Treatment of Depression in Adolescents and Adults

Clinician's Guide to Evidence-Based Practice

David W. Springer, Allen Rubin, Christopher G. Beevers, David W. Springer, Allen Rubin, Christopher G. Beevers

• Publisher: Wiley
• Year: 2011
• ISBN:
  9781118015407
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Praise for Treatment of Depression in Adolescents and Adults

"This outstanding book, written for clinicians, provides a fascinating examination of leading depression treatments supported by cutting-edge scientific evidence. The editors have assembled an impressive list of authors who expertly describe each intervention at a level of detail rarely seen in other books. Clinicians looking for guidance on how to implement evidence-based treatments for depression will find this book indispensable."
— Aaron T. Beck, MD, Professor of Psychiatry, University of Pennsylvania President Emeritus, Beck Institute for Cognitive Therapy and Research

"This is a much-needed book that can increase accessibility of empirically based treatments to practicing clinicians. The chapters are informative, readable, and peppered with clinical examples that bring the treatments to life. This book is an essential bridge to enhance dissemination of some of our most potent treatments for depression to those on the front lines of treatment delivery."
— Adele M. Hayes, PhD, Associate Professor of Psychology, University of Delaware

Evidence-based interventions for treating depression in adolescents and adults

Part of the Clinician's Guide to Evidence-Based Practice Series, Treatment of Depression in Adolescents and Adults provides busy mental health practitioners with detailed, step-by-step guidance for implementing clinical interventions that are supported by the latest scientific evidence.

This thorough, yet practical volume draws on a roster of experts and researchers in the field who have assembled state-of-the-art knowledge into this well-rounded guide. Each chapter serves as a practitioner-focused how-to reference and covers interventions that have the best empirical support for the treatment of depression, including:

• Cognitive Behavior Therapy
  
  

• Behavioral Activation
  
  

• Cognitive Behavioral Analysis System of Psychotherapy for Chronic Depression
  
  

Easy to use and accessible in tone, Treatment of Depression in Adolescents and Adults is indispensable for practitioners who would like to implement evidence-based, culturally competent, effective interventions in their care of clients struggling with depression.

Chapter 1

Introduction: Evidence-Based Practice for Major Depressive Disorder

Christopher G. Beevers

Major depressive disorder (MDD) is a common, recurrent, and impairing condition that predicts future suicide attempts, interpersonal problems, unemployment, substance abuse, and delinquency (Kessler & Walters, 1998). According to the World Health Organization, 121 million people are currently suffering from MDD and it is a leading cause of disability worldwide among people 5 years old and older. The annual economic cost of MDD in the United States alone is staggering—$70 billion in medical expenditures, lost productivity, and other costs (Greenberg, Stiglin, Finkelstein, & Berndt, 1993; Philip, Gregory, & Ronald, 2003). Further, MDD accounts for more than two-thirds of the 30,000 reported suicides each year (Beautrais et al., 1996). Given this enormous impact at societal and individual levels, there is a clear need to develop and disseminate efficacious treatments for this disorder.

Fortunately, a number of empirically supported interventions are available for depressed adolescents and adults. In-depth descriptions of some of the most established treatments are included in this book—Cognitive Behavioral Therapy (CBT), Behavioral Activation (BA), and Cognitive Behavioral Analysis and System of Psychotherapy (CBASP). We include chapters on the application of CBT with adolescents and adults. Further, we include a chapter on how to apply these interventions to diverse populations, such as people with diverse racial and ethnic backgrounds. Each chapter provides a detailed, clinician-focused guide on how to implement these interventions. A review of the research base for each intervention is included in Appendix A.

Prior to reviewing the contents of each chapter in this introduction, we first provide an overview of how depression is defined, a brief description of its epidemiology, and then how depression is typically assessed. We then review other treatments (both pharmacological and nonpharmacological) that have empirical support for the treatment of depression but are not included in this volume. We finish with a brief overview of this volume's chapters.

