Coping with Depression for Adolescents (CWDA) - Detailed Report

The key components for the youth group sessions are:

• Cognitive restructuring
• Behavioral therapy
• Problem solving, communication, negotiation
• Relaxation training
• Goal setting

Parents attend a parallel, but separate, group.

• Parents are informed of the rationale and content of the skills taught to youth in their group.
• Parents are trained in problem solving and negotiation skills.
• Near the end of the groups the parents and youth groups are brought together for facilitated problem solving practice, with the assignment to continue applying these skills at home.

Coping with Depression for Adolescents (CWDA) is rated a "1 - Well-Supported by Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least two rigorous randomized controlled trials with one showing a sustained effect of at least 1 year. For more information on the rating of a "1 - Well-Supported by Research Evidence," please see the Scientific Rating Scale.

Lewinsohn, P. M., Clarke, G. N., Hops, H., & Andrews, J. (1990). Cognitive-behavioral treatment for depressed adolescents. Behavior Therapy, 21, 385-401.

Type of Study: Randomized controlled trial
Number of participants: 59
Population:

Age Range: 14-18
Race/Ethnicity: Not given
Status (e.g., foster care, CW): Recruited via letters to physicians, school counselors, and the media.

Location/Institution: Oregon
Summary: (To include comparison groups, outcomes, measures, notable limitations) Study participants were randomly assigned to Adolescent-Only group therapy, Adolescent and Parent group therapy, or to a wait-list control condition. Potential participants had been screened using DSM-III criteria for Major Depressive Disorder. At intake and post-treatment, a battery of 10 interview and self-report measures assessing depression were administered. Parents also completed the Child Behavior Checklist (CBCL) and a subset of CBCL items was selected by the authors as representative of depressive disorder. At post-intervention, participants in the treated groups showed significant improvements on depression measures. Improvements tended to favor the Adolescent and Parent treatment condition, although this reached statistical significance only for the CBCL. Improvements were maintained at 6 months; however, because wait-list participants had been offered treatment by this time, they could not be used for purposes of comparison. Limitations include lack of comparison data using the control condition, attrition from long-term follow-up and small sample sizes.
Length of post-intervention follow-up: 6 months (intervention conditions only).

Clarke, G. N., Hawkins, W., Murphy, M., Sheeber, L. B., Lewinsohn, P. M., & Seeley, J. R. (1995). Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents: A randomized trial of a group cognitive intervention. Journal of the American Academy of Child and Adolescent Psychiatry, 34(3), 312-321.

Type of Study: Randomized controlled trial
Number of participants: 150
Population:

Age Range: 15.49 years on average
Race/Ethnicity: 92% non-Hispanic White
Status (e.g., foster care, CW) 9th and 10th graders identified at at-risk for depression.

Location/Institution: Not given
Summary: (To include comparison groups, outcomes, measures, notable limitations) High school students in health classes were screened for depression using the Center for Epidemiological Studies—Depression Scale (CES-D) and those with elevated scores underwent a diagnostic interview. Students diagnosed with current depression were referred to services. The remaining at-risk group was randomly assigned to receive preventive treatment, or to care as usual. Participants were re-evaluated for depression at 6 and 12 months. Results showed that 14.5% of the intervention group and 25.7% of the care-as-usual group had incidences of affective disorders during the follow-up period according to diagnostic interview data, although scores on the CES-D, and the Hamilton Depression Rating Scale did not show a difference, possibly due their use only at isolated points in time.
Length of post-intervention follow-up: A median of 13 months.

Clarke, G. N., Rohde, P., Lewinsohn, P. M., Hops, H., & Seeley, J. R. (1999). Cognitive-behavioral treatment of adolescent depression: Efficacy of acute group treatment and booster sessions. Journal of the American Academy of Child and Adolescent Psychiatry, 38(3), 272-279.

Type of Study: Randomized controlled trial
Number of participants: 97
Population:

Age Range: 14 to 18 years
Race/Ethnicity: Not given
Status (e.g., foster care, CW): Adolescents recruited through health professionals, school counselors, and the media.

