c&bp12.2

SECIAL ISSUE: TREATMENT FOR ADOLESCENTS WITH DEPRESSION
Editor: John Curry, Paul Rohde, and Anne Marie Albano

Invited Commentary

Treatment of Depression in Adolescents With Cognitive Behavior Therapy and Medications: A Commentary on the TADS Project
Steven D. Hollon, Judy Garber, and, Richard C. Shelton, Vanderbilt University

This article reviews and comments on the recent Treatment for Adolescents With Depression Study (TADS) that found that cognitive behavior therapy (CBT) was less efficacious than fluoxetine alone and no more efficacious than pill placebo in the treatment of depression in adolescents. Adding CBT to fluoxetine, however, improved treatment response in terms of both the reduction of depressive symptoms and the prevention of harm-related adverse events, including suicide risk. The TADS project was impressive in many respects and generally conducted well. However, the version of CBT used in this study was a novel amalgamation of different approaches, and may have tried to do too much in an overly structured fashion, thereby possibly tying the hands of the more experienced therapists in the trial. We question, therefore, the adequacy with which CBT was implemented and the representativeness of the findings. To explore these issues, we recommend that (a) the results be broken down by therapist and site, and (b) the CBT as implemented in TADS be compared to that provided in other studies that have found greater change in adolescent depression. Finally, we also question whether it was premature to move to large multisite effectiveness trials before establishing the relative efficacy of the respective interventions.

NIMH’s TADS: More Than Just a Tad of Progress?
Peter S. Jensen, Center for the Advancement of Children’s Mental Health at Columbia University/New York State Psychiatric Institute

The Treatment for Adolescents With Depression Study (TADS) derives substantial public health significance from its head-to-head comparisons of carefully administered medication versus a carefully crafted cognitive-behavioral therapy in youth with major depression, the first major clinical trial of its kind. Although the study has a number of limitations, to include somewhat higher than expected socioeconomic status of participants and a somewhat lower than expected rates of minority participation, it stands as an investigation of major international significance in our understanding of effective treatments for adolescents with major depressive disorder. Further studies will need to ensure that its findings are broadly generalizable across the U.S. population, and to parse out the active ingredients of psychotherapies and determine how those active ingredients are related to changes in psychological mechanisms related to depressive disorders.

A Multisite Psychotherapy and Medication Trial for Depressed Adolescents: Background and Benefits
Christopher J. Kratochvil, University of Nebraska Medical Center, Anne Simons, University of Oregon, Benedetto Vitiello, National Institute of Mental Health, John Walkup, Johns Hopkins University, Graham Emslie, University of Texas Southwestern Medical Center at Dallas, David Rosenberg, Wayne State University, and John S. March, Duke University Medical Center

The Treatment for Adolescents With Depression Study (TADS) is an NIMH- supported multisite clinical trial that compares the effectiveness of a depression-specific cognitive behavioral therapy (CBT), medication management with fluoxetine (FLX), the combination of CBT and FLX (COMB), and medical management with pill placebo (PBO). TADS was specifically designed as a comprehensive effectiveness study, able to answer clinically meaningful questions by including a broad and representative sample of depressed teens, delivering treatment at both tertiary medical centers and community clinics, and assessing functional as well as symptomatic outcomes. This report supports the importance of conducting clinical trials in youth with depression to bridge the gap between science and practice.

Vulnerability to Depression Among Adolescents: Implications for Cognitive-Behavioral Treatment
Mark A. Reinecke, Northwestern University, and Anne Simons, University of Oregon

A range of factors, including early experience, parent-child interaction patterns, biological factors, and life events, have been associated with the development of depression among adolescents. Relations between early experience, attachment insecurity, and later depression may be mediated by failures to develop adaptive social skills, the acquisition of maladaptive beliefs or schema, or neurochemical factors (such as altered hypothalamic-pituitary-adrenal response to stress, and changes in serotonergic, noradrenergic, and dopaminergic systems). Prevention and treatment models that attend to the full range of developmental, cognitive, social, and biological factors associated with risk for depression are needed. Such models must account for observed increases in rates of depression during adolescence, as well as for gender differences in rates of depression that become apparent at that time. The Treatment for Adolescents With Depression Study (TADS) treatment protocol attempts to systematically address cognitive, behavioral, and social factors associated with vulnerability for depression among youth. It is a developmentally sensitive, formulation-based treatment model.

