Prevention Review 1

Running Head: PREVENTION OF DEPRESSIVE SYMPTOMS

PREVENTION OF DEPRESSIVE SYMPTOMS IN ADOLESCENTS: A RANDOMIZED TRIAL OF COGNITIVE-BEHAVIOURAL AND

INTERPERSONAL PREVENTION PROGRAMS – A REVIEW

Richelle Greek

Heather Gobbett

University of Calgary
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Prevention of depressive symptoms in adolescents: a randomized trial of

cognitive-behavioural and interpersonal prevention programs – A Review

(Prevention of depressive symptoms in adolescents: a randomized trial of cogntive-behavioural

and interpersonal prevention programs. Journal of Consulting and Clinical Psychology, 75(5),

693- 706 by Horowitz, Garber, Ciesla, Young and Mufson, 2007)

One of the most commonly diagnosed psychiatric disorders among school-aged youth is

depression, a serious and complex disorder that has far-reaching personal, medical and social

costs. Notably, the World Health Organization (n.d.) indicates that depression is already the

second leading cause of the global burden of disease in the age category 15-44 years for both

sexes combined. Indeed depression is stated to be “a common, persistent, and pernicious

occurrence in the lives of youth” (Jacobs, Reinecke, Gollan & Kane, 2008, p.759). Horowitz,

Garber, Ciesla, Young and Mufson (2007) note that sub-threshold depressive symptoms are of

great concern for youth because of their association with risky behaviour. Additionally, these

symptoms represent significant risk factors for the subsequent onset of depressive disorders

(Clarke et al. (1995) as cited in Horowitz et al. (2007). The authors further assert that the

prevention of depression symptoms are of great importance, and therefore the target

skill/dependent variable they identified was the prevention of depressive symptoms. They used

three groups of students as the independent variables that they manipulated in order to obtain the

overall result of the study, which was the prevention of depressive symptoms. The purpose of

this paper is to review the study completed by Horowitz, et al. (2007) that compared the relative

efficacy of two depression prevention programs to each other, and to a no-intervention control

group.

Intervention
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The participants worked in small groups for eight 90-minute weekly sessions during their

wellness classes (Horowitz et al., 2007). The groups were exposed to three separate intervention

programs: 1) Coping with stress course based on a cognitive-behavioural (CB) (; 2) Interpersonal

psychotherapy-adolescent skills training program (IPT-AST); and 3) Non-intervention control

group. The Coping with Stress Course (CWS) developed by Clarke, Lewinsohn, and Hops in

1995, targets adolescents at risk for depression who are experiencing elevated depressive

symptoms, or "demoralization." The general approach of the CWS was modified from cognitive

therapy for depressed adults, developed by Beck and colleagues (Beck, Rush, Shaw, & Emery,

1979) and Ellis (Ellis & Harper, 1961). Where as IPT-AST was developed by Klerman and

Wiessman in 1984 and largely stems from the interpersonal psychoanalysis work of Sullivan

(Rioch, 1985). However it also has historical roots with Meyer’s theory, Bowlby and attachment

theory, psychodynamic psychotherapy and contemporary CB approaches (Rioch).

The theoretical background of CWS is that teaching adolescents new coping strategies

and strengthening their current coping skills provide them with some measure of "immunity" or

resistance against the development of mood disorders later in life. The aim of CWS is to

enhance at-risk adolescents' resilience in order to counteract their vulnerability to depression and

other mood disorders (Horowitz et al., 2007). The program involved cognitive-restructuring

techniques in which participants learned to identify and challenge negative or irrational thoughts.

The goal of the program was that the cognitive-restructuring would help adolescents deal with

stress and therefore provide them with the skills to prevent future occurrences of depression

(Horowitz et al.).

The aim of the IPT-ASY program was to also target adolescents who were experiencing

subclinical symptoms of depression (Horowitz et al., 2007). The program involved teaching
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communication and social skills necessary to develop and maintain positive relationships. The

goal of the program was that by teaching skills in the areas of interpersonal role transitions,

disputes and deficits, adolescents would develop the skills needed to maintain healthy

relationships in the future and therefore decrease future occurrences of depression (Horowitz et

al.).