Location/Institution: Oregon
Summary: (To include comparison groups, outcomes, measures, notable limitations) Participants were required to meet criteria for a current diagnosis of major depressive disorder or dysthymia. They were randomly assigned to receive cognitive-behavioral therapy (CBT) for adolescents only, CBT for adolescents and parents, or a waitlist control condition. The participants in the intervention conditions were also independently assigned to one of three follow-up conditions for the next two years: a booster session and re-evaluation every 2 months, re-assessment every 4 months, or 2 annual re-assessments. Baseline and follow-up measures included a diagnostic interview using the Schedule for Affective Disorders and Schizophrenia for School Age Children—Epidemiologic version (K-SADS-E) and the Longitudinal Interval Follow-up Evaluation (LIFE). Adolescents also completed the Beck Depression Inventory (BDI) and parents completed the Child Behavior Checklist (CBCL). Both of the CBT treatment groups showed improvements on BDI and CBCL scores in comparison with the control group. Treated participants who were assigned to the booster session follow-up condition showed initial gains in comparison with those who were only assessed post-intervention, but the follow-up groups were equivalent by the end of the two-year period. The authors attribute this to high rates of recovery across treatment groups leading to lower motivation to attend booster sessions.
Length of post-intervention follow-up: Up to 2 years, depending on assigned condition. See summary above.

Clarke, G. N., Hornbrook, M., Lynch, R., Polen, M., Gale, J., O’Connor, E., et al. (2002). Group cognitive-behavioral treatment for depressed adolescent offspring of depressed parents in a health maintenance organization. Journal of the American Academy of Child and Adolescent Psychiatry, 41(3), 305-313.

Type of Study: Randomized controlled trial
Number of participants: 88
Population:

Age Range: 13 to 18
Race/Ethnicity: Control group: 8.5% minority; Treatment group: 10% minority.
Status (e.g., foster care, CW): Depressed children of depressed parents recruited through the families’ HMO physician.

Location/Institution: Kaiser Permanente, Portland, Oregon
Summary: (To include comparison groups, outcomes, measures, notable limitations) Adolescent children of depressed parents who were diagnosed by clinical interview as depressed themselves were randomly assigned to with group cognitive-behavioral treatment or to usual care. Baseline and follow-up assessments of adolescents used the Child Behavior Checklist (CBCL), the Schedule for Affective Disorders and Schizophrenia for School Age Children (K-SADS), and the Hamilton Depression Rating Scale (HAM-D). Youth also completed a self-report version of the Center for Epidemiological Studies—Depression Scale (CES-D). Impairment related to depression was assessed with the Global Assessment of Functioning Scale (GAF). The study found no significant differences between the group CBT treatment group and usual HMO treatments at post-treatment or at follow-up. The authors suggest that the negative results may have been due to a less regulated environment than other studies, or to stronger genetic contributions to depression in children of depressed parents. They also note that relatively few people from the initial potential pool of participants were ultimately used, which may have affected results. Finally, the HMO used in this study may typically have provided effective usual care to depressed patients.
Length of post-intervention follow-up: Up to 24 months

Clarke, G. N., Hornbrook, M., Lynch, F., Polen, M., Gale, J., Beardslee, W., et al. (2001). A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents. Archives of General Psychiatry, 58(12), 1127-1134.

Type of Study: Randomized controlled trial
Number of participants: 94
Population:

Age Range: 13 to 18
Race/Ethnicity: Control group: 8.5% minority; Treatment group: 10% minority.
Status (e.g., foster care, CW): Depressed children of depressed parents recruited through the families’ HMO physician.

Location/Institution: Oregon
Summary: (To include comparison groups, outcomes, measures, notable limitations) Note: This study uses the same initial group of families and the same assessments as Clarke et al. (2002). Adolescent children of depressed parents, who were determined to have depression scores of medium severity by clinical interview and by the Center for Epidemiological Studies—Depression Scale (CES-D) were randomly assigned to receive a 15-session version of the Coping with Depression for Adolescents course or to care as usual. Analysis showed improved scores on the CES-D and the Global Assessment of Functioning Scale (GAF) scales for the preventive treatment group in comparison with care as usual, with the comparison group being over 5 times more likely to develop depression at one year. However, the authors note that the protective effect of treatment was no longer significant at two years.
Length of post-intervention follow-up: 2 years

Rohde, P., Clarke, G. N., Mace, D. E., Jorgensen, J. S., & Seeley, J. R. (2004). An efficacy/effectiveness study of cognitive-behavioral treatment for adolescents with comorbid major depression and conduct disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 43(6), 660-668.