Major Depressive Disorder: Definition, Epidemiology, and Course

The Diagnostic and Statistical Manual of Mental Disorders (4th edition—DSM-IV) defines Major Depressive Disorder (MDD) as the presence of five (or more) of the following nine symptoms during the same 2-week period:

1. Depressed mood most of the day, nearly every day.

2. Markedly diminished interest or pleasure in almost all activities (anhedonia).

3. Significant weight loss/gain or decrease/increase in appetite.

4. Insomnia or hypersomnia.

5. Psychomotor retardation or agitation.

6. Fatigue or loss of energy.

7. Feelings of worthlessness (or excessive or inappropriate guilt).

8. Diminished ability to concentrate or make decisions.

9. Recurrent thoughts of death.

Symptoms must be present most of the day, nearly every day, and should represent a significant change from previous functioning. Importantly, one of the nine symptoms has to be either depressed mood or anhedonia. In adolescents or children, irritable mood can be substituted for depressed mood. Less than 5% of depressed adolescents typically endorse anhedonia (Rohde, Beevers, Stice, & O'Neil, 2009), so depressed or irritable mood tends to be the hallmark symptom of adolecent depression. Significant weight loss or gain is typically defined as 5% or more change in body weight in a month when not dieting. These symptoms must cause significant distress or impairment in social, occupational, or other important areas of functioning. Finally, these symptoms should not be attributable to substances (e.g., drug abuse, medication changes), medical conditions (e.g., hypothyroidism), or the death of a loved one.

Recent epidemiological research indicates that the 12-month prevalence rates for MDD was 6.6% (95% CI, 5.9%–7.3%) among adults residing in the United States. Lifetime prevalence for MDD was 16.2% (95% CI, 15.1%–17.3%). Put differently, approximately 13.5 million adults experienced MDD in the past year, and 34 million adults have experienced MDD at some point in their lives. Approximately 51% who experienced MDD in the past year received health-care treatment for MDD, although treatment was considered adequate in only 21% of the cases (Kessler, Berglund et al., 2003). Thus, MDD is a prevalent and pervasive mental health disorder that is unfortunately not treated optimally in the United States.

Obtaining adequate treatment is important, as the course of MDD tends to be relatively prolonged. One of the largest studies of MDD recovery among individuals seeking treatment found that 50% of the sample recovered from MDD by 6 months, 70% within 12 months, and 81% within 24 months. Approximately 17% did not recover within the 5-year follow-up period (Keller et al., 1992). The first 6 months represents a particularly important time period for MDD recovery, as the rate of MDD recovery significantly slows after 6 months. Similarly, Kessler (2009) writes that time to recovery of MDD in nontreatment-seeking populations “appears to be highly variable, although epidemiological evidence is slim” (p. 29). One study found that 40% had recovered from MDD by 5 weeks and 90% had recovered within 12 months (McLeod, Kessler, & Landis, 1992). Another study reported that mean time to recovery was 4 months and that approximately 90% had recovered by 12 months (Kendler, Walters, & Kessler, 1997). Taken together, these data suggest that most participants from a community sample recover from MDD within 12 months.

Risk for MDD is especially pronounced during adolescence (Blazer, Kessler, McGonagle, & Swartz, 1994; Lewinsohn, Hops, Roberts, & Seeley, 1993). Prevalence rates range from 10% to 18.5% (Kessler & Walters, 1998). This is especially true for adolescent girls, who are approximately twice as likely to experience depression as adolescent boys (Hankin et al., 1998). Longitudinal studies show that increases in MDD prevalence for women occur at approximately 15 years of age and persist into adulthood (Hankin et al., 1998; Kessler, Berglund et al., 2003; Lewinsohn, Hops et al., 1993; Nolen Hoeksema & Girgus, 1994; Prinstein, Borelli, Cheah, Simon, & Aikins, 2005).

