneself (e.g., one’s expectations, interpreta-
tions) to fit objective conditions, influencing their subjective im-
pact without altering the actual conditions. Depression is addressed
by applying primary coping to distressing conditions that are
modifiable and secondary coping to conditions that are not. The
goal for each youth is to learn and try out a set of primary and
secondary control skills, identify a subset of the skills that work
best for that individual, then practice applying those best fit skills
in situations that trigger depressive symptoms. Sessions consist
mainly of individual therapy, but include periodic parent meetings
and brief summary meetings for youth, parent, and therapist after
each individual youth session. Therapists are guided by a manual
(Weisz et al., 1999) and youths by a parallel practice book. The
expanded PASCET manual used for this study contains detailed
plans for 10 individual sessions and outlines to guide up to 5 more
sessions, but treatment can be extended flexibly for youths who
need more than 15 sessions to learn and practice the concepts and
Training and Supervision of PASCET and UC Therapists
Training and supervision time had to fit the constraints of busy
clinics, including clinician productivity requirements. On the basis
of these constraints, therapists randomized to PASCET received a
1-day, 6-hr training, then about 30 min of weekly case supervision
in use of the protocol from one of six doctoral-level clinical
psychologists who had prior experience with PASCET. Whenever
possible, we used group supervision, targeting 30 min of case
discussion per therapist. This fit routines in all of the clinics, where
all study therapists—PASCET and UC—received regular super-
vision from clinic staff; regular supervision time was typically
reduced for PASCET therapists to accommodate their project-
related supervision.4Supervision attendance was good, with vir-
tually all scheduled meetings held or rescheduled.
Recording and Coding Treatment Sessions
Both PASCET and UC treatment sessions were recorded, then
coded for protocol adherence, characterization of UC, and treat-
ment differentiation using two coding systems.
PASCET Brief Adherence Scale (PBA).
(Southam-Gerow, Jensen, Gelbwasser, Chu, & Weisz, 2001) pro-
tocol adherence, we used the PBA, which contains 16 items (rated
present vs. absent) reflecting whether the session included specific
elements of PASCET session procedures. Sessions were randomly
selected from Sessions 1–10, that is, the structured sessions fea-
turing primary and secondary control skills (other sessions lacked
the prescriptive content required for adherence coding). We re-
stricted coding of tapes to those cases with at least six session tapes
(n ? 30). From this subsample, we randomly selected 50% of the
cases; one of two expert raters coded all available tapes for each of
the cases. Some 25% of coded tapes were selected randomly and
coded by the second rater; kappa was 1.00 for interrater agreement.
Therapy Process Observational Coding System for Child Psy-
chotherapy—Strategies Scale (TPOCS-S).
TPOCS-S (McLeod, 2001) to characterize the therapy provided in
To gauge PASCET
We used the
UC and to assess differentiation between the PASCET and UC
conditions. TPOCS-S items are designed to represent prominent
therapeutic approaches in youth psychotherapy. We used four
TPOCS-S subscales: CBT (14 items—e.g., cognitive distortions);
Psychodynamic (4 items—e.g., transference); Family (5 items—
e.g., parenting style); and Client-Centered (4 items—e.g., client
perspective). TPOCS-S coders make 7-point extensiveness ratings
on each item, that is, for the extent to which the therapist used each
therapeutic intervention during an entire session.
Four graduate students and one doctoral (Ph.D.)–level clinical
psychologist formed the coding team. Two sessions from each case
(excluding first and last) were randomly sampled if the case had 20
sessions or less (otherwise, 3 were coded). This produced 94 coded
sessions (51 UC, 43 PASCET—the number of sessions between
the two types of treatment differed because UC therapy contained
more sessions). Independent coding of 53 sessions showed good
item-level interrater reliability (mean intraclass correlation ? .71,
SD ? .14).
