Cari McCarty, Ph.D.Cari McCarty, Ph.D.Research Associate Research Associate Professor, PediatricsProfessor, PediatricsDirector of Research, Director of Research, Adolescent MedicineAdolescent Medicine

School-Based Interventions for Childhoodand Adolescent Depression

Prevalence of DepressionPrevalence of Depression

Lifetime prevalence of mood disorders is Lifetime prevalence of mood disorders is 20.8% 20.8% (National Comorbidity Survey Replication)(National Comorbidity Survey Replication)

Hazard rates highest in mid to late Hazard rates highest in mid to late adolescence adolescence (Burke et al., 1990)(Burke et al., 1990)

MDD affects an estimated 6 million children MDD affects an estimated 6 million children and adolescents and adolescents (NIMH, 2002)(NIMH, 2002)

Burden of depressionBurden of depression

Depression now considered a “chronic Depression now considered a “chronic disease”disease”

Even subclinical levels of depressive Even subclinical levels of depressive symptoms interfere substantially with symptoms interfere substantially with adjustmentadjustment

Leading cause of disability worldwideLeading cause of disability worldwide Risk for suicide, other psychiatric disorders, Risk for suicide, other psychiatric disorders,

substance usesubstance use

Media Attention to Suicide

Recent high profile media cases have drawn increased attention to youth suicide (and bullying)

Research Pathway

Developmentand Context

Role of family, peers, school

Youth Depression

Understanding Youth Depression

Parental Depression

Parental Social Support

McCarty et al., 2005; Weisz, Southam-Gerow & McCarty, 2001; McCarty et al., 2007; McCarty et al., 2006; McCarty et al., 2009

Thinking Styles

Stressful events

Low caregiver support School Failure

*girls!

Youth Depression

Research Pathway

Developmentand Context

InterventionEfforts

Role of family, peers, school

Benefit of cognitive-behavioral skills

Youth Depression

Examining Treatment Effects

Family risk factors important (parental depression, family climate, parental cognitive style)

But, families have mostly NOT been incorporated into clinical treatment research with depressed adolescents (32% of studies)

Sander & McCarty (2005). Youth depression in the family context: Familial risk factors and models of treatment. Clinical Child and Family Psychology Review, 8, 203-217.

1998

Psychotherapy for Youth Depression: Evidence of Treatment Effects

Reinecke, Ryan & DuBois

6 CBT Trials

ES = 1.02

1999 2002

Lewinsohn & Clarke

12 Trials

ES = 1.27

Michael & Crowley

14 Trials

ES = .72

Weisz, McCarty & Valeri

35 Trials

ES = .34

Weisz, McCarty, Valeri, 2006. Psych. Bull. 132:132-149

more modest

Component Analysis of EBTs

Goal-settingSelf-monitoringAttention to relationshipsCognitive restructuringProblem-solvingBehavioral activation Child psychoeducationCommunication training

Youth with Suicidal Ideation in Primary Care

Have high levels of functional impairment (84% “definitely impaired”)

Higher levels of comorbidity (externalizing, substance use)

Only 26% received any mental health care in the previous year, including 13% outpatient mental health, 7% antidepressants, and 12% outside counseling/treatment

McCarty et al. (in press). Adolescents with suicidal ideation: Health care use and functioning. Academic Pediatrics.

Intervention Model: Positive Thoughts Intervention Model: Positive Thoughts & Actions& Actions

Individualvulnerabilities

Depression

Interpersonal

Behavioral

Cognitive

CHILDInterpersonal Skills

BehavioralActivation

Cog. RestructuringEmotion Regulation

Problem-Solving

Parentsand

FamilySchool Relationships

Salient Contextual Factors

PARENT Emotion RegulationEmpathy for TeenCommunication

Family

Why intervene in schools?

