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The Moderating Role of Child Maltreatment in Treatment Efficacy for Adolescent Depression
Abstract
Adolescent girls are at heightened risk of depression, and because adolescent depression may initiate a negative developmental cascade, intervention early in adolescence has potential for altering a negative developmental trajectory. Identifying risk factors that impact response to intervention may inform decisions about the type of treatment to provide for adolescent girls with depression. Understanding moderators of outcomes in evidence-based treatment is critical to the delivery of timely and effective interventions. Matching patients effectively with optimal intervention will not only expedite the alleviation of patients’ distress, but will also reduce unnecessary time and resources spent on less advantageous interventions. The current investigation examines the efficacy of Interpersonal Psychotherapy for Depressed Adolescents (IPT-A) in a racially and ethnically diverse sample of 120 low-income adolescent girls age 13–15 with and without histories of child maltreatment. Adolescent and parent report of depressive symptoms were assessed at the beginning and end of treatment and a diagnosis of subsyndromal symptoms of depression or depression were required for purposes of inclusion. Results indicated that among adolescent girls who had experienced two or more subtypes of maltreatment, IPT-A was found to be more efficacious than Enhanced Community Standard (ECS) treatment. Importantly, when the subtype of maltreatment experienced was further probed, among girls with a history of sexual abuse, we found preliminary evidence that IPT-A was significantly more effective than ECS in reducing depressive symptoms, and the effect size was large. Thus, if a history of maltreatment is present, especially including sexual abuse, specifically addressing the interpersonal context associated with depressive symptoms may be necessary.
... Recent work lends support for this hypothesis, indicating that gratitude interventions yield greater benefits in adults (Dickens, 2017). However, other potential theoretically-derived moderators, such as childhood adversity (i.e., CA; e.g., Toth et al., 2020) and trait gratitude (e.g., Dickens 2019), remain insufficiently studied. ...
... CA consists of actual or potential harmful events (e.g., maltreatment, household dysfunction; that may cause children and adolescents to undergo prolonged stress; Fareri & Tottenham 2016). These events have important implications for treatment (e.g., Toth et al., 2020) which may vary depending on their severity and/or chronicity (Smith & Pollak, 2020). Notably, individuals with CA have poor treatment outcomes (e.g., Klein et al., 2009), including low response rates and prolonged remission times (Lippard & Nemeroff, 2020;Nanni et al., 2012;Nelson et al., 2017). ...
... Together, these findings may suggest that, while gratitude interventions may be effective for individuals with low CA severity, they may be less suited for individuals experiencing high levels of CA severity. The present results are in line with previous work (e.g., Toth et al., 2020) and indicate that individuals with CA exhibit poor treatment responses. ...
Outcomes of gratitude interventions are encouraging, but inconsistent across studies. In addition, both mechanisms of change and effect modifiers for these interventions are largely unknown. Recent data point toward potential candidates and suggest reward processing may be a promising mechanism underlying these interventions, while childhood adversity (CA) and trait gratitude may impact on them. However, existing research aimed at investigating these hypotheses is scarce. Building on these, we examined the effectiveness of a gratitude intervention for decreasing depressive symptoms and negative affect and increasing positive affect. We also investigated changes in reward processing following intervention and explored differences in adherence and drop-out between groups. Finally, we investigated the moderating role of CA and trait gratitude.
Participants (N=237, ages between 18–56) were randomly allocated to a gratitude or active control condition (14 days). Following intervention, findings indicated a significant decrease in depressive symptoms and negative affect in both conditions. While positive affect remained stable, a significant time effect emerged for reward processing. CA severity, but not multiplicity, moderated the effectiveness of the intervention, adherence and drop-out. Trait gratitude moderated the effectiveness of the gratitude intervention only on depressive symptoms.
Gratitude interventions may not be the best fit for everyone. Thus, we recommend tailoring interventions, especially in individuals reporting a history of severe CA.
... The sample included socioeconomically disadvantaged and racially and ethnically diverse adolescent girls with depressive symptoms (N = 175) who were part of a larger randomized control trial (RCT) of a depression treatment (Toth et al., 2020). Participants' average age was 14 (SD = .85; ...
... Depiction of the stress-generation and stress-sensitization hypotheses as applied to the association between child maltreatment and adolescent suicidal ideation. on the RCT, see Toth et al., 2020). Adolescents with maltreatment and depression histories were recruited through a Department of Human Services (DHS) liaison and/or through advertisements in DHS waiting rooms. ...
... Cognitive-focused interventions that have evidence of effectiveness with suicidal adolescents, such as CBT for suicide prevention, may be particularly useful (Stanley et al., 2009). Additionally, Interpersonal Psychotherapy (IPT) is an efficacious therapeutic model for individuals with maltreatment histories (Toth et al., 2013;Toth et al., 2020), and may be particularly helpful to reduce depressive symptoms and suicidal ideation for adolescents who experience interpersonal life stressors. Last, stressful life events often occur in the context of family and neighborhood poverty. ...
Background
Exposure to child maltreatment is a well-known risk factor for suicide ideation among adolescents. Recent stressful life events may also contribute to this risk. However, the association between these risk factors is unclear in the etiology of suicide ideation for adolescents from socio-economically disadvantaged backgrounds.
Objective
The present study tested the stress generation and stress sensitivity hypotheses in relation to child maltreatment, recent stressful life events (in the past year), and suicide ideation (in the past two weeks).
Participants and Setting
We utilized a sample of diverse, socioeconomically disadvantaged, depressed adolescent girls (N = 175) who were part of a depression treatment intervention.
Results
Child maltreatment was significantly associated with adolescent suicide ideation, β = .40, p < .001. Results supported the stress sensitivity hypothesis, in that exposure to interpersonal stressors in the past year exacerbated the association between child maltreatment and adolescents’ suicide ideation, β = .18, p < .05. We found evidence for a protective factor, cognitive reappraisal, in the association between stressful life events and suicide ideation, β = −.15, p < .05.
Conclusions
These findings have several implications for clinical practice and suicide prevention with adolescent girls, and contribute to the extant literature on the role of chronic and acute stress in the etiology of adolescent suicide ideation.
... When the results of the IPT-A intervention were analyzed by group, maltreatment histories were related to differential responses to the intervention (Toth et al., 2020). Girls without histories of maltreatment were equally responsive to IPT-A and ECS approaches. ...
... For girls who had experienced child abuse and/or neglect, however, IPT-A was more efficacious in alleviating depressive symptoms. The girls who benefitted the most from the intervention were those who had experienced multiple forms of maltreatment, and especially those girls with sexual abuse histories (Toth et al, 2020). Thus, the relational approach in the IPT-A intervention may be particularly important for youth whose relationships have been characterized by abuse. ...
In this article, we celebrate Dante Cicchetti’s extensive contributions to the discipline of developmental psychopathology. In his seminal article, he articulated why developmental psychopathology was imperative to create research portfolios that could inform the causes, consequences, and trajectories for adults often initiated by early lived experiences (Cicchetti, 1984). In this three-part article, we share our transdisciplinary efforts to use developmental psychopathology as a foundational theory from which to develop, implement, and evaluate interventions for populations who experienced early adversity or who were at risk for child abuse and neglect. After describing interventions conducted at Mt. Hope Family Center that spanned over three decades, we highlight the criticality of disseminating results and address policy implications of this work. We conclude by discussing future directions to facilitate work in developmental psychopathology. Currently, one of three national National Institute of Child Health and Human Development-funded child abuse and neglect centers, we look forward to continuing to build upon Dante’s efforts to disseminate this important work to improve society for our children, our nation’s often most vulnerable and forgotten citizens.
... We hypothesized that the participants in the REThink therapeutic game will report similar robust improvements in these outcomes to those documented in the previous trials [7][8][9][10][11][12] , relative to the control condition after the intervention. Based on previous findings on moderators for the treatment efficacy showing that CM is associated with poor treatment outcomes 13 , we expected that improvements in the outcomes for the REThink intervention will be lower for the youths presenting with higher severity of CM, or with additional risk factors such as insecure parent attachment. ...
... This finding is however in line with our previous findings 8 when the REThink intervention impact in reducing conduct problems in the long-term in general population of children and adolescents was higher for those with CM history. This finding shows great promises, given that CM has been consistently shown to be associated with poor treatment outcomes in youth depression, as assessed by lack of /response or longer time for remission 13 . Given the associations that were found 16 for CM with alterations in reward-based systems, such as reinforcement and incentive-based learning (i.e., reward anticipation, and reward responsiveness), it might be that a game-based intervention, using closed incentivized based learning of emotional skills, supports also the regulation of reward-based systems during stress inducing context in the level 7 of the game. ...
Exposure to child maltreatment (CM) is considered to predispose children to devastating consequences in terms of mental health. Thus, it is a public health priority to provide these children with early preventive interventions that are accessible on a large scale, adapted to their needs, and effective in supporting their mental health. Here we report a randomized control trial to test the efficacy of the REThink online therapeutic game, as compared with a Care as Usual (CAU) control group in the prevention of mental illness in maltreated children. Out of 439 children aged 8–12 that were recruited, 294 children with self-reported maltreatment histories were included in the current study, and were allocated, 146 participants in the REThink group and 148 participants in the CAU group. All children completed pre- and post-intervention assessments measuring mental health, emotion regulation, and irrational cognitions. We also tested potential moderators for these effects, such as the severity of CM and the security of parent attachment. Our results show that children receiving the REThink game intervention outperform the CAU group at post-test, showing a significantly lower level of emotional problems, mental health difficulties, use of maladaptive emotion-regulation strategies such as catastrophizing, rumination, and self-blame, and irrational cognitions. Moreover, children with higher CM severity benefit the most from the REThink game, while children with lower parent attachment security benefit the least. Future research is needed, to investigate the long-term efficacy of the REThink game in promoting the mental health of children exposed to CM.
... Another possible direction for future research is to modify current interventions that are effective in reducing symptomatology among maltreated youth, into adapted interventions that specifically target the reduction of STBs in this population. Interpersonal Therapy for Depressed Adolescents and Dialectical Behavior Therapy for Adolescents are two modalities of note that target mechanisms included in our model (respectively, interpersonal processes and emotion regulation; Berk et al., 2014;Lipsitz & Markowitz, 2013;Toth et al., 2020). These treatment modalities may have potential application to the treatment of STBs among youth exposed to maltreatment. ...
