Do sleep disturbances in depressed adolescents improve following psychological treatment for depression?

Background. Persistent sleep disturbances are one of the most common symptoms of Major Depressive Disorder (MDD) in adolescence. These are not typically targeted in psychological treatments and it is not known if psychological treatment for depression improves sleep. Methods. Secondary analyses were conducted using data from a large, multi-centre, randomised controlled trial (Goodyer et al., 2017b). Young people aged 12-18 years (N = 465; 75% female) met diagnostic criteria for Major Depressive Disorder, based on the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS). They were randomised to one of three psychological treatments. Sleep difficulties were assessed at baseline, post-treatment (36 weeks) and one year follow up (86 weeks) with the K-SADS, and the Mood and Feelings Questionnaire (MFQ). Results. At baseline, 92% of young people exhibited clinically significant sleep difficulties. Exploratory analyses suggest that sleep difficulties significantly decreased from baseline to end of treatment on self-report and interview-based measures, and this decrease was maintained at follow up. Reduction in sleep difficulties did not differ between the psychological treatments. Approximately, half of young people reported residual sleep difficulties at the end of treatment and at follow-up. Limitations. This paper reports secondary data analyses and findings are exploratory. Conclusions. Tentative results suggest that psychological treatments for depression reduced sleep problems for some participants. However, young people with treatment-resistant sleep problems may benefit from adjunctive sleep interventions. Future work with a range of sleep measures is needed to determine those who have residual sleep problems at the end of treatment and post-treatment follow-up

The therapeutic alliance in psychotherapy for adolescent depression: Differences between treatment types and change over time

Although the alliance is usually considered a generic factor common to all therapies, there are theoretical reasons to suspect that it may develop differently in different types of therapies. Yet, in youth psychotherapy, little is known about this issue to date. This study investigated whether the mean strength of the alliance, as well as its trajectory over time, differed between three equally effective psychological treatments for adolescent depression. Data were drawn from the IMPACT study, a randomized controlled trial comparing cognitive-behavioral therapy (CBT) and short-term psychoanalytic psychotherapy (STPP) versus a brief psychosocial intervention (BPI) in the treatment of adolescent depression. Adolescents’ (N = 338) and therapists’ (n = 159) ratings of the alliance were collected using the Working Alliance Inventory short form at 6, 12, and 36 weeks after randomization. Data were analyzed using multilevel linear models. Results showed that adolescents’ and therapists’ mean alliance ratings differed between treatment types, being highest in CBT and lowest in the STPP at all time points. Mean therapists’ alliance ratings increased slightly over time in all arms, while mean adolescents’ ratings were stable over time in CBT and BPI but slightly increased in the STPP group. These findings suggest that the mean strength of the alliance differs between treatment type, and future research is required to pinpoint what factors contribute to these differences and their relationship with treatment outcomes

The alliance–outcome association in the treatment of adolescent depression

A growing body of research has consistently demonstrated a relationship between alliance and treatment outcomes in youth psychotherapy. However, past research often suffered methodological issues that prevented detailed investigation of temporal relationships between alliance and symptomatology. The current study explored the directions of effect between alliance and outcome by examining the associations between early alliance and subsequent outcome while controlling for patients’ baseline severity and prior symptom change. It also examined potential moderators of this association. Data were drawn from the IMPACT study, a randomized controlled trial comparing cognitive-behavioural therapy (CBT) and short-term psychoanalytic psychotherapy (STPP) versus a brief psychosocial intervention (BPI) in the treatment of adolescent depression. Adolescents (N=224) and therapist (n=139) rated the alliance 6 weeks after randomization. Depression severity and overall psychopathology were assessed at baseline, 6, 12, 36, 52 and 86 weeks after randomization. Patients’ age, gender, baseline depression severity, conduct disorder symptoms and treatment type were examined as potential moderators of the alliance-outcome association. Data were analysed using multilevel models. Findings suggested that higher early alliance ratings were associated with subsequent symptom reduction, even after controlling for prior symptom change and baseline severity. There was evidence that the strength of this association was strongest in CBT patients, weaker in STPP, and statistically indistinguishable from zero in BPI. These findings suggest that early therapeutic alliance with adolescents may influence subsequent outcome independent of prior symptom change and initial severity but that the effect of the alliance on outcome might vary across treatment types