Striving for Effectiveness in the Treatment of Adolescent Depression: Cognitive Behavior Therapy for Multisite Community Intervention
John F. Curry and Karen C. Wells, Duke University Medical Center

The Treatment for Adolescents With Depression Study (TADS) was designed to compare the relative and combined effectiveness of cognitive behavior therapy (CBT) and fluoxetine, each of which had demonstrated efficacy in carefully controlled single-site studies. Models of CBT from these efficacy studies served as the foundation for the TADS psychosocial intervention. When interpreting the acute and long-term outcomes of TADS treatment in the context of other studies of CBT for major depression, it is critical to understand the process and the decision making that formed the TADS CBT intervention. The TADS CBT Committee reviewed meta-analyses of child and adolescent psychotherapy as well as studies of CBT for childhood and adolescent depression, relied on expert consultants, and evaluated the treatment process in a feasibility study to derive the essential components of TADS CBT. In this article we describe the rationale for the TADS CBT, the process of treatment design, and the immediate sources of the TADS treatment. Key decisions were made involving the degree of treatment structure, therapist flexibility versus cross-site consistency, duration and intensity of treatment, the involvement of family members in treatment, and core versus optional elements of the intervention.

Characteristics and Components of the TADS CBT Approach
Paul Rohde, Oregon Research Institute, Eugene, Norah C. Feeny, Case Western Reserve University, Michele Robins, University of Pennsylvania Medical School

In this article, we describe the acute phase of a cognitive-behavioral therapy (CBT) developed for and utilized in the Treatment for Adolescents With Depression Study (TADS). The acute phase of TADS CBT consists of 8 skills that were considered essential to any CBT intervention for adolescent depression (e.g., mood monitoring, increasing pleasant activities, identifying cognitive distortions and developing realistic counterthoughts). In addition, 5 optional individual CBT skills (e.g., relaxation, affect regulation) can be incorporated into treatment, depending on the needs of the adolescent. We describe each of these individual skills by reviewing the rationale for their inclusion in the treatment protocol and describing the format that is used to teach the skill area. Recommendations are provided for dealing with common challenges that can occur in the teaching of each skill module. It is our hope that clinicians will find this a useful introduction to this particular form of treatment and a practical guide to dealing with clinical problems common to the delivery of any cognitive behavioral intervention with depressed teens.

Case Formulation in TADS CBT
Gregory M. Rogers, University of Wisconsin Medical School, Mark A. Reinecke, Northwestern University Medical School, and John F. Curry, Duke University Medical Center

For the Treatment for Adolescents With Depression Study (TADS), a cognitive-behavioral therapy (CBT) manual was developed with the aim of balancing standardization and flexibility. In this article, we describe the manual’s case formulation procedures, which served as one major mechanism of flexibility in TADS CBT. We first describe the essential components of a cognitive-behavioral case formulation. We then present a rationale for including individualized case formulation in manual-based treatments and clinical effectiveness studies, and discuss the specific case of TADS. We illustrate case formulation in an effectiveness study with a composite “case” of a 15-year-old male treated with TADS CBT. Clinical implications and future directions are discussed.

Parent Involvement in CBT Treatment of Adolescent Depression: Experiences in the Treatment for Adolescents With Depression Study (TADS)
Karen C. Wells, Duke University Medical Center, and Anne Marie Albano, Columbia University

The Treatment for Adolescents With Depression Study (TADS) evaluated the short- and long-term effectiveness of cognitive behavior therapy (CBT) alone, fluoxetine alone, and their combination, relative to pill placebo, and the 12-week treatment effects were recently published (TADS Team, 2004). Results showed that treatment that combined CBT with fluoxetine was significantly more effective than fluoxetine alone or CBT alone or pill placebo. Combining CBT with fluoxetine also provided a protective effect on the slightly increased risk of harm-related events associated with fluoxetine alone compared to placebo (TADS Team, 2004). In this protocol, CBT treatment included individual CBT sessions with the adolescent as well as parent psychoeducation sessions and parent-teen conjoint sessions. The present article describes the background and rationale for the parent component of the TADS CBT treatment. It also describes the 2 parent psychoeducation sessions and the 5 parent-teen conjoint sessions that were available in this modularized treatment protocol. In addition, the boundaries of the parent component are presented; these boundaries differentiate parent-teen conjoint sessions from a broader family systems approach. Finally, challenges to the effectiveness of parent involvement in TADS CBT treatment are described and include parent engagement, parent psychopathology, working with divorced parents and parents from a variety of family constellations and cultural backgrounds. Within a modular, manualized treatment protocol, flexible attention to these very real issues is essential in engaging and retaining.