... These treatment modalities may have potential application to the treatment of STBs among youth exposed to maltreatment. For example, Interpersonal Therapy for Depressed Adolescents was found to be efficacious in treating depressive symptoms among adolescent girls with a history of maltreatment (Toth et al., 2020). It is possible that an enhanced version of Interpersonal Therapy for Depressed Adolescents of could also effectively treat and reduce suicidal ideation in this population, but this remains to be tested. ...
Experiences of child abuse and neglect are risk factors for youth suicidal thoughts and behaviors. Accordingly, suicide risk may emerge as a developmental process that is heavily influenced by the rearing environment. We argue that a developmental, theoretical framework is needed to guide future research on child maltreatment and youth (i.e., adolescent and emerging adult) suicide, and to subsequently inform suicide prevention efforts. We propose a developmental model that integrates principles of developmental psychopathology and current theories of suicide to explain the association between child maltreatment and youth suicide risk. This model bears significant implications for future research on child maltreatment and youth suicide risk, and for suicide prevention efforts that target youth with child maltreatment experiences.
... The development of frustration as an attempt to meet societal expectations is met with ridicule or dismissal can undermine self-esteem, self-image, and self-con dence, increasing the risk of depressive disorder 7,2,13 . Traumatic experiences, such as maltreatment and abuse 14 , the loss of a loved one, bullying 15 , and relationship problems 7 , also increase the risk of depressive disorders in adolescents 16 . The lack of personal resources and skills makes adolescents particularly vulnerable to deprivation, either due to parental neglect or familial poverty 15,17 . ...
Aim: This study aimed to examine the impact of school-based interventions on depressive disorder in adolescents living in sub-Saharan Africa (SSA). Adolescents living in SSA are even more vulnerable due to cultural misunderstanding and superstition associated with the condition, deprivation and poverty, increased burden of disease, and exposure to traumatic events such as bereavement, violence, and child abuse. The inadequacies of the local health infrastructure also undermine the population’s mental health. The weaknesses of the regional health infrastructure also undermine the population’s mental health. Methodology: This study adopted a qualitative systematic review approach based on secondary data and thematic analysis to analyse the qualitative data collected. Results: Eleven studies were included in the sample, which represented six countries: Kenya (4), Nigeria (3), Burundi (1), Uganda (1), South Africa (1), and Rwanda (1). These findings reiterate the need for more studies exploring mental health treatments and interventions in SSA. All the studies reported improvements in the mental health outcomes of participants, and only one study recommended avoiding school-based interventions for depressive disorders linked to bereavement. Interventions were effective in increasing reach and providing resources for task shifting. Many researchers have used teachers and other adolescents as lay providers, adapted interventions to the local context, and praised the efficiency of brief interventions.
... Individuals with FEP who have a history of childhood trauma are more likely to be classi ed as non-responders to treatment, and exhibit higher readmission rates and lower compliance with psychotherapy than individuals without childhood trauma 29,30 . Some studies have also indicated that childhood trauma can predict treatment e cacy, with speci c interventions being more effective for individuals with a trauma history 31,32 . ...
ACT in Daily Life (ACT-DL) is a blended-care Ecological Momentary Intervention that extends ACT into the daily life of individuals, improving psychotic distress, negative symptoms, and global functioning. However, it remains unclear whether ACT-DL works equally for everyone. We investigated whether moderators (i.e., sociodemographic information, personality, and trauma history) determine clinical outcomes in individuals with early psychosis receiving ACT-DL. Seventy-one participants from the INTERACT trial, using ACT-DL, were analyzed. Outcomes included psychotic distress, negative symptoms, global functioning, and psychological flexibility. Using multivariate-multilevel models, we evaluated the effects of sociodemographics, personality, and childhood trauma across baseline, post-intervention, and six- and 12-month follow-ups. Sociodemographic characteristics and personality predicted clinical outcomes. Higher education demonstrated more substantial improvement in global functioning at 6- (B = 7.43, p = .04) and 12-FU (B = 10.74, p = .002) compared to lower education. Higher extraversion showed less improvement in negative symptoms at 12-FU (B = 1.24, p = .01) and more improvement in global functioning at post-intervention (B = 0.39, p = .046) and 6-FU (B = 1.40, p = .02) compared to lower extraversion. Higher neuroticism showed more improvement in negative symptoms at 12-FU (B = -1.59, p = .001) and higher psychological flexibility at 12-FU (B = 8.38, p = .001) compared to lower neuroticism. Our findings suggest that while ACT-DL improves clinical outcomes in individuals with early psychosis, the improvement rate is dissimilar for individuals and predictable by baseline characteristics. If replicated, these findings enable precision medicine approaches in allocating ACT-DL for early psychosis.
... Evidence suggests a dose-response relationship between the history of child maltreatment and later psychotic development, and child maltreatment is related to the severity, persistence, and content of hallucinations and delusions in early and established psychosis. In addition, patients with history of child maltreatment have an earlier age of onset, lower social and occupational functioning, which are associated with worst treatment outcomes [7,8]. Patient was treated with Risperidone (0,5 mg) b.i.d. and Sodium Valproate (250 mg). ...
Introductions: Depressive disorders are expected consequences of experiencing child maltreatment. Many depressive disorders can occur with or without psychosis, which has different implications for treatment and prognosis. This condition raises the challenge of treating depression in maltreated adolescents because the patient has inadequate family and social support. Consequently, it is difficult for the patient to undergo psychotherapy that involves family. Case: A 17-year-old female was diagnosed with psychotic depression. The patient had symptoms of depression, accompanied by hallucinations, since five years ago. The patient was hospitalized for suicidal ideation and food refusal for days. Patient had a history of child maltreatment by family and experienced bullying since elementary school. Patient believes that her family, especially her mother, had hated her from the beginning. Discussions: After stabilization of the patient’s general condition, psychopathology exploration was done together with selection of appropriate treatment. Combined Cognitive Behavioral Therapy (CBT), Selective Serotonin Reuptake Inhibitor (SSRI) and atypical antipsychotic treatment are the evidence-based treatments for psychotic depression in maltreated adolescents. Studies involving patients with psychotic depression which were treated by combination of sertraline and olanzapine showed significant improvement of depression and psychotic symptoms and reduced the risk of relapse over 36 weeks, compared to sertraline plus placebo. Conclusion: Combination of SSRI, atypical antipsychotic and CBT with a trauma-informed approach should be considered as treatment for psychotic depression in maltreated adolescents.
... Third, experiences of physical and sexual abuse are prevalent among adolescents in Nepal [Ministry of Health and Population (MoHP), 2012]. Research suggests IPT may be particularly helpful for those with a history of maltreatment and/or trauma (Betancourt et al., 2012;Toth et al., 2020). Last, Gunlicks-Stoessel et al. (2010) found greater benefits of IPT among adolescents reporting high levels of conflict with their mother or peers (Gunlicks-Stoessel et al., 2010). ...
Background
Adolescents with depression need access to culturally relevant psychological treatment. In many low- and middle-income countries treatments are only accessible to a minority. We adapted group interpersonal therapy (IPT) for adolescents to be delivered through schools in Nepal. Here we report IPT's feasibility, acceptability, and cost.
Methods
We recruited 32 boys and 30 girls (aged 13–19) who screened positive for depression. IPT comprised of two individual and 12 group sessions facilitated by nurses or lay workers. Using a pre-post design we assessed adolescents at baseline, post-treatment (0–2 weeks after IPT), and follow-up (8–10 weeks after IPT). We measured depressive symptoms with the Depression Self-Rating Scale (DSRS), and functional impairment with a local tool. To assess intervention fidelity supervisors rated facilitators' IPT skills across 27/90 sessions using a standardised checklist. We conducted qualitative interviews with 16 adolescents and six facilitators post-intervention, and an activity-based cost analysis from the provider perspective.
Results
Adolescents attended 82.3% (standard deviation 18.9) of group sessions. All were followed up. Depression and functional impairment improved between baseline and follow-up: DSRS score decreased by 81% (95% confidence interval 70–95); functional impairment decreased by 288% (249–351). In total, 95.3% of facilitator IPT skills were rated superior/satisfactory. Adolescents found the intervention useful and acceptable, although some had concerns about privacy in schools. The estimate of intervention unit cost was US $96.9 with facilitators operating at capacity.
Conclusions
School-based group IPT is feasible and acceptable in Nepal. Findings support progression to a randomised controlled trial to assess effectiveness and cost-effectiveness.
... Although attachment theory stresses the importance of early childhood, adolescence may also be a critical period during which polyvictimization is more likely to lead to depression (Gerke et al., 2018). Polyvictimization is not only linked with depression among adolescents but may influence the efficacy of treatment for depression (Toth et al., 2020). Singly, neglect, physical abuse, and CSA are all associated with adolescent depression (Glied & Pine, 2002;Harkness, Bruce, & Lumley, 2006;Harkness & Lumley, 2008;Infurna et al., 2016). ...
Adverse effects of childhood maltreatment experience and adolescent depression symptoms are theorized to be more profound for adolescents who have suffered multiple maltreatments (polyvictimization). New theoretical insights into the study of polyvictimization suggest that it must be studied using a multiplicative logic, particularly when maltreatment is characterized by invasive exploitation. This study, for the first time, examined the concept of invasive exploitation in the context of polyvictimization and its association with adolescent depression symptoms. The study used a random, three stage probability proportional to size (PPS) cluster sample of 565 mother-adolescent dyads in Kathmandu, Nepal, and also examined the protective effects of maternal empathy. We hypothesized that (a) singly, the empirical categories of maltreatment (neglect, physical abuse, and child sexual abuse) would associate positively with adolescent depressive symptoms and (b) main effects held constant, the interaction effects of a child sexual abuse X neglect and a child sexual abuse X physical abuse would be positive. Regression with clustering corrections found that neglect (B = 3.17, p < .01) and sexual abuse (B = 3.48, p < .05) positively associated with adolescent depression symptoms. Results support the multiplicative invasive exploitation polyvictimization hypothesis (child sexual abuse X neglect interaction; B = 6.14, p < .05). The positive neglect X sexual abuse interaction is consistent with the theory that sexual abuse is distinct as invasive exploitation, and demonstrates that the multiplicative hypothesis can be fruitfully applied to the study of polyvictimization. Interventions targeting polyvictims with experience of invasive exploitation and studies aiming to provide deeper insights into sexual abuse as invasive exploitation are needed.
