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

Antioxidant activity and effects of Kenyan Tea (Camellia sinensis) on the liver function and serum biochemistry in male Wistar rats

Background: Tea is a beverage that is most widely consumed worldwide. Studies have shown that oral consumption of tea has health benefits however, there is paucity of data in Kenya detailing the biochemical effects of tea in the liver and elucidation of its mechanism of action.Methods: The polyphenol composition and antioxidant capacity of tea were determined by HPLC and the Folins Ciocalteu spectrophotometric methods. Metal levels were determined using flame Atomic Absorption Spectrometer (AAS). Aqueous black and green tea extracts were administered to the rats at dosages of 400mg/kg b.w.t. The effect of tea on total blood proteins, Albumin, ZHX1, TBARS, AST, ALP and ALT were determined by spectrophotometric methods. The body weight of each rat was also determined at one week interval.Results: Total Polyphenols (TP), Total Catechins (TC) and Antioxidant Activity (AA) between the black and green teas were significantly (P0.05) effect on TP, ALB, ALT, AST, ALP, MDA and ZHX1 in the test animals compared with the controls. This data indicates that green tea is rich in catechins while black tea being rich in Theaflavins (TFs) and Thearubigins (TRs). Both tea products possess essential and non-essential metals well within the maximum permissible concentrations.Conclusions: Findings from this study indicate both green and black tea aqueous extracts have polyphenols and high antioxidant activity. Administration of the aqueous tea extracts have no toxicological effect on the liver.

Toward precision therapeutics: general and specific factors differentiate symptom change in depressed adolescents.

BACKGROUND: The longitudinal course of multiple symptom domains in adolescents treated for major depression is not known. Revealing the temporal course of general and specific psychopathology factors, including potential differences between psychotherapies, may aid therapeutic decision-making. METHODS: Participants were adolescents with major depressive disorder (aged 11-17; 75% female; N = 465) who were part of the IMPACT trial, a randomized controlled trial comparing cognitive behavioral therapy, short-term psychoanalytic psychotherapy, and brief psychosocial intervention. Self-reported symptoms at baseline and 6, 12, 36, 52, and 86 weeks postrandomization were analyzed with bifactor modeling. RESULTS: General psychopathology factor scores decreased across treatment and one-year follow-up. Specific melancholic features and depressive cognitions factors decreased from baseline to 6 weeks. Conduct problems decreased across treatment and follow-up. Anxiety increased by 6 weeks and then reverted to baseline levels. Obsessions-compulsions did not change. Changes in general and specific factors were not significantly different between the three psychotherapies during treatment. During follow-up, however, conduct problems decreased more in brief psychosocial intervention versus cognitive behavioral therapy (1.02, 95% Bayes credible interval 0.25, 1.96), but not versus short-term psychoanalytic psychotherapy. CONCLUSIONS: The clinical response signature in this trial is best revealed by rapid reductions in depression symptoms and general psychopathology. Protracted improvements in general psychopathology and conduct problems subsequently occur. Psychosocial treatments for adolescent depression have comparable effects on general and specific psychopathology, although a psychoeducational, goal-focused approach may be indicated for youth with comorbid conduct problems

Improving mood with psychoanalytic and cognitive therapies (IMPACT): a pragmatic effectiveness superiority trial to investigate whether specialised psychological treatment reduces the risk for relapse in adolescents with moderate to severe unipolar depression: study protocol for a randomised controlled trial.