Analyses involved (a) addressing missing data, (b) data reduc-
tion, (c) tests of group comparability, (d) primary analyses testing
treatment group effects, and (e) post hoc analyses. All analyses
used the intent-to-treat (ITT) sample. For measures with fewer
than 15% missing items, we scaled the sum of completed items to
fit the scores of the completed measures (e.g., if 2 of the 27 CDI
items were missing, we multiplied total score by 27/25). Partici-
pants missing a measure at any time point were excluded from
analyses with that measure at that time point.
Data Reduction Through Exploratory Factor
Because we sought to make inferences about latent constructs
rather than specific outcome measures, and to reduce the number
of significance tests, we used EFA to identify latent factors un-
derlying the parent- and youth-report depression measures. Tests
of normality showed generally normal distributions, with only
youth-report CDI showing moderate positive skew. Maximum-
likelihood estimation produced two factors based on a scree-test.
We used an oblique Promax rotation (Hendrickson & White, 1964)
to identify the two-factor solution with the simplest structure. One
factor, Parent-Reported Depression, included all parent-report
measures: CDI-P (loading: .89), DISC-P depression symptoms
(.53), CBCL Withdrawn-Depressed (.69), and CBCL Anxious-
Depressed (.74). The other factor, Youth-Reported Depression,
included both youth-report measures: CDI (.99) and DISC-C de-
pression symptoms (.37). The distinction between factors is clear;
the .99 loading of the CDI on the Youth-Reported Depression
factor suggests caution in interpreting loadings on each factor (Van
Driel, 1978). Using unit weighting (Kline, 2004), we averaged
standardized values of each factor’s measures to compute a factor
score for each participant. To obtain posttreatment factor scores on
4Mean supervision time per week, by therapist report, was 3.47 hr,
including individual, group, treatment team, and staff meeting supervision.
We do not have data on the exact amount by which regular supervision was
reduced for PASCET therapists.
SPECIAL SECTION: COGNITIVE–BEHAVIORAL THERAPY FOR YOUTH DEPRESSION
metrics comparable to those of the pretreatment factors, we stan-
dardized each of the posttreatment factor’s measures using the
measures’ pretreatment means and standard deviations.
As a context for later analyses of depression measures, we
assessed the success of randomization in producing similar
PASCET and UC groups, the content of the treatment sessions,
the duration of treatment in PASCET and UC, and patterns of
Group comparisons on pretreatment variables.
whether randomization created comparable PASCET and UC
groups, we compared the groups at T1 using t tests for continuous
measures and chi-square tests for categorical measures. Our tests
included demographic measures (ethnicity, gender, family in-
come), youth-report clinical measures (CDI, DISC depression
symptom count, youth depression factor score), parent-report clin-
ical measures (parent CDI, DISC depression symptom counts,
DISC symptom counts for externalizing disorders, CBCL
Anxious-Depressed, CBCL Withdrawn, CBCL Externalizing,
Parent-Reported Depression factor score, ETOS), and combined
measures (DISC parent-plus-youth combined diagnoses). The two
groups did not differ significantly on any pretreatment measure
(see Table 1).5
Adherence coding: PASCET sessions.
gauge PASCET adherence contains 16 items rated present or
absent. For the PASCET cases coded, the mean proportion of
required elements present in the sessions was .98 (range ? .88–
1.00, SD ? .01).
Coding of UC sessions.
Interventions used by UC therapists
showed high variability, with essentially no use of any PASCET-
specific protocol procedures. Thus, the TPOCS-S was used to
characterize UC in terms of the broad therapeutic approaches used,
including CBT, psychodynamic, family, and client-centered. UC
therapy sessions were rated higher on client-centered (M ? 3.58,
SD ? 0.77) than on CBT (M ? 1.62, SD ? 0.45); t(19) ? 9.00,
p ? .001; psychodynamic (M ? 1.73, SD ? 0.74), t(19) ? 12.28,
p ? .001; and family (M ? 2.12, SD ? 0.96), t(19) ? 5.04, p ?
.001, interventions. UC sessions also had higher ratings on family
intervention than on CBT, t(19) ? 2.34, p ? .05. In general, UC
therapists used interventions from multiple theoretical orientations,
with an emphasis on nonbehavioral approaches.
Distinctness of UC and PASCET.