... Similarly, in a recent RCT of IPT-AST versus GC in schools, trauma exposure moderated short-term rates of change in depressive symptoms such that the benefits of IPT-AST over GC dissipated in adolescents with trauma exposure [57]. However, a recent study of IPT-A found enhanced effects among youth with a maltreatment history [58]. More research is needed on the impact of trauma and comorbid conditions to inform clinical decision making about which intervention to provide to a given adolescent. ...
This study evaluated the fidelity, feasibility, acceptability, and preliminary outcomes of a depression prevention program, interpersonal psychotherapy—adolescent skills training (IPT-AST), in urban pediatric primary care (PC) with a sample of primarily Black youth. Twenty-two adolescents with elevated depressive symptoms participated in this open clinical trial. Adolescents were identified through a screening questionnaire completed at well visits. Ratings of IPT-AST fidelity and session attendance were recorded. Youth and caregivers reported on their attitudes toward the intervention and completed measures of adolescents’ symptoms and functioning pre- and post-intervention. Results demonstrated high levels of fidelity, attendance, and acceptability, despite some difficulties with recruitment. Adolescents and caregivers reported significant improvements in functioning. There were marginally significant reductions in self-reported depression, anxiety, and total mental health symptoms. Caregivers reported a significant decrease in total mental health symptoms. Findings provide preliminary information regarding the implementation and effects of IPT-AST when delivered in PC.
Objective:
State mental health systems are retraining their workforces to deliver services supported by research. Knowledge about evidence-based therapies (EBTs) for child and adolescent disorders is robust, but the feasibility of their statewide scaling has not been examined. The authors reviewed implementation feasibility for 12 commonly used EBTs, defining feasibility for statewide scaling as an EBT having at least one study documenting acceptability, facilitators and barriers, or fidelity; at least one study with a racially and ethnically diverse sample; an entity for training, certification, or licensing; and fiscal data reflecting the costs of implementation.
Methods:
The authors reviewed materials for 12 EBTs being scaled in New York State and conducted a literature review with search terms relevant to their implementation. Costs and certification information were supplemented by discussions with treatment developers and implementers.
Results:
All 12 EBTs had been examined for implementation feasibility, but only three had been examined for statewide scaling. Eleven had been studied in populations reflecting racial-ethnic diversity, but few had sufficient power for subgroup analyses to demonstrate effectiveness with these samples. All had certifying or licensing entities. The per-clinician costs of implementation ranged from 3,500, with overall ongoing costs ranging from 6,000. A fiscal analysis of three EBTs revealed hidden costs ranging from 24,000 per clinician, potentially limiting sustainability.
Conclusions:
The evidence necessary for embedding EBTs in state systems has notable gaps that may hinder sustainability. Research-funding agencies should prioritize studies that focus on the practical aspects of scaling to assist states as they retrain their workforces.
Background:
Although children with histories of maltreament are more likely to engage with mental healthcare than non-maltreated children, few studies have examined the impact of maltreatment on children's mental health outcome improvement over time.
Objective:
The current study addresses this gap in the present literature by exploring the ways that histories of physical, sexual, and emotional abuse and exposure to domestic violence can influence children's improvement on mental health outcomes commonly associated with trauma.
Participants and setting:
De-identified routine care data from 58 community mental health agencies across Ontario, Canada, representing 16,517 children was obtained. This data represented assessments that occurred between February 2015 and December 2021.
Methods:
General linear models were used to illustrate the effect of each trauma type on change scores computed between baseline and follow-up assessments of externalizing behaviours, risk of harm to others, depressive symptoms, risk of suicide and self-harm, and anxiety, while adjusting for baseline scores, inpatient status, time between assessments, and select demographic variables.
Results:
When the effects of each trauma type was considered separately, children without histories of trauma consistently showed greater improvement than those with that trauma across all mental health outcomes (0.07-0.44, p < 0.01). When all trauma types were considered together, sexual abuse was associated with some of the most significant negative impacts on children's mental health improvements.
Conclusions:
Our findings highlight an urgent need for the implementation of standardized, evidence-based assessments that screen trauma histories of children accessing mental health supports and research examining the impact of trauma on children's treatment responsiveness.
Child maltreatment (CM) is a robust risk factor for adolescent depressive and post-traumatic stress disorder (PTSD) symptoms. Quality attachment relationships have been posited as a protective factor but findings are equivocal and studies have not adequately considered the complex network of interpersonal relationships that adolescents rely on. The current study applied a person-centered approach to (a) identify subgroups of adolescent females characterized by distinct patterns of attachment quality with peers, fathers, and mothers and (b) determine if the effect of maltreatment on depressive and PTSD symptoms varied as a function of distinct patterns of attachment quality. Data came from a prospective, longitudinal cohort study of 464 racially diverse and adolescent females designed to examine the developmental sequelae of substantiated CM (260 maltreated and 204 demographically matched, nonmaltreated comparisons). Latent profile analysis (LPA) revealed four profiles of attachment characterized by: (a) above-average attachment quality across all three relationships (N = 207, 44.6%); (b) below-average quality with father and friends and above-average quality with mothers (N = 128, 27.6%); (c) below-average quality across all three relationships (N = 106, 22.9%); and (d) very low-(−1 SD) quality with mothers and above-average quality with fathers and friends (N = 23, 5.0%). Moderation models revealed that cumulative maltreatment exposure resulted in greater adolescent depressive symptoms only for those with a profile of attachment consisting of very low-quality maternal attachment and high-quality father and friend attachments. Profiles did not significantly moderate the effect of maltreatment on PTSD symptoms. Results identify subgroups of maltreatment survivors most vulnerable to the development of depression in adolescence. Such groups should be targets for the provision of finite clinical resources with clinical interventions that seek to promote healthy maternal attachment relationships to mitigate the impact of maltreatment on depression.
Adverse childhood experiences (ACEs) and sociopolitical stressors have negative consequences for young adults’ mental health. The current study examined how patterns of ACEs were associated with event-related clinical distress following the 2016 United States presidential election and tested whether difficulties in emotion regulation exacerbated ACE effects in 751 young adults. A latent class analysis (LCA) identified four classes of ACE exposure: Minimal Exposure (55.2%), Moderate Household Dysfunction (21.3%), High Verbal and Physical Abuse (17.8%), and Systemic Exposure (5.6%). Young adults in the Systemic Exposure class reported more event-related intrusion symptoms compared to all other classes. Lower levels of difficulty in emotion regulation were protective for classes with lower ACE exposure but were not relevant for classes with higher ACE exposure. Thus, ACEs may occur in unique constellations that have implications for sociopolitical stressors and mental health outcomes in young adulthood.
Importance
Depression, suicidal ideation, and self-harm behaviors in youth are associated with functional impairment and suicide.
Objective
To review the evidence on screening for depression or suicide risk in children and adolescents to inform the US Preventive Services Task Force (USPSTF).
Data Sources
PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022.
Study Selection
English-language, randomized clinical trials (RCTs) of screening for depression or suicide risk; diagnostic test accuracy studies; RCTs of psychotherapy and first-line pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms.
Data Extraction and Synthesis
Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.
Main Outcomes and Measures
Test accuracy, symptoms, response, remission, loss of diagnosis, mortality, functioning, suicide-related events, and adverse events.
Results
Twenty-one studies (N = 5433) were included for depression and 19 studies (N = 6290) for suicide risk. For depression, no studies reported on the direct effects of screening on health outcomes, and 7 studies (n = 3281) reported sensitivity of screening instruments ranging from 0.59 to 0.94 and specificity from 0.38 to 0.96. Depression treatment with psychotherapy was associated with improved symptoms (Beck Depression Inventory pooled standardized mean difference, −0.58 [95% CI, −0.83 to −0.34]; n = 471; 4 studies; and Hamilton Depression Scale pooled mean difference, −2.25 [95% CI, −4.09 to −0.41]; n = 262; 3 studies) clinical response (3 studies with statistically significant results using varying thresholds), and loss of diagnosis (relative risk, 1.73 [95% CI, 1.00 to 3.00; n = 395; 4 studies). Pharmacotherapy was associated with improvement on symptoms (Children’s Depression Rating Scale–Revised mean difference, −3.76 [95% CI, −5.95 to −1.57; n = 793; 3 studies), remission (relative risk, 1.20 [95% CI, 1.00 to 1.45]; n = 793; 3 studies) and functioning (Children’s Global Assessment Scale pooled mean difference, 2.60 (95% CI, 0.78 to 4.42; n = 793; 3 studies). Other outcomes were not statistically significantly different. Differences in suicide-related outcomes and adverse events for pharmacotherapy when compared with placebo were not statistically significant. For suicide risk, no studies reported on the direct benefits of screening on health outcomes, and 2 RCTs (n = 2675) reported no harms of screening. One study (n = 581) reported on sensitivity of screening, ranging from 0.87 to 0.91; specificity was 0.60. Sixteen RCTs (n = 3034) reported on suicide risk interventions. Interventions were associated with lower scores for the Beck Hopelessness Scale (pooled mean difference, −2.35 [95% CI, −4.06 to −0.65]; n = 644; 4 RCTs). Findings for other suicide-related outcomes were mixed or not statistically significantly different.
Conclusion and Relevance
Indirect evidence suggested that some screening instruments were reasonably accurate for detecting depression. Psychotherapy and pharmacotherapy were associated with some benefits and no statistically significant harms for depression, but the evidence was limited for suicide risk screening instruments and interventions.
Importance:
Anxiety in children and adolescents is associated with impaired functioning, educational underachievement, and future mental health conditions.
Objective:
To review the evidence on screening for anxiety in children and adolescents to inform the US Preventive Services Task Force.
Data sources:
PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022.
Study selection:
English-language, randomized clinical trials (RCTs) of screening; diagnostic test accuracy studies; RCTs of cognitive behavioral therapy (CBT) or US Food and Drug Administration-approved pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms.
Data extraction and synthesis:
Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.
Main outcomes and measures:
Test accuracy, symptoms, response, remission, loss of diagnosis, all-cause mortality, functioning, suicide-related symptoms or events, adverse events.