BACKGROUND: Up to 70% of adolescents with moderate to severe unipolar major depression respond to psychological treatment plus Fluoxetine (20-50 mg) with symptom reduction and improved social function reported by 24 weeks after beginning treatment. Around 20% of non responders appear treatment resistant and 30% of responders relapse within 2 years. The specific efficacy of different psychological therapies and the moderators and mediators that influence risk for relapse are unclear. The cost-effectiveness and safety of psychological treatments remain poorly evaluated. METHODS/DESIGN: Improving Mood with Psychoanalytic and Cognitive Therapies, the IMPACT Study, will determine whether Cognitive Behavioural Therapy or Short Term Psychoanalytic Therapy is superior in reducing relapse compared with Specialist Clinical Care. The study is a multicentre pragmatic effectiveness superiority randomised clinical trial: Cognitive Behavioural Therapy consists of 20 sessions over 30 weeks, Short Term Psychoanalytic Psychotherapy 30 sessions over 30 weeks and Specialist Clinical Care 12 sessions over 20 weeks. We will recruit 540 patients with 180 randomised to each arm. Patients will be reassessed at 6, 12, 36, 52 and 86 weeks. Methodological aspects of the study are systematic recruitment, explicit inclusion criteria, reliability checks of assessments with control for rater shift, research assessors independent of treatment team and blind to randomization, analysis by intention to treat, data management using remote data entry, measures of quality assurance, advanced statistical analysis, manualised treatment protocols, checks of adherence and competence of therapists and assessment of cost-effectiveness. We will also determine whether time to recovery and/or relapse are moderated by variations in brain structure and function and selected genetic and hormone biomarkers taken at entry. DISCUSSION: The objective of this clinical trial is to determine whether there are specific effects of specialist psychotherapy that reduce relapse in unipolar major depression in adolescents and thereby costs of treatment to society. We also anticipate being able to utilise psychotherapy experience, neuroimaging, genetic and hormone measures to reveal what techniques and their protocols may work best for which patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN83033550.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

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

Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial.

$\textbf{BACKGROUND}$: Psychological treatments for adolescents with unipolar major depressive disorder are associated with diagnostic remission within 28 weeks in 65-70% of patients. We aimed to assess the medium-term effects and costs of psychological therapies on maintenance of reduced depression symptoms 12 months after treatment. $\textbf{METHODS}$: We did this multicentre, pragmatic, observer-blind, randomised controlled superiority trial (IMPACT) at 15 National Health Service child and adolescent mental health service (CAMHS) clinics in three regions in England. Adolescent patients (aged 11-17 years) with a diagnosis of DSM IV major depressive disorder were randomly assigned (1:1:1), via a web-based randomisation service, to receive cognitive behavioural therapy (CBT) or short-term psychoanalytical therapy versus a reference brief psychological intervention. Randomisation was stochastically minimised by age, sex, self-reported depression sum score, and region. Patients and clinicians were aware of group allocation, but allocation was concealed from outcome assessors. Patients were followed up and reassessed at weeks 6, 12, 36, 52, and 86 post-randomisation. The primary outcome was self-reported depression symptoms at weeks 36, 52, and 86, as measured with the self-reported Mood and Feelings Questionnaire (MFQ). Because our aim was to compare the two psychological therapies with the brief psychosocial intervention, we first established whether CBT was inferior to short-term psychoanalytical psychotherapy for the same outcome. Primary analysis was by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN83033550. $\textbf{FINDINGS}$: Between June 29, 2010, and Jan 17, 2013, we randomly assigned 470 patients to receive the brief psychosocial intervention (n=158), CBT (n=155), or short-term psychoanalytical therapy (n=157); 465 patients comprised the intention-to-treat population. 392 (84%) patients had available data for primary analysis by the end of follow-up. Treatment fidelity and differentiation were established between the three interventions. The median number of treatment sessions differed significantly between patients in the brief psychosocial intervention group (n=6 [IQR 4-11]), CBT group (n=9 [5-14]), and short-term psychoanalytical therapy group (n=11 [5-23]; p<0·0001), but there was no difference between groups in the average duration of treatment (27·5 [SD 21·5], 24·9 [17·7], 27·9 [16·8] weeks, respectively; Kruskal-Wallis p=0·238). Self-reported depression symptoms did not differ significantly between patients given CBT and those given short-term psychoanalytical therapy at weeks 36 (treatment effect 0·179, 95% CI -3·731 to 4·088; p=0·929), 52 (0·307, -3·161 to 3·774; p=0·862), or 86 (0·578, -2·948 to 4·104; p=0·748). These two psychological treatments had no superiority effect compared with brief psychosocial intervention at weeks 36 (treatment effect -3·234, 95% CI -6·611 to 0·143; p=0·061), 52 (-2·806, -5·790 to 0·177; p=0·065), or 86 (-1·898, -4·922 to 1·126; p=0·219). Physical adverse events (self-reported breathing problems, sleep disturbances, drowsiness or tiredness, nausea, sweating, and being restless or overactive) did not differ between the groups. Total costs of the trial interventions did not differ significantly between treatment groups. $\textbf{INTERPRETATION}$: We found no evidence for the superiority of CBT or short-term psychoanalytical therapy compared with a brief psychosocial intervention in maintenance of reduced depression symptoms 12 months after treatment. Short-term psychoanalytical therapy was as effective as CBT and, together with brief psychosocial intervention, offers additional patient choice for psychological therapy, alongside CBT, for adolescents with moderate to severe depression who are attending routine specialist CAMHS clinics.National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, and the Department of Health

Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial.

BACKGROUND: Psychological treatments for adolescents with unipolar major depressive disorder are associated with diagnostic remission within 28 weeks in 65-70% of patients. We aimed to assess the medium-term effects and costs of psychological therapies on maintenance of reduced depression symptoms 12 months after treatment. METHODS: We did this multicentre, pragmatic, observer-blind, randomised controlled superiority trial (IMPACT) at 15 National Health Service child and adolescent mental health service (CAMHS) clinics in three regions in England. Adolescent patients (aged 11-17 years) with a diagnosis of DSM IV major depressive disorder were randomly assigned (1:1:1), via a web-based randomisation service, to receive cognitive behavioural therapy (CBT) or short-term psychoanalytical therapy versus a reference brief psychological intervention. Randomisation was stochastically minimised by age, sex, self-reported depression sum score, and region. Patients and clinicians were aware of group allocation, but allocation was concealed from outcome assessors. Patients were followed up and reassessed at weeks 6, 12, 36, 52, and 86 post-randomisation. The primary outcome was self-reported depression symptoms at weeks 36, 52, and 86, as measured with the self-reported Mood and Feelings Questionnaire (MFQ). Because our aim was to compare the two psychological therapies with the brief psychosocial intervention, we first established whether CBT was inferior to short-term psychoanalytical psychotherapy for the same outcome. Primary analysis was by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN83033550. FINDINGS: Between June 29, 2010, and Jan 17, 2013, we randomly assigned 470 patients to receive the brief psychosocial intervention (n=158), CBT (n=155), or short-term psychoanalytical therapy (n=157); 465 patients comprised the intention-to-treat population. 392 (84%) patients had available data for primary analysis by the end of follow-up. Treatment fidelity and differentiation were established between the three interventions. The median number of treatment sessions differed significantly between patients in the brief psychosocial intervention group (n=6 [IQR 4-11]), CBT group (n=9 [5-14]), and short-term psychoanalytical therapy group (n=11 [5-23]; p<0·0001), but there was no difference between groups in the average duration of treatment (27·5 [SD 21·5], 24·9 [17·7], 27·9 [16·8] weeks, respectively; Kruskal-Wallis p=0·238). Self-reported depression symptoms did not differ significantly between patients given CBT and those given short-term psychoanalytical therapy at weeks 36 (treatment effect 0·179, 95% CI -3·731 to 4·088; p=0·929), 52 (0·307, -3·161 to 3·774; p=0·862), or 86 (0·578, -2·948 to 4·104; p=0·748). These two psychological treatments had no superiority effect compared with brief psychosocial intervention at weeks 36 (treatment effect -3·234, 95% CI -6·611 to 0·143; p=0·061), 52 (-2·806, -5·790 to 0·177; p=0·065), or 86 (-1·898, -4·922 to 1·126; p=0·219). Physical adverse events (self-reported breathing problems, sleep disturbances, drowsiness or tiredness, nausea, sweating, and being restless or overactive) did not differ between the groups. Total costs of the trial interventions did not differ significantly between treatment groups. INTERPRETATION: We found no evidence for the superiority of CBT or short-term psychoanalytical therapy compared with a brief psychosocial intervention in maintenance of reduced depression symptoms 12 months after treatment. Short-term psychoanalytical therapy was as effective as CBT and, together with brief psychosocial intervention, offers additional patient choice for psychological therapy, alongside CBT, for adolescents with moderate to severe depression who are attending routine specialist CAMHS clinics. FUNDING: National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, and the Department of Health.National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, and the Department of Health