UC using TPOCS-S coding of 20 PASCET and 20 UC cases.
PASCET sessions showed more CBT than UC sessions; UC treat-
ment scored higher than PASCET on the Psychodynamic and
Family subscales (see Table 2).
Duration of UC versus PASCET.
was 20.52 (SD ? 16.07) for UC and 16.45 (SD ? 6.07) for
PASCET, t(29.53)6? 1.20, p ? .24, d ? .34. Mean treatment
duration was 39.26 weeks (SD ? 28.98) for UC and 25.20 weeks
(SD ? 15.40) for PASCET, t(34.75) ? 2.19, p ? .04, d ?.60. For
the 75% of the sample that had no depressive disorder at posttreat-
ment (see below), mean duration was 42.39 weeks (SD ? 29.44)
for UC and 24.19 weeks (SD ? 16.60) for PASCET, t(29.66) ?
2.42, p ? .02, d ? .79.
UC families canceled sessions marginally
more often and no showed nonsignificantly more often than did
The PBA scale used to
We compared PASCET and
Mean number of sessions
PASCET families (Table 3). Total missed sessions (cancelled plus
no-shows) was marginally higher for UC than for PASCET fam-
ilies, t(29.14) ? 1.70, p ? .10, d ?.49.
We compared UC and PASCET groups using three dimensions of
the Hoagwood et al. (1996) model: diagnoses–symptoms, systems,
and consumer perspectives. We used analyses of covariance for all
continuous measures, with treatment entered as the independent vari-
able and pretreatment score entered as a covariate. We considered
hierarchical linear modeling (HLM) but rejected this approach be-
cause our sample size would not have produced stable HLM esti-
mates, and we only had assessment data from two time points.
depressive disorder at pretreatment; 75% showed no depressive
disorder at posttreatment. There was no significant difference
between PASCET and UC in the percentage who shed their
diagnosis, regardless of whether we focused on any depressive
disorder (73.3% vs. 77.3%) or MDD, MinDD, or DD, separately.
In analyses of covariance (ANCOVAs), with clinic as a random
effect, we used Youth-Reported Depression and Parent-Reported
Depression factor scores as composite indices of depression symp-
tomatology, adding other measures of interest (see Table 3). None
of the ANCOVAs showed a significant effect of treatment group.
Mental health systems domain.
vices provided during the treatment phase of the study (Table 4)
showed that UC families were more likely than PASCET families
to receive additional mental health services (e.g., treatment from a
second therapist, school-based services, psychotropic medication).
In comparison with PASCET youths, more UC youths used all
psychotropics combined, and more UC youths used depression-
An increasingly important consideration in youth treatment, from a
systems perspective, is cost. Guided by clinic administrators, we
estimated cost of treatment for each youth by adding the costs ([av-
erage manufacturer’s price] obtained from the Internet for medica-
tions and from clinic administrators for all other elements) of (a)
psychotherapist time for sessions; (b) psychiatric staff costs for med-
ication assessment, prescription, and monitoring/titration sessions; (c)
medications for depression; and (d) weekly clinic administrative costs
of keeping a case open and keeping records current (this included
ongoing costs during weeks when sessions were missed, such as
continued updating of clinic records, staff calls to families who miss
sessions, efforts to reschedule the next session, and reminder calls
before sessions). Mean cost per case was significantly higher for UC
All youths had met criteria for a
Analyses of additional ser-
5Because our sample came from seven clinics, we conducted prelimi-
nary analyses to determine whether the youths differed among these
clinics, using tests structured like those described in this paragraph for
clinical and sociodemographic variables at Time 1, with clinic entered as
a random effect. Using analysis of variance for continuous measures and
chi-square for categorical measures, we found only one significant differ-
ence: Clinics differed on youth CDI scores (p ? .046).
6When group variances differed significantly (p ? .05) and violated the
equal variance assumption of the standard t test, we used the relatively
robust Welch statistic and its associated degrees of freedom (Blalock,
1972; Welch, 1951).
WEISZ ET AL.