The factor structure of the Working Alliance Inventory Short-form in youth psychotherapy: an empirical investigation

Objective: The Working Alliance Inventory short form (WAI-S) is one of the most commonly used alliance measures with adolescents. Yet, its factor structure has received minimal attention in the youth alliance literature. This study investigated the factor structure of the WAI-S in psychotherapy for adolescent depression and explored its measurement invariance across time, therapeutic approaches and patients’ and therapists’ perspectives. The existence of method effects associated with the negatively worded items of the scale was also assessed. Method: The setting of this study is the IMPACT trial, a randomised controlled trial assessing the effects of three therapeutic interventions in the treatment of adolescent depression. The WAI-S was completed at 6, 12 and 36 weeks after randomisation by 338 adolescents and 159 therapists. Data were analysed using confirmatory factor analysis. Results: The hypothesised Bond-Task-Goal alliance structure was not supported and a general, one-factor model was found to be more psychometrically valid. The existence of a method effect and measurement invariance across time and treatment arms were also found. Conclusions: While the distinction between the specific alliance dimensions is conceptually and clinically interesting, at an empirical level the alliance features of the WAI-S in youth psychotherapy remain strongly intercorrelated

Quality of Artemisinin-Containing Antimalarials in Tanzania's Private Sector--Results from a Nationally Representative Outlet Survey.

Ensuring that artemisinin-containing antimalarials (ACAs) are of good quality is a key component of effective malaria treatment. There are concerns that a high proportion of ACAs are falsified or substandard, though estimates are rarely based on representative data. During a nationally representative survey in Tanzania, ACAs were purchased from private retail drug outlets, and the active pharmaceutical ingredient (API) was measured. All 1,737 ACAs contained the labeled artemisinin derivative, with 4.1% being outside the 85-115% artemisinin API range defined as acceptable quality. World Health Organization (WHO) prequalified drugs had 0.1 times the odds of being poor quality compared with non-prequalified ACAs for the artemisinin component. When partner components of combination therapies were also considered, 12.1% were outside the acceptable API range, and WHO prequalified ACAs had 0.04 times the odds of being poor quality. Although the prevalence of poor quality ACAs was lower than reported elsewhere, the minority of samples found to be substandard is a cause for concern. Improvements in quality could be achieved by increasing the predominance of WHO prequalified products in the market. Continued monitoring of quality standards is essential

Short-term psychoanalytic psychotherapy with depressed adolescents: Comparing in-session interactions in good and poor outcome cases

OBJECTIVE: To identify and describe in-session interaction patterns between psychoanalytic therapists and adolescents diagnosed with major depressive disorder, comparing good and poor outcome cases. METHOD: Audio recordings for 100 psychotherapy sessions from 10 Short-Term Psychoanalytic Psychotherapies were analysed using the Adolescent Psychotherapy Q-Set (APQ). The cases and sessions were evenly divided into two groups (poor outcome and good outcome, 5 patients and 50 sessions per group). Interaction patterns were analysed with an Exploratory Factor Analysis (EFA), while group differences were assessed through t-tests. RESULTS: The EFA revealed three factors: (1) "Open, engaged young person working collaboratively with a therapist to make sense of their experiences", (2) "Directive therapist with a young person fluctuating in emotional state and unwilling to explore", (3) "Young person expressing anger and irritation and challenging the therapist". Factor 1 was significantly more prominent in the good outcome cases, while factor 3, on the contrary, was more significantly related to the poor outcome cases. Factor 2 was equally present in both groups. CONCLUSION: Besides reinforcing to researchers and clinicians the association between a collaborative psychotherapy process with good outcomes, our findings also provide empirical data regarding the role of anger in adolescent depression and the psychotherapy process

Trajectories of change in general psychopathology levels among depressed adolescents in short-term psychotherapies