SEAL (Social, emotional, and academic learning) perspective

Broad reach of target population More likely to reach underserved youth Mental health service accessibility is poor in

many communities Potentially less stigma

TARGET AREASTARGET AREAS

Learning Learning GradesGrades Study Skills—Organization & Time ManagementStudy Skills—Organization & Time Management HomeworkHomework

RelationshipsRelationships FamilyFamily FriendsFriends School & CommunitySchool & Community

Healthy Mind and BodyHealthy Mind and Body Stress & MoodsStress & Moods SleepSleep NutritionNutrition ExerciseExercise

Goals of the Parent ComponentGoals of the Parent Component

Engaging parents in the intervention Engaging parents in the intervention processprocess

Providing parents a common language Providing parents a common language and understanding of the core skills and understanding of the core skills

Fostering a better parent-child relationship Fostering a better parent-child relationship

Raising parent awareness of students’ Raising parent awareness of students’ goals and progress goals and progress

Pilot Testing of InterventionPilot Testing of Intervention

2005-2007 School Years 2005-2007 School Years

– Eckstein, Hamilton, McClure, Whitman Middle Eckstein, Hamilton, McClure, Whitman Middle SchoolsSchools

Screened 684 youth for depression; 67 Screened 684 youth for depression; 67 included in intervention studyincluded in intervention study

Gains in skills (coping, cognition, Gains in skills (coping, cognition, communication)communication)

Middle School Matters StudyMiddle School Matters Study

Randomized to the previously developed Randomized to the previously developed program (Positive Thoughts & Actions) or brief program (Positive Thoughts & Actions) or brief intervention (MAPS)intervention (MAPS)

Screened for Depressive

Symptoms using MFQ

N=1190

Eligible based on inclusion &

exclusion criteria

N=242

Enrolled in Prevention Trial

N=123

Positive Thoughts & ActionsPositive Thoughts & Actions

11 groups, led by 6 different leaders in 4 11 groups, led by 6 different leaders in 4 different schoolsdifferent schools

Alderwood Middle School: Alderwood Middle School: After-School ModelAfter-School Model

MAPS MAPS

1-2 hour individual interview, computer-assisted, 1-2 hour individual interview, computer-assisted, elements of assessment, empathy, motivational elements of assessment, empathy, motivational interviewing, social support, and brief problem-interviewing, social support, and brief problem-solving solving

Middle School Matters - Intervention

REACHING YOUR GOALS

GOALSDeciding what we want to and who we want to be

 

STEPSBreaking goals into smaller steps takes us closer to our goals

To be effective, steps and goals need to be:

Realistic

ControllableWithin reachNot too easy

Specific

ClearMeasurableHas a timeline

Desirable

Something valuedA healthy choiceHelpful to all involved

PLANNING FOR TRIGGERS AND ROADBLOCKS

Hit your roadblocks and triggers head on! How? Make a plan that includes both thoughts and actions:

TRIGGERS Set us off course from the path to our goals

ROADBLOCKS

Get in the way of reaching our goals

First identify the thoughts and roadblocks that keep you from being successful.  Then make a plan for what you can tell yourself and what you can do to stay on course.

 

THOUGHTS— What we tell ourselves to stay on track

ACTIONS— What we do to stay on track

MEETINGS WITH PARENTS

Meeting 1Getting to Know Each OtherHome visit with parent and student Meeting 2Understanding Your Child’s Emotional DevelopmentGroup parent meeting Meeting 3Communicating with Your 7th Grader Group parent meeting Meeting 4Staying Successful Home visit with parent and student 

Ongoing Research Questions

Who is most at risk of developing depression?

What are the effects of skills-based group intervention vs. individual support?

Are effects specific to depression?

What components of the prevention are most important?

For whom does it work?

Summary Points

There are many common components of effective treatments for youth depression

Interventions in non-specialty settings (schools & primary care) may help provide access & reduce stigma

Benefits and barriers to in-school vs. after-school models must be weighed

Acknowledgements

Postdocs FundingHeather Violette, Ph.D. National Institute of Mental HealthBrian Wymbs, Ph.D.

Interventionists Research AssociatesRick Cruz Leticia HollemanMarissa Corona Mary Casey-GoldsteinAlyson Barry Elizabeth McCauleyJessie Waimau-AriotaUrsala SchwennSonja KottkeMarjorie NewmanCezanne HardyLisa Gloria-WallaceBecky Parrish