Consumer perspectives domain.
differ reliably by condition. However, on the TASC-P, PASCET
parents (see Table 3).
Youths’ TASC-C scores did not
Prediction of Outcome in Usual Care
Because UC showed considerable variability across the sample,
with some representation of CBT, client-centered, psychodynamic,
and family approaches, we sought to learn whether any of these
approaches might predict depression reduction in UC. We conducted
hierarchical regressions predicting the Parent-Reported Depression
and Youth-Reported Depression factors scores from the four
TPOCS-S subscales. For each regression analysis, the baseline score
on the outcome measure was entered prior to the TPOCS-S subscale
to control for initial severity. Three of the subscales failed to predict
outcome, but the Psychodynamic subscale predicted reduced Parent-
Reported Depression (? ? ?.44, R2change ? .20, p ? .05), F(2,
14) ? 4.11, p ? .05, R2? .37. Post hoc analyses showed two of the
four items on the Psychodynamic subscale to be significant predic-
tors: transference, for example, noting how the youth’s interactions
with the therapist resemble other relationships in the youth’s life (? ?
?.52, R2change ? .24), p ? .05, F(2, 14) ? 5.37, p ? .05, R2? .43,
and explores past, for example, noting a connection between past
behavior and experiences and current youth behavior and experiences
(? ? ?.44, R2Change ? .19, p ? .05), F(2, 14) ? 4.13, p ? .05,
We assessed the extent to which brief training and limited case
consultation in PASCET would influence therapist behavior and
Coding of Treatment Sessions in Primary and Secondary Control Enhancement Training (PASCET)
and Usual Care (UC)
Type of treatment
Cohen’s dM SDM SD
Posttreatment Comparison of Primary and Secondary Control Enhancement Training (PASCET) and Usual Care (UC)
on Multiple Outcomes
Cohen’s dM SDnM SDn
DISC-C MDD symptoms
Youth depression factor
DISC-P MDD Symptoms
Parent depression factor
DISC total diagnoses
Estimated cost (U.S. dollars)
Treatment duration (weeks)
No. of treatment sessions
2.18 1.19 172.051.58190.2634 0.790.09
disorder; TASC ? Therapeutic Alliance Scale for Children; CDI-P ? Children’s Depression Inventory—Parent Report; CBCL ? Child Behavior Checklist;
DISC-P ? Diagnostic Interview Schedule for Children—Parent Report; TASC-P ? Therapeutic Alliance Scale for Children—Parent Report; DISC ?
Diagnostic Interview Schedule for Children.
CDI ? Children’s Depression Inventory; DISC-C ? Diagnostic Interview Schedule for Children—Child Report; MDD ? major depressive
SPECIAL SECTION: COGNITIVE–BEHAVIORAL THERAPY FOR YOUTH DEPRESSION
clinical, consumer, and systems outcomes in community clinic
practice. Our coding of session tapes indicated that the training and
consultation had a measurable impact on therapist behavior, with
PASCET sessions including coded elements of the protocol and
with TPOCS-S coding showing significantly higher ratings for
PASCET than for UC on the use of CBT approaches and signif-
icantly lower ratings than UC on psychodynamic and family
approaches that were not in the PASCET protocol. This suggests
that the training and supervision procedures did lead to implemen-
tation of the basic protocol elements. However, the quality of that
implementation deserves attention (as discussed later).
On clinical outcomes, whereas all youths began the study with
a depressive disorder, more than 70% in both conditions had no
depressive disorder at posttreatment. Scores on continuous depres-
sion measures also dropped to subclinical levels, for example,
mean CDI scores in both the PASCET (M ? 8.00) and UC (M ?
8.22) groups dropped well below established clinical range cutoff
points (see Craighead, Curry, & Ilardi, 1995; Fristad, Weller,
Weller, Teare, & Preskorn, 1988; Kovacs, 2003; Timbremont &
Braet, 2001). This pattern points to clinically meaningful change in
depression levels from pre- to posttreatment. However, PASCET
and UC youths were not significantly different at posttreatment in
rates of depressive disorders or on symptom measures. Yet, the
duration of treatment preceding these reductions in depressive
disorders and symptoms was markedly shorter for PASCET than
for UC youths (24 vs. 39 weeks). The overall pattern of findings
could fit two different interpretations. We consider each.