Results:
Thirty-nine studies (N = 6065) were included. No study reported on the direct benefits or harms of screening on health outcomes. Ten studies (n = 3260) reported the sensitivity of screening instruments, ranging from 0.34 to 1.00, with specificity ranging from 0.47 to 0.99. Twenty-nine RCTs (n = 2805) reported on treatment: 22 on CBT, 6 on pharmacotherapy, and 1 on CBT, sertraline, and CBT plus sertraline. CBT was associated with gains on several pooled measures of symptom improvement (magnitude of change varied by outcome measure), response (pooled relative risk [RR], 1.89 [95% CI, 1.17 to 3.05]; n = 606; 6 studies), remission (RR, 2.68 [95% CI, 1.48 to 4.88]; n = 321; 4 studies), and loss of diagnosis (RR range, 3.02-3.09) when compared with usual care or wait-list controls. The evidence on functioning for CBT was mixed. Pharmacotherapy, when compared with placebo, was associated with gains on 2 pooled measures of symptom improvement-mean difference (Pediatric Anxiety Rating Scale mean difference, -4.0 [95% CI, -5.5 to -2.5]; n = 726; 5 studies; and Clinical Global Impression-Severity scale mean difference, -0.84 [95% CI, -1.13 to -0.55]; n = 550; 4 studies) and response (RR, 2.11 [95% CI, 1.58 to 2.98]; n = 370; 5 studies)-but was mixed on measures of functioning. Eleven RCTs (n = 1293) reported harms of anxiety treatments. Suicide-related harms were rare, and the differences were not statistically significantly different.
Conclusions and relevance:
Indirect evidence suggested that some screening instruments were reasonably accurate. CBT and pharmacotherapy were associated with benefits; no statistically significant association with harms was reported.
Distinguishing profiles of trauma exposure among low-income adolescent females with depressive symptoms is important for understanding comorbidity, family relationships, and treatment. Specifically, child maltreatment is essential to examine in comparison to other traumas. Participants included 170 adolescent females (65.3% Black; 21.2% White; 13.5% other race; 14.1% Latina/x) with depressive symptoms and their primary caregiver from low-income families. Latent class analysis (LCA) identified three trauma classes. Probabilities of endorsing different subtypes of maltreatment (physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse), number of subtypes of maltreatment, and non-maltreatment traumas (accident, experiencing or witnessing physical assault, death or injury of loved one, medical trauma) varied among groups. Higher levels of family dysfunction and traumatic stress symptoms were reported in both classes with maltreatment exposure as compared to the class with only non-maltreatment trauma exposure. Findings have implications for family-focused interventions for maltreated adolescent females with depressive symptoms from low-income contexts.
Purpose of review:
To examine recent evidence that informs the treatment of depression in children and adolescents.
Recent findings:
There are no new leads in the prevention and early intervention of depression in children and adolescents. For acute treatment of major depressive disorder, talking therapies are moving increasingly to internet-based platforms. Family therapy may have a slight edge over individual psychotherapy in the short-term. Patients with severe depression with endogenous features have a more robust response to pharmacotherapy than do patients with mild-to-moderate depression. Findings in relation to reward sensitivity and changes in brain-derived neurotrophic factor levels contradict research conducted in adults, suggesting developmental differences in the mechanisms underlying depression. Ketamine infusion could have a role for adolescents with treatment refractory depression. There was no new evidence concerning relapse prevention.
Summary:
Most new findings have been concerned with moderators and mediators of treatment.
Background
Interpersonal psychotherapy for adolescents (IPT‐A) is a manualised, time‐limited intervention for young people with depression. This systematic review aimed to determine the effectiveness of IPT‐A for treating adolescent depression.
Method
A systematic search of relevant electronic databases and study reference lists was conducted. Any study investigating the effectiveness of IPT‐A in 12‐ to 20‐year‐olds with a depressive disorder was eligible. Synthesis was via narrative summary and meta‐analysis.
Results
Twenty studies were identified (10 randomised trials and 10 open trials/case studies), many of which had small sample sizes and were of varying quality. Following IPT‐A, participants experienced large improvements in depression symptoms (d = −1.48, p < .0001, k = 17), interpersonal difficulties with a medium effect (d = −0.68, p < .001, k = 8) and in general functioning with a very large effect (d = 2.85, p < .001, k = 8). When compared against control interventions, IPT‐A was more effective than non‐CBT active controls in reducing depression symptoms (d = −0.64, p < .001, k = 5) and was no different from CBT (d = 0.05, p = .88, k = 2). There was no difference between IPT‐A and active control interventions in reducing interpersonal difficulties (d = −0.26, p = .25, k = 5).
Conclusions
Interpersonal psychotherapy for adolescents is an effective intervention for adolescent depression, improving a range of relevant outcomes. IPT‐A is consistently superior to less structured interventions and performs similarly to CBT. However, these conclusions are cautious, as they are based on a small number of controlled studies, with minor adaptations to the standard IPT‐A protocol, and/or were conducted by the intervention developers. Further robust RCTs are therefore required. The lack of superiority in IPT‐A for improving interpersonal difficulties highlights a need for studies to explore the underpinning mechanisms of change.
Objective:
Maltreatment exposure is a robust predictor of adolescent depression. Yet despite this well-documented association, few studies have simultaneously examined how maltreatment subtypes relate to qualitatively distinct depressive symptoms. The present multiwave longitudinal study addressed this gap in the literature by examining how different maltreatment subtypes independently impact depressed mood and anhedonia over time in a diverse adolescent sample.
Method:
Adolescents (N = 673, Mage = 14.83, SDage = 0.66, 57.1% female, 32.8% Hispanic, 30.4% Caucasian, 25.0% African American) completed self-report inventories for child-maltreatment and annual self-report measures of depressed mood and anhedonia over the course of 6 years. We used latent-growth-curve modeling to test how maltreatment exposure predicted anhedonia and depressed mood, and whether these relations differed as a function of sex and/or race/ethnicity.
Results:
Overall, both emotional abuse (p < .001) and neglect (p = .002) predicted levels of depressed mood over time, whereas only emotional neglect predicted levels (p < .001) and trajectories (p = .001) of anhedonia. Physical and sexual abuse did not predict depressive symptoms after accounting for emotional abuse and neglect (ns). These findings were largely invariant across sex and race.
Conclusion:
Findings suggest that the consequences of emotional neglect may be especially problematic in adolescence because of its impact on both depressed mood and anhedonia, and that emotional abuse's association with depression is best explained via symptoms of depressed mood. These findings are congruent with recent findings that more "silent types" of maltreatment uniquely predict depression, and that abuse and neglect experiences confer distinct profiles of risk for psychological distress. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
Background:
Women with depression and childhood sexual abuse histories constitute more than 20% of the female patient population in publicly funded community mental health centers (CMHCs). Interventions are needed that address depression and posttraumatic stress disorder (PTSD) symptoms and social health.
Method:
We compared Interpersonal Psychotherapy-Trauma (IPT-T), an IPT adaptation for this population and setting, to Clinic Psychotherapy (CP). CP clinicians were free to implement the psychotherapy of choice. Women (n = 162; 54% White, 10.5% Hispanic; 52.2% Medicaid-insured) with a major depressive episode (MDE) and history of sexual abuse before 18 were randomly assigned to IPT-T or CP. Participants were offered 16 free sessions of IPT-T or CP. Outcomes were MDE remission, improved depression (Beck Depression Inventory, Hamilton Depression Rating Scale) and PTSD symptoms (Modified PTSD Symptom Scale), and improved social health (e.g., UCLA Loneliness Scale). Weighted generalized estimating equations were used to examine outcomes at 8 (primary) and 20 (secondary) months postrandomization.
Results:
IPT-T led to greater improvements in PTSD symptoms and many social health indicators, including loneliness and social support, at both 8- and 20-month follow-up. Effect sizes ranged from .18 to .39 at the primary endpoint (8 months). IPT-T and CP yielded comparable improvements in depression symptoms and MDE remission.
Conclusion:
Evidence-based psychotherapies like IPT-T are needed in CMHCs, where some of the most vulnerable patients receive treatment. With comparable findings for depression, IPT's superior improvements in social health and PTSD symptoms are cause for optimism. IPT-T should be evaluated in dissemination trials. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
Background:
Moderators of differential psychotherapy outcome for posttraumatic stress disorder (PTSD) are rare, yet have crucial clinical importance. We tested the moderating effects of trauma type for three psychotherapies in 110 unmedicated patients with chronic DSM-IV PTSD.
Methods:
Patients were randomized to 14 weeks of prolonged exposure (PE, N = 38), interpersonal psychotherapy (IPT, N = 40), or relaxation therapy (RT, N = 32). The Clinician-Administered PTSD Scale (CAPS) was the primary outcome measure. Moderator candidates were trauma type: interpersonal, sexual, physical. We fit a regression model for week 14 CAPS as a function of treatment (a three-level factor), an indicator of trauma type presence/absence, and their interactions, controlling for baseline CAPS, and evaluated potential confounds.
Results:
Thirty-nine (35%) patients reported sexual, 68 (62%) physical, and 102 (93%) interpersonal trauma. Baseline CAPS scores did not differ by presence/absence of trauma types. Sexual trauma as PTSD criterion A significantly moderated treatment effect: whereas all therapies had similar efficacy among nonsexually-traumatized patients, IPT had greater efficacy among sexually traumatized patients (efficacy difference with and without sexual trauma: IPT vs. PE and IPT vs. RT P's < .05), specifically in PTSD symptom clusters B and D (P's < .05).
Conclusions:
Few studies have assessed effects of varying trauma types on effects of differing psychotherapies. In this exploratory study, sexual trauma moderated PTSD outcomes of three therapies: IPT showed greater benefit for sexually traumatized patients than PE or RT. The IPT focuses on affect to help patients determine trust in their current environments may particularly benefit patients who have suffered sexual assault.
Across 5 decades, hundreds of randomized trials have tested psychological therapies for youth internalizing (anxiety, depression) and externalizing (misconduct, attention deficit and hyperactivity disorder) disorders and problems. Since the last broad-based youth meta-analysis in 1995, the number of trials has almost tripled and data-analytic methods have been refined. We applied these methods to the expanded study pool (447 studies; 30,431 youths), synthesizing 50 years of findings and identifying implications for research and practice. We assessed overall effect size (ES) and moderator effects using multilevel modeling to address ES dependency that is common, but typically not modeled, in meta-analyses. Mean posttreatment ES was 0.46; the probability that a youth in the treatment condition would fare better than a youth in the control condition was 63%. Effects varied according to multiple moderators, including the problem targeted in treatment: Mean ES at posttreatment was strongest for anxiety (0.61), weakest for depression (0.29), and nonsignificant for multiproblem treatment (0.15). ESs differed across control conditions, with “usual care” emerging as a potent comparison condition, and across informants, highlighting the need to obtain and integrate multiple perspectives on outcome. Effects of therapy type varied by informant; only youth-focused behavioral therapies (including cognitive-behavioral therapy) showed similar and robust effects across youth, parent, and teacher reports. Effects did not differ for Caucasian versus minority samples, but more diverse samples are needed. The findings underscore the benefits of psychological treatments as well as the need for improved therapies and more representative, informative, and rigorous intervention science.