The aim of the non-intervention was to provide a control group. The students in this

group were presented with the regular wellness curriculum

Strengths and Limitations of the Method and Design

Participant Demographics/research Design

Strengths.

The study had a fairly good sample size of 308 and the study demographics included

representation from diverse cultural groups, as well as a good male and female mix.

The design of the research included a six-month follow up of skills, it used randomization of the

participants to one of three groups, and efforts were made to avoid cross-contamination of

strategies. Participants were monitored by senior level clinicians who supervised the therapists

so as to consider participant safety. Additionally, school counsellors were informed about the

project and were available for consultation and referrals for any student in need of more

immediate attention

Limitations.

The research design allowed only for 15 participants in each of the CB & IPT-AST

sessions, meaning that more students were delegated to the control group, which seemed

unbalanced. Therefore, the CB group had 112 participants; the IPT-AST group had 99

participants; and the no-intervention control group had 169 participants.

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Data Collection Procedures & outcome measures

Strengths.

The assessment measures had good reliability, validity and internal consistency and were

significantly correlated. The measures used were: 1) The Children’s Depression Inventory

(CDS), which had good reliability and validity with children and adolescents and internal

consistency of CDI at baseline was .89; 2) The Center for Epidemiological Studies Depression

Scale (CES-D), which had good internal consistency, reliability and validity.

Another strength that was within the research design, possible mediators and moderators

were examined. The moderators included an examination of the initial level of depressive

symptoms, gender, sociotropy and achievement orientation; and the mediators examined

involved looking at attributional style, coping and perceived quality of the parent-child

relationship.

Limitations.

Though the CDS was developed in 1992, the CES-D was developed in the 1970’s.

Therefore, despite efforts made to find a representational group for the sample; the instrument

used was normed on outdated samples.

Intervention Integrity checks

Strengths.

Group leaders for this study were master’s-level clinical psychology graduate students or

recent clinical psychology PhD’s, all of who received prior therapy training. The co-leaders

assigned to each group were clinical graduate students or undergraduate honors students

Treatment integrity was planned for out ahead of time and maintained throughout intervention

using:
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• Detailed treatment manuals used for both CB and IPT-AST

• Training workshops before beginning the study for group leaders and co-leaders

• Weekly supervision meetings were held throughout the intervention with clinical experts

• Careful review of each session with plans for the next session drawn up based on the

manuals.

Limitations.

Though the control groups had leaders and co-leaders; the no-intervention control group

was lead by teachers rather than outside adults, which may have limited the extent to which

students felt comfortable discussing personal issues. Additionally, independent observations

of therapists were not completed, so absolute fidelity to intervention protocols cannot be

assured. It is important to note that the school did not allow the taping of group sessions,

which would have been helpful for review for fidelity.

Follow-up Data

Strength.

One of the strengths of the study is that it sought to measure the effects of the program

over a 6-month period.

Limitation.

The authors indicate that one of the limitations of this study is that the participants in

each of the intervention groups may have thought they were expected to report less depressive

symptoms because of what the authors call a demand characteristic (Horowitz et al., 2007). In

other words, their decrease in scores were perhaps simply because of their expectation that they

should feel less depressed rather than the treatment being effective. Horowitz and his colleagues
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further note that the increase in depressive symptoms that were reported for the non intervention

group could not be accounted for by this type of expectancy.

Though there was an increase in depressive symptoms in the no-intervention control

group at the post-intervention assessment, interestingly, it was followed by a drop in symptoms

in the 6-month follow-up evaluation. Upon analysis of the attrition rates, the authors found that

those with the higher levels of depressive symptoms at post-intervention (among the control

group only) were significantly less likely to have completed the follow-up assessment.

Therefore, they may have lost the very people who would have been most likely to show

continued elevations in depression scores.