Treatment for adolescents with subthreshold symptoms of MDD may be particularly important, as adolescents with elevated symptoms (but who do not meet criteria for MDD) are at high risk for future onset of MDD. Lewinsohn, Roberts, and colleagues et al. (1994) found that elevated depressive symptoms was one of the most potent risk factors for future MDD onset over the subsequent year out of dozens of risk factors. Seeley, Stice, and Rohde (2009) recently examined a broad array of putative risk factors (e.g., parental support, negative life events, depressive and bulimic symptoms, substance use, attributional style, body dissatisfaction, physical activity, social adjustment, delinquency) for MDD onset in a longitudinal study of 496 adolescent girls 15 to 18 years old. Among 18 variables tested, the strongest predictor of future MDD onset was subthreshold depressive symptoms. Girls with elevated symptoms were at approximately five times greater risk for future MDD onset than girls with low symptoms (28% versus 6%).

Unfortunately, treatment utilization among depressed adolescents is also lacking. Approximately 60% of adolescent with MDD receive treatment (Lewinsohn, Rohde, & Seeley, 1998). Individual outpatient psychotherapy administered by a mental health provider is the most common form of treatment. Adolescents with more severe depression, a comorbid condition, a past history of MDD, a history of suicidal attempts, and academic problems, and females were more likely to receive treatment. However, those who had received treatment were not less likely to relapse into another episode of depression during young adulthood (Lewinsohn et al., 1998). This suggests that the typical treatment received by depressed adolescents may not have been effective at changing the underlying cause of depression onset.

Assessment of Depression

A number of questionnaires and diagnostic interviews are available to assess depression symptoms and MDD in adolescents and adults. We review these assessments for adults and adolescents separately.

Adults

The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) diagnoses is the most common method for determining whether an adult meets criteria for MDD (and many other DSM-IV diagnoses). This is a semistructured interview that inquires about current and past symptoms. Length of an SCID interview can be quite variable—individuals with no past or current symptoms can complete the interview in about 15 minutes. Individuals with more complex symptom presentations can take several hours to complete a SCID interview. A typical SCID interview takes about 90 minutes. With adequate interviewer training, the SCID interview has excellent reliability and has been used extensively in depression research. Determining the validity of the SCID is more complex, as it is typically used as the gold standard to determine a diagnosis. Nevertheless, there is ample evidence that an SCID diagnosis converges with diagnoses derived from other diagnostic interviews (First, Spitzer, Williams, & Gibbon, 1995). For more detail on the SCID, see http://www.scid4.org/.

The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) is a psychiatric diagnostic interview designed to be administered by nonclinicians. The CIDI assesses for most Axis I disorders (including MDD) as defined by the DSM-IV and the ICD-10. It also assesses service use, use of medications, and barriers to treatment. There is substantial evidence for the reliability and validity of the CIDI. It has been translated into numerous languages and is typically used in large-scale epidemiological studies (Kessler, Berglund et al., 2003). For more information, see http://www.hcp.med.harvard.edu/wmhcidi/index.php.

The Mini-International Neuropsychiatric Interview (MINI) is another diagnostic interview that was developed jointly by psychiatrists and clinicians in the United States and Europe (Sheehan et al., 1998). It is much briefer than the SCID and CIDI, with an administration time of approximately 20 minutes. It assesses 15 of the most common DSM-IV Axis I disorders, including current and past history of MDD. Due to its brevity, it is often used as a screening interview that is subsequently confirmed with a subsequent in-depth diagnostic interview. It also has excellent reliability and validity (Sheehan et al., 1997). For more information, see https://www.medical-outcomes.com/index.php.

A number of self-report and interviewer-based assessments of depression severity are also available. The most commonly used interview-based depression severity assessments with adults include the Hamilton Rating Scale for Depression (HAM-D) and the Inventory of Depressive Symptomatology (IDS). The 17-item HAM-D was originally developed in 1960 and subsequently revised a number of times (Hamilton, 1960). It has been used primarily in antidepressant medication trials. The HAM-D has been criticized on the basis that it has poor content validity (may overemphasize somatic symptoms, which are especially responsive to antidepressant medication treatment), having a nonoptimal response format for many items, several items do not appear to discriminate people at high and low ends of the depression continuum, and other psychometric flaws (Bagby, Ryder, Schuller, & Marshall, 2004).