African-American and Latino Families in TADS: Recruitment and Treatment Considerations
Michael Sweeney, Columbia University College of Physicians and Surgeons , Michele Robins, Children’s Hospital of Philadelphia, Maryse Ruberu, University of Texas Southwestern Medical Center, Jennifer Jones, Columbia University College of Physicians and Surgeons

The goal of this article is to review the experiences of some of the African-American and Latino families who participated in the Treatment for Adolescents With Depression Study (TADS). The importance of this article derives from the historical and current inequities in mental health care for families of color. We describe the attempts within the TADS study to ensure an appropriate representation of families of color; a description of the age, and of the length and severity of depression of the African-American and Latino adolescents who participated in the TADS trial. The article additionally attempts, through case example, to convey the experiences of several of the African-American and Latino families who participated in TADS.

Implementation Challenges to TADS Cognitive-Behavioral Therapy
Betsy D. Kennard, University of Texas Southwestern Medical Center of Dallas, Golda S. Ginsburg, Johns Hopkins University School of Medicine, Norah C. Feeny, Case Western Reserve University, Michael Sweeney, Columbia University, New York State Psychiatric Institute, Robin Zagurski, University of Nebraska Medical Center

This article discusses treatment obstacles that were frequently encountered by CBT therapists in the Treatment for Adolescents With Depression Study (TADS) trial. The most common or challenging treatment obstacles and their respective solutions were distilled from the minutes of national conference calls attended by TADS CBT supervisors and therapists. Obstacles were categorized into the following 6 themes: (1) comorbid disorders (i.e., anxiety, conduct, attention problems, and learning disorders); (2) severe depressive symptoms (i.e., anhedonia and hopelessness); (3) self-harm and suicidal ideation; (4) school refusal; (5) interpersonal factors, and; (6) treatment noncompliance. Case illustrations are provided throughout to illustrate these treatment obstacles and how they were addressed within the treatment manual.

Relapse and Recurrence Prevention in the Treatment for Adolescents With Depression Study
Anne D. Simons, University of Oregon, Paul Rohde, Oregon Research Institute, Betsy D. Kennard, University of Texas Southwestern Medical Center at Dallas, and Michele Robins, University of Pennsylvania Medical School

Relapse and recurrence in adolescent depression are important problems. Much less is known about relapse prevention compared to the acute treatment of depression in adolescents. Based on previous research, theoretical predictions, and clinical experience, the Treatment for Adolescents With Depression Study (TADS) protocol was designed to determine whether the usual high rates of relapse and recurrence could be decreased by extending acute treatment in the form of booster sessions that included (a) thorough education about the nature of depression, including its longitudinal course; (b) achievement of full symptom remission, (c) graded transfer of skills from therapist to adolescent (i.e., teaching the teen to be his or her own therapist); (d) focus on known risk factors for relapse, such as cognitive factors, family criticism, etc.; and (e) inclusion of the family as a function of need and developmental level. This article reviews the literature on risk factors for relapse and recurrence and then describes how these issues were approached in the cognitive behavioral treatment in TADS.

Integrating Cognitive Behavioral Therapy and Pharmacotherapy in the Treatment of Adolescent Depression
Golda S. Ginsburg, Johns Hopkins University School of Medicine , Anne Marie Albano, Columbia University, Robert L. Findling, University Hospitals of Cleveland and Case Western Reserve University, Christopher Kratochvil, University of Nebraska, and John Walkup, Johns Hopkins University School of Medicine

Recent evidence from the Treatment for Adolescents With Depression Study (TADS) suggests that combining cognitive behavioral and pharmacological treatments holds the most promise for ameliorating depression among adolescents. This article describes lessons learned during the TADS trial about how to integrate these two treatments in the care of adolescents with depression. Toward this end, both common and unique components of each perspectives approach to data gathering and treatment selection are presented. Procedures for changing “dosage” and adding adjunctive treatments to each of these interventions are also discussed. Finally, issues related to sequencing treatments and guidelines for sharing information across treatment providers are offered.