Objective:
To assess predictors and moderators of a cognitive-behavioral prevention (CBP) program for adolescent offspring of parents with depression.
Method:
This 4-site randomized trial evaluated CBP compared to usual community care (UC) in 310 adolescents with familial (parental depression) and individual (youth history of depression or current subsyndromal symptoms) risk for depression. As previously reported by Garber and colleagues, a significant prevention effect favored CBP through 9 months; however, outcomes of CBP and UC did not significantly differ when parents were depressed at baseline. The current study expanded on these analyses and examined a range of demographic, clinical, and contextual characteristics of families as predictors and moderators and used recursive partitioning to construct a classification tree to organize clinical response subgroups.
Results:
Depression onset was predicted by lower functioning (hazard ratio [HR] = 0.95, 95% CI = 0.92-0.98) and higher hopelessness (HR = 1.06, 95% CI = 1.01-1.11) in adolescents. The superior effect of CBP was diminished when parents were currently depressed at baseline (HR = 6.38, 95% CI = 2.38-17.1) or had a history of hypomania (HR = 67.5, 95% CI = 10.9-417.1), or when adolescents reported higher depressive symptoms (HR = 1.04, 95% CI = 1.00-1.08), higher anxiety (HR = 1.05, 95% CI = 1.01-1.08), higher hopelessness (HR = 1.10, 95% CI = 1.01-1.20), or lower functioning (HR = 0.94, 95% CI = 0.89-1.00) at baseline. Onset rates varied significantly by clinical response cluster (0%-57%).
Conclusion:
Depression in adolescents can be prevented, but programs may produce superior effects when timed at moments of relative wellness in high-risk families. Future programs may be enhanced by targeting modifiable negative clinical indicators of response.
Clinical trial registration information:
Prevention of Depression in At-Risk Adolescents; http://clinicaltrials.gov/; NCT00073671.
Importance
Several widely held beliefs about child abuse and neglect may be incorrect. It is most commonly assumed that some forms of abuse (eg, physical and sexual abuse) are more harmful than others (eg, emotional abuse and neglect); other assumptions are that each form of abuse has specific consequences and that the effects of abuse differ across sex and race.Objective
To determine whether widely held assumptions about child abuse and neglect are valid by testing the hypothesis that different types of child maltreatment (CM) actually have equivalent, broad, and universal effects.Design, Setting, and Participants
This observational study assessed 2292 racially and ethnically diverse boys (1254 [54.7%]) and girls (1038 [45.3%]) aged 5 to 13 years (mean [SD] age, 9.0 [2.0] years) who attended a research summer camp program for low-income, school-aged children from July 1, 1986, to August 15, 2012. Of these children, 1193 (52.1%) had a well-documented history of maltreatment. Analysis was conducted from September 25, 2013, to June 1, 2015.Main Outcomes and Measures
Various forms of internalizing and externalizing personality and psychopathologic traits were assessed using multiple informant ratings on the California Child Q-Set and Teacher Report Form as well as child self-reported depression and peer ratings of aggression and disruptive behavior.Results
Structural analysis showed that different forms of CM have equivalent psychiatric and behavioral effects, ranging from anxiety and depression to rule-breaking and aggression. We also found that nonsexual CM alters 2 broad vulnerability factors, internalizing (β = 0.185; SE = 0.028; P < .001) and externalizing (β = 0.283; SE = 0.023; P < .001), that underlie multiple forms of psychiatric and behavioral disturbance. We show that CM has comparable consequences for boys and girls of different races, and our results allowed us to describe a base rate and co-occurrence issue that makes it difficult to identify the unique effects of child sexual abuse. Conclusions and Relevance
Our findings challenge widely held beliefs about how child abuse should be recognized and treated—a responsibility that often lies with the physician. Because different types of child abuse have equivalent, broad, and universal effects, effective treatments for maltreatment of any sort are likely to have comprehensive psychological benefits. Population-level prevention and intervention strategies should emphasize emotional abuse, which occurs with high frequency but is less punishable than other types of child maltreatment.
Objective:
Exposure to trauma reminders has been considered imperative in psychotherapy for posttraumatic stress disorder (PTSD). The authors tested interpersonal psychotherapy (IPT), which has demonstrated antidepressant efficacy and shown promise in pilot PTSD research as a non-exposure-based non-cognitive-behavioral PTSD treatment.
Method:
The authors conducted a randomized 14-week trial comparing IPT, prolonged exposure (an exposure-based exemplar), and relaxation therapy (an active control psychotherapy) in 110 unmedicated patients who had chronic PTSD and a score >50 on the Clinician-Administered PTSD Scale (CAPS). Randomization stratified for comorbid major depression. The authors hypothesized that IPT would be no more than minimally inferior (a difference <12.5 points in CAPS score) to prolonged exposure.
Results:
All therapies had large within-group effect sizes (d values, 1.32-1.88). Rates of response, defined as an improvement of >30% in CAPS score, were 63% for IPT, 47% for prolonged exposure, and 38% for relaxation therapy (not significantly different between groups). CAPS outcomes for IPT and prolonged exposure differed by 5.5 points (not significant), and the null hypothesis of more than minimal IPT inferiority was rejected (p=0.035). Patients with comorbid major depression were nine times more likely than nondepressed patients to drop out of prolonged exposure therapy. IPT and prolonged exposure improved quality of life and social functioning more than relaxation therapy.
Conclusions:
This study demonstrated noninferiority of individual IPT for PTSD compared with the gold-standard treatment. IPT had (nonsignificantly) lower attrition and higher response rates than prolonged exposure. Contrary to widespread clinical belief, PTSD treatment may not require cognitive-behavioral exposure to trauma reminders. Moreover, patients with comorbid major depression may fare better with IPT than with prolonged exposure.
A randomized clinical trial was conducted to evaluate the efficacy of interpersonal psychotherapy (IPT) for ethnically and racially diverse, economically disadvantaged women with major depressive disorder. Non-treatment-seeking urban women (N = 128; M age = 25.40, SD = 4.98) with infants were recruited from the community. Participants were at or below the poverty level: 59.4% were Black and 21.1% were Hispanic. Women were screened for depressive symptoms using the Center for Epidemiologic Studies Depression Scale; the Diagnostic Interview Schedule was used to confirm major depressive disorder diagnosis. Participants were randomized to individual IPT or enhanced community standard. Depressive symptoms were assessed before, after, and 8 months posttreatment with the Beck Depression Inventory-II and the Revised Hamilton Rating Scale for Depression. The Social Support Behaviors Scale, the Social Adjustment Scale-Self-Report, and the Perceived Stress Scale were administered to examine mediators of outcome at follow-up. Treatment effects were evaluated with a growth mixture model for randomized trials using complier-average causal effect estimation. Depressive symptoms trajectories from baseline through postintervention to follow-up showed significant decreases among the IPT group compared to the enhanced community standard group. Changes on the Perceived Stress Scale and the Social Support Behaviors Scale mediated sustained treatment outcome.
This article presents psychometric characteristics of the UCLA PTSD Reaction Index for DSM IV (PTSD-RI) derived from a large sample of children and adolescents (N = 6,291) evaluated at National Child Traumatic Stress Network centers. Overall mean total PTSD-RI score for girls was significantly higher as compared with boys. Age-related differences were found in that overall mean total PTSD-RI scores and within sex groups were higher among those aged 7-9 years and 16-18 years. There were no significant differences in mean total PTSD-RI scores across racial/ethnic groups. The PTSD-RI total scale displayed good to excellent internal consistency reliability across age ranges, sex, and racial/ethnic groups (α = .88-.91). Correlations of PTSD-RI scores with PTS subscale scores on the TSCC-A for the entire sample and within sex, age, and ethnic/racial groups provided evidence of convergent validity, although not discriminant validity. In contradistinction to previously reported 4-factor models, an exploratory factor analysis revealed 3 factors that mostly reflected the underlying dimensions of PTSD in DSM IV. PTSD-RI scores were associated with increased odds ratios for functional/behavior problems (odds ratio [OR] = 1-1.80). These findings are striking in light of the wide range of trauma exposures, age, and race/ethnicity among subjects.
Child sexual abuse is considered a modifiable risk factor for mental disorders across the life course. However the long-term consequences of other forms of child maltreatment have not yet been systematically examined. The aim of this study was to summarise the evidence relating to the possible relationship between child physical abuse, emotional abuse, and neglect, and subsequent mental and physical health outcomes.
A systematic review was conducted using the Medline, EMBASE, and PsycINFO electronic databases up to 26 June 2012. Published cohort, cross-sectional, and case-control studies that examined non-sexual child maltreatment as a risk factor for loss of health were included. All meta-analyses were based on quality-effects models. Out of 285 articles assessed for eligibility, 124 studies satisfied the pre-determined inclusion criteria for meta-analysis. Statistically significant associations were observed between physical abuse, emotional abuse, and neglect and depressive disorders (physical abuse [odds ratio (OR) = 1.54; 95% CI 1.16-2.04], emotional abuse [OR = 3.06; 95% CI 2.43-3.85], and neglect [OR = 2.11; 95% CI 1.61-2.77]); drug use (physical abuse [OR = 1.92; 95% CI 1.67-2.20], emotional abuse [OR = 1.41; 95% CI 1.11-1.79], and neglect [OR = 1.36; 95% CI 1.21-1.54]); suicide attempts (physical abuse [OR = 3.40; 95% CI 2.17-5.32], emotional abuse [OR = 3.37; 95% CI 2.44-4.67], and neglect [OR = 1.95; 95% CI 1.13-3.37]); and sexually transmitted infections and risky sexual behaviour (physical abuse [OR = 1.78; 95% CI 1.50-2.10], emotional abuse [OR = 1.75; 95% CI 1.49-2.04], and neglect [OR = 1.57; 95% CI 1.39-1.78]). Evidence for causality was assessed using Bradford Hill criteria. While suggestive evidence exists for a relationship between maltreatment and chronic diseases and lifestyle risk factors, more research is required to confirm these relationships.
This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. All forms of child maltreatment should be considered important risks to health with a sizeable impact on major contributors to the burden of disease in all parts of the world. The awareness of the serious long-term consequences of child maltreatment should encourage better identification of those at risk and the development of effective interventions to protect children from violence. Please see later in the article for the Editors' Summary.