Objective: to identify and describe trajectories of change in general psychopathology (p) levels among depressed adolescents who received one of three types of short-term therapies (namely Cognitive-Behavioural Therapy, Short-Term Psychoanalytic Psychotherapy, and a Brief Psychosocial Intervention). Method: Participants were 465 adolescents with MDD who participated in an RCT comparing three treatments for depression. Narrow-band measures of depression, anxiety, obsessions-compulsions, and conduct problems were assessed at six-time points, and bifactor analysis was performed to extract p factor scores. These scores were submitted to Latent Class Growth Analyses to identify patterns of change over time. Results: Three different trajectories of change in p were identified. Two trajectories displayed reductions in p across time-points: one a rapid decrease, and the other slower but steady improvement. The third trajectory indicated a limited decrease in p up until the 12th week after baseline but no further improvement at subsequent time-points. Patients’ baseline p significantly predicted their outcome trajectories. Conclusion: Exploring change in p seemed to describe more parsimoniously the patients’ outcomes than the narrow-band assessment of depressive symptoms. Patients with high baseline p were more likely to have poorer outcomes, potentially indicating a need to develop more intensive and tailored treatments for this population

Predicting dropout in adolescents receiving therapy for depression.

OBJECTIVE: Therapy dropout is a common occurrence, especially in adolescence. This study investigated whether dropout could be predicted from a range of child, family, and treatment factors in a sample of adolescents receiving therapy for depression. METHOD: This study draws on data from 406 participants of the IMPACT study, a randomized controlled trial, investigating three types of therapy in the treatment of adolescent depression. Logistic regression was used to estimate the effects of predictors on the odds of dropout. RESULTS: Few pre-treatment predictors of dropout were found, with the only significant predictors being older age, antisocial behaviour, and lower scores of verbal intelligence. Missed sessions and poorer therapeutic alliance early in treatment also predicted dropout. Most child and family factors investigated were not significantly associated with dropout. CONCLUSIONS: There may be little about depressed adolescents' presentation prior to therapy starting that indicates their risk of dropout. However, within-treatment factors indicated that warning signs of dropout may be identifiable during the initial phase of therapy. Identifying and targeting early treatment indicators of dropout may provide possibilities for improving engagement. Clinical and methodological significance of this article: In the literature, a great deal of attention has been paid to child and family factors that predict therapy dropout, yet in this study, few pre-treatment characteristics were predictive of dropout. However, findings revealed possible warning signs of dropout in the early part of treatment, as poor therapeutic alliance and missed sessions were both found to be predictive of dropout. These findings call for therapists to be aware of such warning signs and clinical guidelines for managing cases at risk of dropout are warranted

A Complex mHealth Coaching Intervention to Prevent Overweight, Obesity, and Diabetes in High-Risk Women in Antenatal Care: Protocol for a Hybrid Type 2 Effectiveness-Implementation Study