Interpretation A: PASCET Produced Faster Improvement
One possibility is that PASCET led to faster improvement than
did UC. This interpretation warrants attention in the light of certain
data from our study and two lines of previous research. First, we
found that treatment duration was shorter for PASCET than for UC
in the full sample and that the difference was somewhat larger
among PASCET youths than among UC youths who achieved
remission. It is possible that UC, by averaging about 4 months
longer than PASCET, may have benefited from the natural time
course of depression remission. Median time to recovery from an
MDD episode in clinically referred youths has been found to range
from 7 to 9 months (see Kovacs, 1996); our average UC youth was in
treatment more than 9 months. By contrast, our average PASCET
case was in treatment for only 6 months; Kovacs (1996) reported
6-month recovery rates of only 33%-40%. In sum, the average
duration of UC in our study approximated the median time to
recovery documented by Kovacs (1996), whereas the average
duration of PASCET was well below the average time to recovery
reported by Kovacs.
A potentially relevant line of evidence relates to the Hawthorne
effect and related findings suggesting that subjecting any process
to study can change that process. Data available from six of our
seven participating clinics, during the decade prior to the begin-
ning of the current study (from Weersing & Weisz, 2002), showed
that average duration of UC for depressed youths was 23 weeks in
the absence of a randomized trial; in the current trial, pitting UC
against PASCET, UC for depressed youths averaged 39 weeks, a
70% increase over the period when there was no trial. The fact that
PASCET and UC outcomes were to be compared did seem to
engender a competitive climate. As an example, one UC clinician
was overheard telling other UC clinicians, “We’re going to beat
those manual people!” Given the natural time course of depression,
outcomes could be enhanced to the extent that cases are held open
for extended periods. It is possible that the significantly longer
duration of UC, relative to PASCET, reflected a tendency by UC
clinicians to continue treating youths until improvement was
noted. Improvement may also have been boosted by the UC
group’s significantly higher rate of additional services, medication
in general, and antidepressants in particular, as compared with the
Studies of youth depression treatment follow-up (e.g., Birmaher
et al., 2000; Clarke, Rohde, Lewinsohn, Hops, & Seeley, 1999;
The TADS Team, 2007) have rather consistently shown that par-
ticipants continue to improve after acute intervention and that
eventually all treated groups show roughly equal (and high) levels
of improvement and remission. This suggests that the primary
benefit of a more successful treatment may lie not in ultimate
outcome but in speed of improvement. This in turn suggests a way
to frame the present findings: Several lines of evidence connect to
the possibility that PASCET may have produced faster depression
relief than UC, including the following: (a) Our data showing that
UC lasted longer than PASCET, particularly when depression
remitted and especially when the therapist supported termination;
Additional Services Used by Primary and Secondary Control Enhancement Training (PASCET) and
Usual Care (UC) Youths
Any additional services
Any psychotropic medication
Any depression medication
WEISZ ET AL.
(b) our data showing that duration of UC in participating clinics
increased by 70% when the PASCET versus UC trial was intro-
duced; (c) studies of the natural time course of remission, resem-
bling duration of UC in our study (and markedly longer than the
duration of PASCET); and (d) studies of youth depression treat-
ment follow-up suggesting that the main benefit of successful
treatments lies in speed of improvement, not ultimate outcome.
However, because our design did not include measurement of
depression at common time points for all participants, a definitive
test of this interpretation awaits further research.
Interpretation B: PASCET and UC Did Not Differ
We note an alternative interpretation of our findings: that the
absence of posttreatment condition effects on depression symp-
toms or diagnoses means that PASCET and UC did not differ in
effectiveness in the community clinic context of the present study.
If this were the case, several strands of research would be relevant.