Prevention programs have increasingly emerged to address the rising prevalence rates of depressive disorders among individuals across the life span. In the present article, empirically supported prevention programs are reviewed and discussed in an effort to isolate “active” components of intervention that may facilitate stronger outcomes. Specific interventions are contrasted across selective and indicated programs, challenges within the field of prevention highlighted, and areas for future research discussed. To date, targeted programs with at-risk children have yielded promising results, but it is unclear which elements of these multicomponent programs have the greatest impact on outcome. Results suggest that cognitive skills, interpersonal approaches, and the inclusion of parent treatment components are important mechanisms of change. Dismantling studies are further needed to identify the value of specific techniques, ascertain the optimal format of parent interventions, and evaluate dosing effects.
The present cross-sectional study examined the relations of particular forms of childhood adversity (e.g., emotional maltreatment
vs. physical abuse vs. sexual abuse) to specific early maladaptive schema themes (e.g., worthlessness/loss vs. danger) and
symptom profiles (i.e., anhedonic vs. anxious). Seventy-six depressed adolescents retrospectively reported on their childhood
experiences of emotional maltreatment, physical abuse, and sexual abuse in a contextual semi-structured interview. They were
also administered the Young Schema Questionnaire to measure early maladaptive schemas, and the Mood and Anxiety Symptom Questionnaire
to measure anhedonic and anxious symptomatology. Consistent with specificity hypotheses, schemas with themes of loss/worthlessness
preferentially mediated the relation between childhood adversity and anhedonic symptoms, while schemas with themes of danger
preferentially mediated the relation between childhood adversity and anxious symptoms. Sexual abuse was not significantly
associated with either depression or anxiety symptoms and, thus, mediation models involving sexual abuse were not tested.
Implications for fine-grained models of etiology in depression are discussed.
This article considers the implications for prevention science of recent advances in research on family poverty and children's mental, emotional, and behavioral health. First, we describe definitions of poverty and the conceptual and empirical challenges to estimating the causal effects of poverty on children's mental, emotional, and behavioral health. Second, we offer a conceptual framework that incorporates selection processes that affect who becomes poor as well as mechanisms through which poverty appears to influence child and youth mental health. Third, we use this conceptual framework to selectively review the growing literatures on the mechanisms through which family poverty influences the mental, emotional, and behavioral health of children. We illustrate how a better understanding of the mechanisms of effect by which poverty impacts children's mental, emotional, and behavioral health is valuable in designing effective preventive interventions for those in poverty. Fourth, we describe strategies to directly reduce poverty and the implications of these strategies for prevention. This article is one of three in a special section (see also Biglan, Flay, Embry, & Sandler, 2012; Muñoz, Beardslee, & Leykin, 2012) representing an elaboration on a theme for prevention science developed by the 2009 report of the National Research Council and Institute of Medicine.
Child welfare agencies serve as gate keepers for children's mental health services (MHS). Yet, the impact of offered services on behavioral outcomes has not been well studied. Data from the National Survey of Child and Adolescent Well-Being (NSCAW) were examined to measure caregivers' reported change in children's emotional-behavioral problems. Over 600 children in three age groups were matched and problem levels compared across 3 years. Although behavioral problems for the total group improved across time, scores for children who received MHS slightly worsened. Children who received MHS scored 1.4-3.7 points worse than children who did not receive MHS. Additionally, young Black, Hispanic, and other racially identified children had more problems than young White children, regardless of service. Higher behavior problem scores were noted for school-age children and adolescents. Although child welfare appears to rely on a cluster of MHS, including school-based counseling and private practitioner services, future service delivery should expand from improving access to achieving outcomes.
The prevalence of depressive mood was examined in a representative and nationwide sample of approximately 12,000 Norwegian adolescents. From the age of 14, girls scored 0.5 SD above boys in depressed mood, a difference that was stable throughout the adolescent period. At the age of 12, no gender difference was found. The gender difference was due to girls becoming more depressed from 13 to 14 years of age. An extended version of the gender intensification hypothesis (J. P. Hill & M. E. Lynch, 1983) was tested as an explanation for the gender difference in depressed mood. Structural equation modeling and regression analyses showed that the gender difference could be explained, in part, by increased developmental challenges for girls--pubertal development, dissatisfaction with weight and attainment of a mature female body, and increased importance of feminine sex role identification. Depressed mood was not associated with masculinity or school change, as had been predicted.
The two evidence-based treatments for depression in youth are cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). Although these interventions have demonstrated efficacy, no data are yet available on the mechanisms of action of IPT, and data on the mediating role of cognitive processes in CBT are mixed. Both CBT and IPT appear to perform well across a range of demographic groups and clinically complicating characteristics. Moderator analyses suggest that CBT may be more efficacious for youths with strengths in cognitive and behavioral skills (e.g., low levels of cognitive distortions), rather than the converse. The IPT moderation literature is smaller, but available data suggest that IPT may serve as a compensation model, having stronger effects for youths with family conflict and interpersonal problems. Additional, programmatic research is needed to fill clear gaps in the knowledge base on mediators and moderators of CBT and IPT effects.
Child maltreatment represents a pervasive societal problem. Exposure to maltreatment is predictive of maladjustment across development with enduring negative effects found in adulthood. Compelling evidence suggests that some parents with a history of child abuse and neglect are at elevated risk for the maltreatment of their own children. However, a dearth of research currently exists on mediated mechanisms that may underlie this continuity. Ecological and transactional theories of child maltreatment propose that child maltreatment is multiply determined by various risk factors that exist across different ecological systems. Intimate partner violence (IPV) often co-occurs with child maltreatment and may represent a pathway through which risk for child abuse and neglect is transmitted across generations within a family. Informed by theories on the intergenerational transmission of child maltreatment and utilizing a community-based, cross-sectional sample of 245 racially and ethnically diverse, low-income mothers and daughters, the objective of this study was to investigate IPV as a propagating process through which risk of child abuse and neglect is conferred from parent to child. We found evidence suggesting that mothers’ history of maltreatment is associated with both their IPV involvement and their adolescent daughters’ maltreatment victimization (with exposure to IPV as a maltreatment subtype excluded for clarity). Maternal IPV also partially accounted for the continuity of maltreatment victimization from mother to adolescent. A secondary analysis that included the adolescent's own engagement in dating violence provided compelling but preliminary evidence of the emergence of a similar pattern of relational violence, whereby adolescent girls with maltreatment histories were likewise involved in abusive intimate relationships. Future directions and clinical implications of these findings are discussed.
Maltreatment experiences are complex, and it is difficult to characterize the heterogeneity in types of maltreatment. Subtypes, such as emotional maltreatment, sexual abuse, physical abuse, and neglect commonly co-occur and may persist across development. Therefore, treating individual maltreatment subtypes as independently occurring is not representative of the nature of maltreatment as it occurs in children's lives. Latent class analysis (LCA) is employed herein to identify subgroups of maltreated children based on commonalities in maltreatment subtype and chronicity. In a sample of 674 low-income urban children, 51.6% of whom experienced officially documented maltreatment, our analyses identified four classes of children, with three distinct classes based on maltreatment subtypes and chronicity, and one group of children who did not experience maltreatment. The largest class of maltreated children identified was the chronic, multi-subtype maltreatment class (57% of maltreated children); a second class was characterized by only neglect in a single developmental period (31% of maltreated children), and the smallest class was characterized by a single subtype of maltreatment (emotional maltreatment, physical, or sexual abuse) occurring in a single developmental period (12% of maltreated children). Characterization of these groups confirms the overlapping nature of maltreatment subtypes. There were notable differences between latent classes on child behavioral and socio-emotional outcomes measured by child self-report and camp counselors report during a one-week summer camp. The largest differences were between the non-maltreated class and the chronic maltreatment class. Children who experienced chronic, multi-subtype maltreatment showed higher levels of externalizing behavior, emotion dysregulation, depression, and anxiety.
Previous research has indicated that Interpersonal Psychotherapy (IPT) is generally effective for ameliorating symptoms for adults suffering from depression. Indeed, this has been demonstrated through numerous clinical and open trials, and further confirmed on a larger degree through several meta-analyses. However, no such comprehensive reviews have been conducted exclusively with adolescents, a population for which interpersonal relationships holds immense developmental importance. Therefore, a meta-analysis of the effectiveness of IPT-A, the version of IPT modified to specifically address depression in adolescents, was conducted in the present review. A total of ten studies yielding 766 participants were included in the present meta-analysis and analyzed using a standardized mean gain (SMG) effect size. The results indicate that IPT-A was significantly effective at reducing depressive symptoms in adolescents and significantly more effective than control or treatment-as-usual groups in treating depression in adolescents. IPT-A yielded an overall effect size (Hedges g) of 1.19, while the aggregate effect size for control/placebo groups was 0.58. Overall, the results of this review suggest that IPT-A holds similar promise for improving adolescent depression as the original version does for adults.
In this study, we evaluate the efficacy and safety of interpersonal psychotherapy (IPT) for adolescents with depression. We searched our existing database and electronic databases, including PubMed, Cochrane, EMBASE, PsycINFO, Web of Science, and CINAHL databases (from inception to May 2016). We included randomized controlled trials comparing IPT with various control conditions, including waitlist, psychological placebo, treatment as usual, and no treatment, in adolescents with depression. Finally, we selected seven studies comprising 538 participants comparing IPT with three different control conditions. Pooled analyses suggested that IPT was significantly more effective than control conditions in reducing depressive symptoms at post-treatment and follow-up, and increasing the response/remission rate at post-treatment. IPT was also superior to control conditions for all-cause discontinuation and quality of life/functioning improvement outcomes. However, there was no evidence that IPT reduces the risk of suicide from these data. Meta-analysis demonstrated publication bias for primary efficacy, while the adjusted standardized mean difference using the trim-and-fill method indicated IPT was still significantly superior to the control conditions. Current evidence indicates IPT has a superior efficacy and acceptability compared with control conditions in treating adolescents with depression.
In this chapter, we provide an overview of the historical issues accompanying the study of child maltreatment and address advances and challenges that have emerged over decades of research in this area. A developmental psychopathology perspective provides a framework for discussing etiological models, psychological and biological sequelae, and methodological considerations, as well as for highlighting implications for intervention and social policy. The utilization of a multilevel perspective that integrates socioemotional, cognitive, psychophysiological, neurobiological, and genetic levels of analysis infused throughout our discussion of research. We conclude by proffering recommendations for research initiatives that will continue to advance the field and ultimately improve the lives of children who have been victimized by abuse and neglect.