Outcomes

The purpose of both CB and IPT-AST programs were designed to decrease future

occurrences of depression in adolescents. The results from this study indicated that students who

participated in both the CB and the IPT-AST programs showed significant decreases in their

depressive symptoms, specifically those in the high-risk sub-group, however the results were

short-term (Horowitz et al., 2007). When compared to each other, the two active intervention

programs did not show significant differences, suggesting that one program was not better than

the other (Horowitz et al.). Overall, Horowitz and his colleagues found that the positive effects

of the programs were not maintained over time, therefore suggesting that they are not effective in

treating future occurrences of depression. They did however suggest that a focus should be on

obtaining methods that help to maintain the positive short-term effects that were created from

both the CB and the IPT_AST programs (Horowitz et al.).

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Implications for Research

This study did not include the use of diagnostic interviews, and therefore the information is

based solely on depressive symptoms. One cannot assume that a preventative effect on

symptoms would necessarily affect a diagnosis of adolescent depression. Therefore, future

research on prevention studies should be geared toward measuring both depressive symptoms

and diagnosis.

The sample size was relatively small for a universal intervention study. Universal prevention

studies typically require very large sample sizes to show an effect. Therefore, despite small

effects were detected; this may be an important aspect to future research studies of this kind.

More research is needed so as to understand the efficacy of this research to a full high school

population, as well as to a more ethnically diverse sample.

Future studies should examine how other potential predictors and moderators affect

depressive symptoms in adolescents, such as parental psychopathology and child co-morbidity.

Within this study, efforts were made to consider the moderating effects of both sociotropy and

achievement orientation for all participants. The fact that Horowitz et al. (2007) made efforts to

consider these moderators was identified as a strength of the study. The authors also suggest that

because higher baseline sociotropy moderated the IPT-AST program in particular (predicting

lower levels of depressive symptoms), future studies of programs that use this intervention

should study this characteristic in more detail. The authors suggested breaking it down into its

various components and considering how each might contribute to overall depressive symptoms

(Horowitz).

Lastly, the authors suggest that an important area for future research is how to design

prevention programs that have more enduring effects.

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Implications for Practice

The implications for practice with respect to the CB and IPT-AST programs and their

affect on depression are promising because both programs produced an immediate reduction in

depression symptoms and demonstrated an improvement in overall functioning. Because both

programs produced similar results, the authors suggested that multiple approaches might be able

to prevent depressive symptoms in adolescents, rather than just focusing on one program

(Horowitz et al., 2007).

However, Horowitz and his colleagues (2007) also cautioned that any intervention is

probably better than doing nothing, regardless of the content of the program. Another limitation

of both CB and IPT-AST is that their positive results are not consistent beyond the 6-month

follow-up, suggesting that the preventative effects of the programs in their current format are

limited.

References

Beck, A., Rush, A., Shaw, B., and Emery, G. (1979). Cognitive therapy of depression. New

York: Guilford Press.

Clarke, G., Lewinsohn, P., and Hops H. (1990). Adolescent Coping with Depression Course,

Eugene, Oreg.: Castalia Press. Retrieved March 16, 2010 from

http://www.promisingpractices.net/program.asp?programid=151.

Ellis, A., and Harper, R. (1961). A guide to rational living. Hollywood California: Wilshire

Book.
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Horowitz, L., Ciesla, A., Garber, J., Young, J. and Muson, L. (2007). Prevention of depressive

symptoms in adolescents: a randomized trial of cogntive-behavioural and interpersonal

prevention programs. Journal of Consulting and Clinical Psychology, 75(5), 693- 706.

Jacobs, R.H., Reincke, M.A., Gollan, J.K. & Kane, P. (2008). Empirical evidence of cognitive

vulnerability for depression among children and adolescents: A cognitive science and

developmental perspective. Clinical Psychology Review, 28, 759-782.

Rioch, D. (1985). Recollections of Harry Stack Sullivan and of the development of his

interpersonal psychiatry. Psychiatry, 48(2): 141-58.

World Health Organization. (n.d.) Mental health: Depression. Retrieved February 25, 2010 from

http://www.who.int/mental_health/management/depression/definition/en/