Previous findings (e.g., Brent, Kolko, Birmaher, Baugher, &
Bridge, 1998; Hammen, Rudolph, Weisz, Rao, & Burge, 1999;
Southam-Gerow, Chorpita, Miller, & Gleacher, 2008, 2003;
Wright et al., 2007) have suggested that youths referred to com-
munity clinics through normal community channels are more
likely than those treated in research clinics or traditional efficacy
trials to show high levels of externalizing comorbidity, poverty,
and family stress; other studies have shown that effects of CBT are
markedly diminished in youths with significant externalizing co-
morbidity (Rohde, Clarke, Mace, Jorgensen, & Seeley, 2004) and
in youths referred from community sources (rather than recruited
through ads; Brent et al., 1998; Weersing, Iyengar, Kolko, Birma-
her, & Brent, 2006). Our sample was completely community
referred and had high rates of externalizing comorbidity. The
notion that CBT faces challenges with community-referred youths
is consistent with findings of Kerfoot et al. (2004; noted in the
introduction) that teaching CBT to practitioners did not improve
outcomes for depressed youths referred from and treated in the
If it were true that PASCET did not outperform UC, two other
perspectives on our findings would deserve attention. First, Fixsen
et al. (2005) stressed that when a previously tested intervention is
applied in a new context, null findings may reflect, not a problem
with the intervention itself, but rather incomplete implementation
in the new context. Fixsen et al. (2005) stressed that information
dissemination, and training alone “repeatedly have been shown to
be ineffective” (p. 70; see also, Grimshaw et al., 2001) and that
“successful implementation efforts. . .require a longer-term multi-
level approach” (Fixsen et al., p. 70). Fixsen et al. noted that the
implementation approaches supported by evidence include (a)
skill-based training, (b) practice-based coaching, (c) practitioner
selection, (d) practitioner performance evaluation, (e) program
evaluation, (f) facilitative administrative practices, and (e) systems
interventions. Our procedures included only the elements in a and
b; some of the best supported approaches—for example, selecting
the best practitioners to conduct the new intervention—were ruled
out by the need to create a fair experimental test of PASCET
versus UC (which required random assignment of clinicians). The
evidence from Fixsen et al. suggests that our approach to exam-
ining PASCET in community clinics is a first step, with some of
the best documented requirements for implementing interventions
in new settings not yet included.
A closely related point pertains to the marked difference be-
tween therapists in their familiarity and skill with the treatment
procedures used in the two conditions. UC therapists used their
own preferred and familiar treatment procedures, which they them-
selves had selected. By contrast, PASCET therapists used an unfa-
miliar approach guided by a manual they had not selected or even
seen before. The PASCET therapists’ total exposure to PASCET
prior to starting treatment with study cases consisted of one 6-hr
training program. No PASCET therapist had any practice case
prior to the first study case, and for 18 of the 24 PASCET
therapists, their first PASCET case was their only study case. Most
PASCET therapists did show acceptable fidelity, but fidelity mea-
sures, including ours, assess only whether the main components
and skills of the manual are included in the sessions. Not covered
in such measures is the competence or skill with which therapists
used the components and skills. This is a study limitation, but we
are not aware of a relevant measure that has been validated.
Our session videotape reviews suggested a broad range in ther-
apist skill with PASCET; some therapists introduced treatment
components and skills effectively but many appeared uncomfort-
able and unnatural. Some therapists read portions of the manual to
the youths, some lost track of where they were in the protocol, and
others introduced key points in ways that left youngsters confused
or bored. Therapist lack of skill in the protocol may have under-
mined PASCET effectiveness. In the future, it will be useful to
assess the impact of PASCET when delivered by community clinic
therapists who have gained experience and familiarity with the
protocol and can deliver it comfortably and skillfully.
If it were true that PASCET did not outperform UC in reducing
depressive symptoms and disorders, it would be worthwhile to ask
whether approaches other than CBT might be a better fit for the
therapists, youths, and settings of community clinic care. This
possibility is suggested by our unexpected finding that clinical
outcomes in UC were predicted not by therapists’ use of CBT but
by their use of psychodynamic methods. Of course, our data on
frequency of various approaches tell us nothing about the quality
with which the approaches were used; poorly conducted CBT
might well not predict outcomes, whereas skillfully conducted
CBT might. Despite these caveats, the finding warrants attention in
future research (see below).