Depression in youth is prevalent and disabling and tends to presage a chronic and recurrent course of illness and impairment in adulthood. Clinical trial research in youth depression has a 30-year history, and evidence-based treatment reviews appeared in 1998 and 2008. The current review of 42 randomized controlled trials (RCTs) updates these reviews to include RCTs published between 2008 and 2014 (N = 14) and reevaluates previously reviewed literature. Given the growing maturity of the field, this review utilized a stringent set of methodological criteria for trial inclusion, most notable for excluding trials based in subclinical samples of youth that had been included in previous reviews (N = 12) and including well-designed RCTs with null and negative findings (N = 8). Findings from the current review suggest that evidence for child treatments is notably weaker than for adolescent interventions, with no child treatments achieving well-established status and the evidentiary basis of treatments downgraded from previous reports. Cognitive behavioral therapy (CBT) for clinically depressed children appears to be possibly efficacious, with mixed findings across trials. For depressed adolescents, both CBT and interpersonal psychotherapy are well-established interventions, with evidence of efficacy in multiple trials by independent investigative teams. This positive conclusion is tempered by the small size of the interpersonal psychotherapy literature (N = 6) and concern that CBT effects may be attenuated in clinically complicated samples and when compared against active control conditions. Data on predictors, moderators, and mediators are examined and priorities for future research discussed.
Sure, and longitudinal studies in the social and behavioral sciences generally contain missing data. Mean and covariance structure models play an important role in analyzing such data. Two promising methods for dealing with missing data are a direct I,maximum-likelihood and a two-stage approach based on the unstructured mean and covariance estimates obtained by the EM-algorithm. Typical assumptions under these two methods are ignorable nonresponse and normality of data. However, data sets in social and behavioral sciences are seldom normal. and experience with these procedures indicates that normal theory based methods for nonnormal data very often lead to incorrect model evaluations. By dropping the normal distribution assumption, we develop more accurate procedures for model inference. Based on the theory of generalized estimating equations, a way to obtain consistent standard errors of the two-stage estimates is given. The asymptotic efficiencies of different estimators are compared under various assumptions. Ne also propose a minimum chi-square approach and show that the estimator obtained by this approach is asymptotically at least as efficient as the two likelihood-based estimators for either normal or nonnormal darn. The major contribution of this paper is that for each estimator, we give a test statistic whose asymptotic distribution is chi-square as long as the underlying sampling distribution enjoys finite fourth-order moments. Ne also give a characterization for each of the two likelihood ratio rest statistics,when the underlying distribution is nonnormal. Modifications to the likelihood ratio statistics are also Riven. Our working assumption is that the missing data mechanism is missing comptetely at random. examples and Monte Carlo studies indicate that, for commonly encountered nonnormal distributions, the procedures developed in this paper are quite reliable even for samples with missing data that ar-e missing at random.
Most empirically supported interventions for adolescent mental health problems are either downward adaptations of adult treatments or upward adaptations of child treatments. Although these treatments show respectable effects with teens, a review of the outcome research reveals significant gaps, both in coverage of adolescent conditions and problems (e.g., eating disorders, suicidality) and in attention to the biological, psychological, and social dimensions of adolescent development, The authors critique the field. propose a biopsychosocial framework for the development of dysfunction and intervention, and discuss ways the developmental literature can and cannot inform intervention and research. A long-term goal is an array of developmentally tailored treatments that are effective with clinically referred teens and an enriched understanding of when, how, and why the treatments work.
The notion of an average expectable environment for promoting normal development proposes that there are species-specific ranges of environmental conditions that elicit normative developmental processes. This chapter provides a review of child maltreatment. Of particular salience is the growing contribution of neurobiological and genetic research to the study of child maltreatment, such that ontogenic development can be considered from both psychological and neurobiological perspectives. The ecological-transactional model of child maltreatment explains how processes at each level of ecology exert reciprocal influences on each other and shape the course of child development. The extent of variation in personality characteristics and personality organization among maltreated children represents an area of investigation that has recently gained attention in the maltreatment literature. The maladaptive trajectories of maltreated children diverge from those of nonmaltreated children over time such that maltreated children's problems become more severe as children get older, especially in peer relationships.
Previous meta-analyses of psychotherapies for child and adolescent depression were limited because of the small number of trials with direct comparisons between two treatments. A network meta-analysis, a novel approach that integrates direct and indirect evidence from randomized controlled studies, was undertaken to investigate the comparative efficacy and acceptability of psychotherapies for depression in children and adolescents. Systematic searches resulted in 52 studies (total N=3805) of nine psychotherapies and four control conditions. We assessed the efficacy at post-treatment and at follow-up, as well as the acceptability (all-cause discontinuation) of psychotherapies and control conditions. At post-treatment, only interpersonal therapy (IPT) and cognitive-behavioral therapy (CBT) were significantly more effective than most control conditions (standardized mean differences, SMDs ranged from −0.47 to −0.96). Also, IPT and CBT were more beneficial than play therapy. Only psychodynamic therapy and play therapy were not significantly superior to waitlist. At follow-up, IPT and CBT were significantly more effective than most control conditions (SMDs ranged from −0.26 to −1.05), although only IPT retained this superiority at both short-term and long-term follow-up. In addition, IPT and CBT were more beneficial than problem-solving therapy. Waitlist was significantly inferior to other control conditions. With regard to acceptability, IPT and problem-solving therapy had significantly fewer all-cause discontinuations than cognitive therapy and CBT (ORs ranged from 0.06 to 0.33). These data suggest that IPT and CBT should be considered as the best available psychotherapies for depression in children and adolescents. However, several alternative psychotherapies are understudied in this age group. Waitlist may inflate the effect of psychotherapies, so that psychological placebo or treatment-as-usual may be preferable as a control condition in psychotherapy trials.
This study examines alternative ways of specifying models in the complier average causal effect (CACE) estimation method, where the major interest is in estimating causal effects of treatments for compliers. A fundamental difficulty involved in the CACE estimation method is in dealing with missing compliance information among study participants. Given that, the assumption of the exclusion restriction plays a critical role in separating the distributions of compliers and non-compliers. If no pretreatment covariates are available, assuming the exclusion restriction is unavoidable to obtain unique ML estimates in CACE models, although the assumption can be often unrealistic. One disadvantage of assuming the exclusion restriction is that the CACE estimate can be biased if the assumption is violated. Another disadvantage is that the assumption limits the flexibility of CACE modeling in practice. However, if pretreatment covariates are available, more modeling options other than strictly forcing the exclusion restriction can be considered to establish identifiability of CACE models. This study explores modeling possibilities of CACE estimation within an ML-EM framework in the presence of covariate information.
No one treatment is likely to affect all patients with a disorder in the same way. A treatment highly effective for some may be ineffective or even harmful for others. Statistically significant or not, the effect sizes of many treatments tend to be small. Consequently, emphasis in clinical research is gradually shifting (1) to increased focus on effect sizes and (2) to discovery and documentation of moderators of treatment effect on outcome in randomized clinical trials, that is, personalized medicine, in which individual differences between patients are explicitly acknowledged. How to test a null hypothesis of moderation of treatment outcome is reasonably well known. The focus here is on how, under parametric assumptions, to define the strength of moderation, that is, a moderator effect size, either for scientific purposes or for assessment of clinical significance, in order to compare moderators and choose among them and to develop a composite moderator, which might more strongly moderate the effect of a treatment on outcome than any single moderator that might ultimately provide guidance for clinicians as to whom to prescribe what treatment. Copyright © 2013 John Wiley & Sons, Ltd.
The study of depression in children and adolescents has gone through a series of contradictory formulations as theorists have attempted to understand this complex form of disorder in youngsters. Conceptualizations have ranged from the belief that depression in children was impossible due to the immaturity of ego development prior to adolescence and the concomitant inability to experience guilt (Rie, 1966) to the belief that depression in children is prevalent and may be manifested in a variety of symptoms quite divergent from those evidenced in adulthood, i. e., depressive equivalents (Cytryn & McKnew, 1972; Glaser, 1967) to the assertion that symptoms indicating depression are the same across the age span from childhood to adulthood (American Psychiatric Association, 1987; Kashani et al., 1981; Puig-Antich, 1980). Such divergence in thinking indicates that the topic of depression in childhood and adolescence is an area of active and significant theoretical and empirical inquiry.
Discussed interpersonal psychotherapy (ITP) for depressed adolescents. Interpersonal psychotherapy for depressed adolescents is a short-term, manualized, individual treatment for adolescent depression. The focus of the treatment is on alleviating depressive symptoms and improving interpersonal functioning. Details of ITP and how it works are outlined. The efficacy of ITP has been demonstrated in 2 randomized controlled clinical trials. Current empirical investigations of ITP aims to provide treatment in community-based practice settings and/or with adaptations to make treatment delivery more cost-effective and accessible to more teens. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Survey and longitudinal studies in the social and behavioral sciences generally contain missing data. Mean and covariance structure models play an important role in analyzing such data. Two promising methods for dealing with missing data are a direct maximum-likelihood and a two-stage approach based on the unstructured mean and covariance estimates obtained by the EM-algorithm. Typical assumptions under these two methods are ignorable nonresponse and normality of data. However, data sets in social and behavioral sciences are seldom normal, and experience with these procedures indicates that normal theory based methods for nonnormal data very often lead to incorrect model evaluations. By dropping the normal distribution assumption, we develop more accurate procedures for model inference. Based on the theory of generalized estimating equations, a way to obtain consistent standard errors of the two-stage estimates is given. The asymptotic efficiencies of different estimators are compared under various assumptions. We also propose a minimum chi-square approach and show that the estimator obtained by this approach is asymptotically at least as efficient as the two likelihood-based estimators for either normal or nonnormal data. The major contribution of this paper is that for each estimator, we give a test statistic whose asymptotic distribution is chi-square as long as the underlying sampling distribution enjoys finite fourth-order moments. We also give a characterization for each of the two likelihood ratio test statistics when the underlying distribution is nonnormal. Modifications to the likelihood ratio statistics are also given. Our working assumption is that the missing data mechanism is missing completely at random. Examples and Monte Carlo studies indicate that, for commonly encountered nonnormal distributions, the procedures developed in this paper are quite reliable even for samples with missing data that are missing at random.