Type of Study: Randomized controlled trial
Number of participants: 93
Population:

Age Range: 13-17
Race/Ethnicity: 45% white
Status (e.g., foster care, CW) Non-incarcerated youth recruited through a county juvenile justice department.

Location/Institution: Lane County, Oregon
Summary: (To include comparison groups, outcomes, measures, notable limitations) Youth in the juvenile justice system meeting DSM-IV criteria for both major depressive disorder and conduct disorder were randomly assigned to receive either the Coping with Depression for Adolescents intervention or an alternative life skills/tutoring course. Outcomes were assessed using the Schedule for Affective Disorders and Schizophrenia for School Age Children—Epidemiologic version (K-SADS-E) and the Longitudinal Interval Follow-up Evaluation (LIFE). Researchers also had access to the participants’ criminal records for 12 months preceding the study and 12 months following the study. Youth in the treatment condition were significantly more likely to demonstrate recovery from depression and maintained recovery for 6 months. However, by 6 months and 12 months the comparison group had achieved similar levels of improvement. There were no treatment effects on conduct disorder. Limitations include a reliance on self-report measures and some similarities between the treatments used in the two conditions.
Length of post-intervention follow-up: 6 and 12 months

Clarke, C., Debar, L., Lynch, F., Powell, J., Gale, J., O’Connor, E., et al. (2005). A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication. Journal of the American Academy of Child and Adolescent Psychiatry, 44(9), 888-898.

Type of Study: Randomized controlled trial
Number of participants: 152
Population:

Age Range: 12-18
Race/Ethnicity: Dual treatment: 15.07 % minority; Comparison: 12.99% minority
Status (e.g., foster care, CW) Adolescents recruited from an HMO.

Location/Institution: Portland, Oregon
Summary: (To include comparison groups, outcomes, measures, notable limitations) Participants were adolescents who had been prescribed treatment for depression with a selective serotonin reuptake inhibitor (SSRI) medication. They were randomly assigned to a cognitive-behavioral plus SSRI condition or to a comparison group of treatment as usual with the SSRI only. Overall, the results did not find an advantage for the CBT plus SSRI treatment over the SSRI alone, with the exception of scores on one scale: the Short Form 12 Mental Component Scale. Participants in the treatment condition also had fewer outpatient medical visits and reduced their use of the SSRI during the course of the study. Improvement on the Center for Epidemiology Depression Scale (CES-D) was shown, but did not achieve statistical significance. The authors hypothesize that treatment as usual at this site may have been more effective than that used in previous studies with adults. The decreased use of the SSRI in the treatment group was also unplanned and may have affected the intervention’s outcome on depression.
Length of post-intervention follow-up: 1 year

Clarke, G. N., DeBar, L. L., & Lewinsohn, P. M. (2003). Cognitive behavioral group treatment for adolescent depression. In A. E. Kazdin & J. R. Weisz (Eds.), Evidence-based psychotherapies for children and adolescents. (pp. 120-134). New York: Guilford Press.

Clarke, G. N., Lewinsohn, P. M., & Hops, H. (1990). Instructor's manual for the Adolescent Coping With Depression course. Retrieved April 5, 2008 from Kaiser Permanente Center for Health Research Web site: http://www.kpchr.org/acwd/acwd.html.

Lewinsohn, P. M, Clarke, G. N., Rohde, P., Hops, H., & Seeley, J. R. (1996). A course in coping: A cognitive-behavioral approach to the treatment of adolescent depression. In E. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for children and adolescents disorders: Empirically based strategies for clinical practice. (pp. 109-135). Washington, DC: American Psychological Association Press.