Prognostic Implications for Adolescents With Depression Who Drop Out of Psychological Treatment During a Randomized Controlled Trial

OBJECTIVE: High therapy dropout rates among adolescents have been reported, but little is known about whether dropout is associated with poor outcomes. This study aimed to examine clinical outcomes in adolescents with depression who dropped out of psychological therapy and to determine whether this varied by treatment type. METHOD: Data were drawn from the Improving Mood with Psychoanalytic and Cognitive Therapies (IMPACT) study, a randomized controlled trial, comparing a brief psychosocial intervention, cognitive-behavioral therapy, and short-term psychoanalytic psychotherapy in the treatment of adolescent major depression. The sample comprised 406 adolescents with a diagnosis of major depression, 169 of whom dropped out of treatment before the planned end of therapy. Primary outcome was self-report Mood and Feelings Questionnaire (MFQ); secondary outcomes were Health of the Nation Outcome Scale for Children and Adolescents, Revised Children's Manifest Anxiety Scale, Modified Leyton Obsessional Inventory, and clinical diagnosis. RESULTS: During follow-up, there was a nonsignificant trend for dropouts to report higher depressive symptoms than completers. However, modeling showed insufficient evidence for an association between dropout and outcomes. CONCLUSION: In contrast to studies of adult therapy, there was no strong evidence that adolescent patients who dropped out had poorer clinical outcomes compared with those who completed therapy, when dropout was defined as ending treatment without agreement of the therapist. This challenges us to understand why adolescents stop going to therapy, how dropout should be defined, and whether what is prescribed is what is always needed. CLINICAL TRIAL REGISTRATION INFORMATION: Improving Mood and Preventing Relapse With Psychoanalytic Psychotherapy and Cognitive Behavior Therapy; http://www.isrctn.com/; 83033550

In Context: Lessons About Adolescent Unipolar Depression From the Improving Mood With Psychoanalytic and Cognitive Therapies Trial

This review paper summarizes the results of the Improving Mood with Psychoanalytic and Cognitive Therapies (IMPACT) study and its implications for psychological treatment of adolescents with moderate to severe unipolar major depression. IMPACT was a pragmatic, superiority, randomized controlled trial conducted in the United Kingdom, which compared the clinical and cost-effectiveness of short-term psychoanalytic therapy (STPP), cognitive−behavioral therapy (CBT), and a brief psychosocial intervention (BPI) in reducing depression symptoms in 465 adolescents with unipolar major depression, aged 11 to 17 years. Although this was a clinically heterogeneous group of adolescents, some symptoms (eg, sleep and concentration difficulties, irritability/anger) were common and disabling. The trial reported no significant difference among the 3 treatments in reducing depression symptoms. One year after treatment, 84% of participants showed improvement in depressive symptoms (<50% of baseline symptoms) and improved psychosocial functioning, achieving this through different symptom reduction trajectories. Although participants attended fewer treatment sessions than planned, the 3 treatments were delivered with fidelity to their respective models. Ending treatment without therapist agreement occurred in 37% of cases. This was not associated with outcomes by treatment group. Adolescents emphasized the importance of the therapeutic relationship in all 3 treatments. Results suggest that although most adolescents respond to time-limited, structured psychological therapy, subgroups of depressed adolescents are likely to need additional treatment or support. These include adolescents who live in complex circumstances and/or who believe that their needs are not met in therapy, some who stop treatment early, and the 16% to 18% of adolescents who do not respond to treatment