This project is funded by the European Union Commission Horizon 2020 grant entitled "Implementation Action to Prevent Diabetes from Bump 2 Baby (IMPACT DIABETES B2B) " under grant agreement 847984, with collaborative National Health and Medical Research Council, Australia co -funding under grant number APP1194234. The project is sponsored by University College Dublin. The funders and the sponsor have no role in the design of the study, the collection, analysis, and interpretation of data, or in the writing of the manuscript or decision to publish. The contributors associated with IMPACT DIABETES B2B Consortium1 are as follows: Janine Wirth, School of Agriculture and Food Science, University College Dublin, Dublin, Ireland; Mary Codd, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland; Ricardo Segurado, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland; Jacqueline Boyle, Eastern Health Clinical School, Monash University, Melbourne, Australia; Georgia Soldartis, Monash Health, Melbourne, Australia; Alberto Puertas, School of Medicine, University of Granada, Granada, Spain; Francisca S Molina, School of Medicine, University of Granada, Granada, Spain; Maria Garcia-Ricobaraza, School of Medicine, University of Granada, Granada, Spain; Nanna Husted Jensen, Department of Public Health, Aarhus University, Aarhus, Denmarkv; Elena Rey Velasco, Liva Healthcare, Copenhagen, Denmark.Background: Women with overweight and obesity are at higher risk of developing complications in pregnancy such as gestational diabetes and longer-term chronic conditions. Research concerning health behavior change interventions during pregnancy and postpartum shows promising effects, but implementation into routine services is sparsely investigated. Most interventions focus on the antenatal or postpartum life stages, failing to meet the needs of women. IMPACT DIABETES Bump2Baby is a multicenter project across 4 high-income countries developed to test the implementation of an antenatal and postpartum evidence-based mobile health (mHealth) coaching intervention called Bump2Baby and Me (B2B&Me) designed to sit alongside usual care in the perinatal period. Objective: We aim to explore the feasibility and implementation of the B2B&Me intervention and investigate the effectiveness of this intervention in women at risk of gestational diabetes. Methods: IMPACT DIABETES Bump2Baby is a hybrid type 2 effectiveness-implementation study, which integrates an evidence-based mHealth coaching app that includes personalized health behavior change coaching provided by health care professionals alongside antenatal care from the first antenatal visit to 12 months postpartum. The mHealth app offers the possibility of synchronous calls, asynchronous contact (including coach-participant text and video messaging exchanges tailored to the participant’s needs), and ongoing access to an extensive library of bespoke intervention materials. Participants will interact asynchronously with their health coach throughout the intervention via the app. This randomized controlled trial across 4 clinical sites within Ireland, the United Kingdom, Spain, and Australia will recruit 800 women in early pregnancy to evaluate the effectiveness on postpartum weight. The Exploration, Preparation, Implementation, and Sustainment implementation framework is the theoretical underpinning of the study. The implementation evaluation will be assessed at the individual, hospital staff, and broader community levels using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Data sources for the RE-AIM evaluation will include app and platform analytics, screening and training records, participant medical records, key informant interviews, participant and partner exit interviews, cost data, study questionnaires, staff surveys, and blood sample analyses. Results: The study was approved and registered with the Australian New Zealand Clinical Trials Registry on November 19, 2020. Recruitment commenced on February 9, 2021, and data collection is ongoing. Publication of the results is expected in 2024. Conclusions: This is the first hybrid effectiveness-implementation study of an 18-month mHealth coaching intervention in at-risk women that we are aware of. As research aims to move toward real-world implementable solutions, it is critical that hybrid studies are conducted. The data from this large multicenter study will be useful in planning the potential implementation and scale-up of evidence-based perinatal health behavior change interventions.Horizon 2020 847984National Health and Medical Research Council (NHMRC) of Australia APP119423

Therapists' techniques in the treatment of adolescent depression

When comparing the relative effectiveness of different psychological treatment approaches using clinical trials, it is essential to establish fidelity to each manualized therapy, and differentiation between the treatment arms. Yet few psychological therapy trials include details about the assessment of treatment integrity and little is known about the specific techniques used by therapists, or to what degree these techniques are shared or distinct across different therapeutic approaches. The aims of this study were to (a) establish the fidelity of two established psychological therapies, cognitive- behavior therapy (CBT) and short-term psychoanalytic psychotherapy (STPP), in the treatment of adolescent depression; and (b) examine whether they were delivered with adherence to their respective treatment modalities, and if they could be differentiated from each other and from a reference treatment (a brief psychosocial intervention; BPI). The study also aimed to identify shared and distinct techniques used within and across the three treatments. Audiotapes (N = 230) of therapy sessions collected as part of a trial were blind double-rated using the Comparative Psychotherapy Process Scale (Hilsenroth, Ackerman, Blagys, Baity, & Mooney, 2003; Hilsenroth, Defife, Blake, & Cromer, 2007), which includes subscales for Cognitive-Behavioral and Psychodynamic- Interpersonal techniques. The treatments were delivered with reasonable fidelity and there was clear differentiation in the use of CBT and STPP, and between these two established psychological therapies and BPI. An item-level analysis identified techniques used across all three treatments, techniques that were shared between BPI and CBT, and techniques that were unique to CBT and STPP