The system for providing mental health services to children is fragmented and complex, and children and their families face multiple barriers to accessing care. This is especially true for children in low-income families, who have the greatest rate of mental health disorders but have the highest underutilization of services. The first section of this paper describes the unmet need for children's mental health services, including reasons for the disproportionate need among low-income children. The second section provides a brief overview of the history of children's mental health policies. The third section outlines the types of services available to children, highlighting the problems with this service delivery system. This is followed by a discussion of barriers that families face in accessing care. The paper concludes with recommendations for improving this fragmented system of service delivery.
The authors review the currently available evidence-based treatments of child and adolescent major depressive disorder. Medication monotherapy, namely with selective serotonin reuptake inhibitors, is supported by large clinical trials in adolescents. For mild to moderate depression, cognitive behavior therapy (CBT) and interpersonal therapy are reasonable options as monotherapies. There is also evidence that the combination of medication and CBT is superior to medication alone for accelerating the pace of treatment response and remission, despite some negative studies. Response, remission, and recurrence rates after acute treatment and during long-term follow-ups are also presented and discussed.
Evidence suggests that childhood maltreatment may negatively affect not only the lifetime risk of depression but also clinically relevant measures of depression, such as course of illness and treatment outcome. The authors conducted the first meta-analysis to examine the relationship between childhood maltreatment and these clinically relevant measures of depression.
The authors conducted searches in MEDLINE, PsycINFO, and Embase for articles examining the association of childhood maltreatment with course of illness (i.e., recurrence or persistence) and with treatment outcome in depression that appeared in the literature before December 31, 2010. Recurrence was defined in terms of number of depressive episodes. Persistence was defined in terms of duration of current depressive episode. Treatment outcome was defined in terms of either a response (a 50% reduction in depression severity rating from baseline) or remission (a decrease in depression severity below a predefined clinical significance level).
A meta-analysis of 16 epidemiological studies (23,544 participants) suggested that childhood maltreatment was associated with an elevated risk of developing recurrent and persistent depressive episodes (odds ratio=2.27, 95% confidence interval [CI]=1.80–2.87). A meta-analysis of 10 clinical trials (3,098 participants) revealed that childhood maltreatment was associated with lack of response or remission during treatment for depression (odds ratio=1.43, 95% CI=1.11–1.83). Meta-regression analyses suggested that the results were not significantly affected by publication bias, choice of outcome measure, inclusion of prevalence or incidence samples, study quality, age of the sample, or lifetime prevalence of depression.
Childhood maltreatment predicts unfavorable course of illness and treatment outcome in depression.
Interpersonal Psychotherapy (IPT), a time-limited, evidence-based treatment, has shown efficacy in treating major depressive disorder and other psychiatric conditions. Interpersonal Psychotherapy focuses on the patient's current life events and social and interpersonal functioning for understanding and treating symptoms. This case report demonstrates the novel use of IPT as treatment for posttraumatic stress disorder (PTSD). Preliminary evidence suggests IPT may relieve PTSD symptoms without focusing on exposure to trauma reminders. Thus IPT may offer an alternative for patients who refuse (or do not respond to) exposure-based approaches. Interpersonal Psychotherapy focuses on two problem areas that specifically affect patients with PTSD: interpersonal difficulties and affect dysregulation. This case report describes a pilot participant from a study comparing 14 weekly sessions of IPT to treatment with two other psychotherapies. We describe the session-by-session IPT protocol, illustrating how to formulate the case, help the patient identify and address problematic affects and interpersonal functioning, and to monitor treatment response.
Recent literature has emphasized the simultaneous assessment of multiple physiological stress response systems in an effort to identify biobehavioral risk factors of psychopathology in maltreated populations. The current study assessed whether an asymmetrical stress response, marked by activation in one system and a blunted response in another system, predicted higher levels of psychopathology over time.
Data were collected from an ongoing, prospective study of females with a substantiated history of childhood sexual abuse (n=52) and a non-abused comparison group (n=77). Childhood sexual abuse was determined at the initial study visit. Vagal tone and cortisol were measured 7 years later to assess physiological response to a laboratory stressor across these systems. Depressive symptoms and antisocial behaviors were assessed 6 years after the completion of the laboratory stressor.
Structural equation modeling indicated that a prior history of childhood sexual abuse predicted an asymmetrical physiological response to stress in late adolescence. In turn, this asymmetrical response predicted both higher levels of depression and antisocial behaviors in young adulthood.
Childhood sexual abuse may sensitize females to respond to moderate daily stressors in a manner that places them at higher risk for experiencing depressive symptoms and antisocial behaviors over time.
The management of mild to moderate stress in the everyday lives of maltreated females may be a particularly useful point of intervention in order to protect against later psychopathology.
Validity studies of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) interview are modest in number given the international acceptance and extensive use of this instrument in epidemiological and treatment research. The results are somewhat mixed and limited, particularly for adolescent depression.
The objective of this study was to assess the convergent-divergent validity of the screen criteria and depression diagnoses (major depressive episode) generated with the diagnostic interview Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL).
Participants were 86 consecutively admitted inpatients aged 12-17 years and their parents. Both convergent and divergent validity of the depression diagnoses were assessed against 11 standard self-report or parent-report rating scales, all of which had been translated, adapted and in most cases validated in Iceland. A total of 25 subscales were included in calculations.
Convergent validity was confirmed, with adolescents who screened positive or met criteria for major depressive episode scoring higher than other patients did on scales assessing depressive symptoms. However, divergent validity was only partially supported in this highly comorbid inpatient sample. Severity based on number of diagnostic criteria met had a generally substantial correlation with the rating scales.
This study provides a substantial additional amount of convergent-divergent validity data related to this extensively used diagnostic instrument.
This article details the application of Complier Average Causal Effect (CACE) analysis to the examination of youth outcomes from adaptive substance use prevention trials.
CACE analysis is illustrated using youth-reports of tobacco-use from ages 11 to 22, from the Adolescent Transitions Program, a family-focused randomized encouragement trial designed for delivery in the school setting.
Female gender and early peer deviance predicted family engagement with active intervention components. Further, long-term reductions in youth tobacco use from age 11 to age 22 were found for families that engaged with treatment.
CACE modeling techniques enable researchers to examine factors that predict engagement with core intervention components and to examine intervention effects specifically for youth who engaged with those components.
Aquí se expone la influyente teoría interpersonal de la psiquiatría desarrollada por Sullivan a partir del psicoanálisis.
Early clinical observations and recent systematic studies overwhelmingly document a greater role for psychosocial stressors in association with the first episode of major affective disorder than with subsequent episodes. The author postulates that both sensitization to stressors and episode sensitization occur and become encoded at the level of gene expression. In particular, stressors and the biochemical concomitants of the episodes themselves can induce the protooncogene c-fos and related transcription factors, which then affect the expression of transmitters, receptors, and neuropeptides that alter responsivity in a long-lasting fashion. Thus, both stressors and episodes may leave residual traces and vulnerabilities to further occurrences of affective illness. These data and concepts suggest that the biochemical and anatomical substrates underlying the affective disorders evolve over time as a function of recurrences, as does pharmacological responsivity. This formulation highlights the critical importance of early intervention in the illness in order to prevent malignant transformation to rapid cycling, spontaneous episodes, and refractoriness to drug treatment.
To describe the psychometric properties of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL) interview, which surveys additional disorders not assessed in prior K-SADS, contains improved probes and anchor points, includes diagnosis-specific impairment ratings, generates DSM-III-R and DSM-IV diagnoses, and divides symptoms surveyed into a screening interview and five diagnostic supplements.
Subjects were 55 psychiatric outpatients and 11 normal controls (aged 7 through 17 years). Both parents and children were used as informants. Concurrent validity of the screen criteria and the K-SADS-PL diagnoses was assessed against standard self-report scales. Interrater (n = 15) and test-retest (n = 20) reliability data were also collected (mean retest interval: 18 days; range: 2 to 36 days).
Rating scale data support the concurrent validity of screens and K-SADS-PL diagnoses. Interrater agreement in scoring screens and diagnoses was high (range: 93% to 100%). Test-retest reliability kappa coefficients were in the excellent range for present and/or lifetime diagnoses of major depression, any bipolar, generalized anxiety, conduct, and oppositional defiant disorder (.77 to 1.00) and in the good range for present diagnoses of posttraumatic stress disorder and attention-deficit hyperactivity disorder (.63 to .67).
Results suggest the K-SADS-PL generates reliable and valid child psychiatric diagnoses.
Two of the major cognitive theories of depression, the theory of Beck [Beck, A. T. (1967). Depression: clinical, experimental and theoretical aspects. New York: Harper & Row. and Beck, A. T. (1987) Cognitive models of depression. Journal of Cognitive Psychotherapy: an International Quarterly, 1, 5-37] and the hopelessness theory [Abramson, Metalsky, & Alloy, (1989) Hopelessness depression: a theory-based subtype of depression. Psychological Review, 96, 358-372], include the hypothesis that particular negative cognitive styles increase individuals' likelihood of developing episodes of depression, in particular, a cognitively mediated subtype of depression, when they encounter negative life events. The Temple-Wisconsin Cognitive Vulnerability to Depression (CVD) project is a two-site, prospective longitudinal study designed to test this cognitive vulnerability hypothesis, as well as the other etiological hypotheses of Beck's and the hopelessness theories of depression. In this article, based on CVD project findings to date, we review evidence that the hypothesized depressogenic cognitive styles do indeed confer vulnerability for clinically significant depressive disorders and suicidality. In addition, we present evidence regarding moderators of these depressogenic cognitive styles, the information processing and personality correlates of these styles and the possible developmental antecedents of these styles. We end with a consideration of future research directions and the clinical implications of cognitive vulnerability to depression.
Early childhood maltreatment has been associated with adverse adult health outcomes, but little is known about the magnitude of adult health care use and costs that accompany maltreatment. We examined differences in annual health care use and costs in women with and without histories of childhood sexual, emotional, or physical abuse or neglect.
A random sample of 1225 women members of a health maintenance organization completed a 22-page questionnaire inquiring into childhood maltreatment experiences as measured by the Childhood Trauma Questionnaire. Health care costs and use data were obtained from the automated cost-accounting system of the health maintenance organization, including total costs, outpatient and primary care costs, and emergency department visits.
Women who reported any abuse or neglect had median annual health care costs that were 0.47-245 (95% confidence interval, 381.93) greater than costs among women who did not report abuse. Women with sexual abuse histories had significantly higher primary care and outpatient costs and more frequent emergency department visits than women without these histories.
Although the absolute cost differences per year per woman were relatively modest, the large number of women in the population with these experiences suggests that the total costs to society are substantial.