Findings on Therapeutic Alliance, Service Use, and Cost
and Their Clinical Implications
Beyond symptom and diagnostic change, our findings showed a
number of condition differences that have clear clinical relevance.
The PASCET group, as compared with the UC condition, used
significantly fewer adjunctive services, was lower in total cost, and
generated higher parent ratings of therapeutic alliance. Thus, along
some significant clinical and practical dimensions, PASCET
showed advantages over UC that might be of real value to prac-
titioners and provider organizations. Using fewer adjunctive ser-
vices can mean more efficient intervention that does not require
complex case management and liaison with other providers. Stron-
ger alliance with parents can enhance their participation in the
treatment process and increase the likelihood of getting their
children to scheduled appointments, and our findings did show
SPECIAL SECTION: COGNITIVE–BEHAVIORAL THERAPY FOR YOUTH DEPRESSION
marginally better session attendance by PASCET youths. Finally,
shortened time in treatment and reduced cost can mean reduced
waitlists, shorter waits, and more families served.
Limitations, Strengths, and Directions for
It is instructive to consider both limitations and strengths of our
study. One limitation is a relatively small sample, with reduced
power to detect effects; this may have made a difference on
measures showing small to medium effect sizes but not on others.
Another limitation was heterogeneity of the therapists and youths,
including highly mixed problem profiles and multiple comorbidi-
ties, with numerous externalizing disorders; this certainly in-
creased error variance and may have undermined treatment focus
on depression. In addition, the heterogeneity of UC interventions
limited our ability to interpret findings in relation to a specific
alternative treatment. We could have limited heterogeneity in these
various forms by (a) using only a few carefully selected therapists
rather than randomly assigning all who volunteered, (b) ruling out
youths with comorbidities, particularly those whose disorders
might have complicated treatment (e.g., ADHD, oppositional de-
fiance disorder, conduct disorder), and (c) designing our own
homogeneous control condition rather than having UC therapists
use their own familiar and preferred approaches. Our failure to
take any of these measures, while problematic in some respects,
can also be viewed as a strength, increasing clinical representa-
tiveness by including the therapists, youths, and treatments of true
usual clinical care.
Our results highlight several objectives for research on
evidence-based practice and everyday clinical care. One part of the
research agenda needs to consist of testing practices that have
worked well in efficacy trials to determine whether these prac-
tices—or some adaptation of them—can be effective in an every-
day care context. Our study suggests that such research is feasible,
and it highlights several ways such research can be strengthened in
the future. Our finding that psychodynamic procedures predicted
outcome in UC suggests a treatment model that may warrant
testing in the future and, more broadly, illustrates the potential
value of carefully documenting the contents of UC (rather than
regarding UC as a mere control condition). Our study highlights
the fact that efforts to identify effective practices for everyday care
must contend with complex clients, significant comorbidity, and
challenging economic and time constraints in clinical care settings,
which limit the time available for learning new skills. Such chal-
lenges place the development of strategies for efficient training
and flexible treatment of comorbidity and an ever-changing land-
scape of stressors high on the research agenda.
Ultimately, the challenge of bringing EBT into everyday prac-
tice is essentially a balancing task, that is, ensuring sufficient
therapist skill building to produce real competence, and thus ben-
eficial effects, while ensuring that the clinician time required fits
the economic realities of clinical practice. In this era of widespread
calls for exporting tested treatments to practice settings, there is
remarkably little research on how to accomplish this goal. The
present study provides one example of an array of possible ap-
proaches (see also, example, Chambers, Ringeisen, & Hickman,
2005; Chorpita, 2006; Chorpita et al., 2002; Mufson et al., 2004;
Schoenwald & Hoagwood, 2001; Southam-Gerow, 2005;
Southam-Gerow, Austin, & Marder, 2008), many more of which
will be developed and tested in the years ahead.
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Received January 16, 2008
Revision received August 4, 2008
Accepted August 6, 2008 ?
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