As a result, a newer interview-based assessment of depression severity, the IDS, is gaining popularity (Rush, Thomas, & Paul-Egbert, 2000). The 30-item IDS (and the 16-item Quick IDS) assess the severity of depression symptoms in the past seven days. The items measure all DSM-IV symptoms of MDD, although a total score is typically used to assess depression severity. There is much evidence to suggest that the IDS has good psychometric properties, including good internal reliability, test-retest reliability and adequate content, criterion, and construct validity (e.g., Rush et al., 2003). The IDS has been translated into more than 20 different languages and is used widely in medical research. Items can be added to the IDS to facilitate computation of the HAM-D total score within the IDS interview. Further, there is also a self-report version of the IDS to be completed by patients. The IDS (and its corresponding short and self-report versions) are available for download at http://www.ids-qids.org/index.html.

There are also a number of other excellent self-report assessments of depression severity. The Beck Depression Inventory-II (BDI-II) is a 21-item self-report questionnaire that is among the most commonly used instrument to assess depression severity (Beck, Steer, & Brown, 1996). It is often used in research involving psychological treatments. The BDI-II has demonstrated adequate internal consistency, test-retest reliability, and construct validity (Dozois, Dobson, & Ahnberg, 1998). A score of 12 or less is considered nondepressed, whereas a score of 20 or greater typically indicates moderate or greater depression severity (Dozois et al., 1998). To obtain the BDI-II, see http://www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015–8018–370&Mode=summary.

Alternatively, the Center for Epidemiologic Studies—Depression (CESD) is another common assessment of depression severity (Radloff, 1977). The CESD was developed to be a brief self-report scale designed to measure depression severity in the general (nonpsychiatric) population. It has 16 items that measure the severity of depression symptoms in the past week. It has very good internal consistency and test-retest reliability. Validity was established by correlating the CESD with other depression inventories and clinical ratings of depression (Radloff, 1977). A 10-item version has also been developed (Irwin, Artin, & Oxman, 1999). It is a widely used depression scale, particularly when the majority of the sample is expected to be currently depressed.

Adolescents

The Kiddie-Sads-Present and Lifetime version (K-SADS-PL) is a semistructured diagnostic interview designed to assess severity ratings of symptomatology as well as current and past episodes of psychopathology in adolescents according to DSM-IV criteria (Kaufman et al., 1997). The full interview assesses more than 35 mental health diagnoses, including MDD. The K-SADS-PL is administered to parents and the adolescent. Other sources of information may also be incorporated (e.g., school reports) into a summary rating. It is typically recommended to start the interview with the adolescent first, followed by the parents. Clinical judgment is required when there are discrepancies in the content of the reports from adolescents and parents. The K-SADS has been found to have acceptable test-retest reliability (k's = .60–1.00), inter-rater reliability (k's = .60 –1.00), and i...

Table of contents

• Cover
• Clinician's Guide to Evidence-Based Practice Series
• Title Page
• Copyright
• Series Introduction
• Acknowledgments
• About the Editors
• About the Contributors
• Chapter 1: Introduction: Evidence-Based Practice for Major Depressive Disorder
• Chapter 2: Cognitive Behavior Therapy Treatment for Adolescents
• Chapter 3: Cognitive Behavior Therapy for Depressed Adults
• Chapter 4: Behavioral Activation for Depression
• Chapter 5: Cognitive Behavioral Analysis System of Psychotherapy for Chronic Depression
• Chapter 6: One Size Does Not Fit All: Cultural Considerations in Evidence-Based Practice for Depression
• Afterword
• Appendix A: Research Providing the Evidence Base for the Interventions in This Volume
• Appendix B: The Evidence-Based Practice Process
• Professional Resources and Recommended Reading
• Author Index
• Subject Index
• Study Package Continuing Education Credit Information