We recently published the two year follow up of the teens who received rumination-focused cognitive behavioral therapy.
During graduate school I worked on the biggest clinical trial for adolescent depression at the Northwestern University site. I've written elsewhere in this blog about what we learned from that study (the Treatment for Adolescents with Depression Study, TADS). In addition to what we learned in TADS, we also followed teens for several more years as they began to transition into what is now called emerging adulthood Last year, a fabulous graduate student - Amy Peters - and I wrote about the long term outcomes in real-world functioning of teenagers who receive treatment for depression during their adolescence.
I was interested in looking at the data all these years later because I had conducted the clinical interviews for the project when the teens were transitioning into adulthood. It struck me that some teens were doing great and achieving milestones such as going off to college, whereas others were struggling in new ways (some of my best research ideas have come from my clinical observations).
We published these results this year (download the full article here):
Most studies look at improvement in symptoms, meaning whether depression or anxiety symptoms decreased during the course of treatment. This is an important measure, but perhaps even more important is the measurement of whether treatment improves the teen's ability to function in the real-world. Functioning is defined by items such as school attendance and performance, having friends and a social life, and getting along reasonably well with one's family. In this article we looked at overall (or global) functioning over the years following treatment. We found that a delay of treatment by even just 12 weeks (which occurred among those randomized to the placebo group) was associated with poorer functional outcomes during the transition to adulthood. This finding received commentary by Dr. David Brent, an esteemed leader in the field:
The take home message of these findings is that it is important to receive treatment sooner rather than later. The number of days the brain experiences depression may be related to real-world functioning over the long term. The upside is that treatment works and for the majority of teens who received treatment, functioning continued to improve over time.
I am currently completing a two-year longitudinal follow up of a sample of adolescents who completed 8 weeks of Rumination-focused Cognitive Behavior Therapy (R-CBT) or an assessment-only control. Rumination is when we get stuck in negative thinking without being able to move forward in a productive way. One of the key skills taught in R-CBT is mindfulness. Over the course of the 8 week intervention, teens learned to notice when they were ruminating and to shift out of rumination into a more adaptive way of thinking or being. All adolescents completed a brain scan before and after the 8 week intervention period. A first look at the data suggests that R-CBT reduced residual symptoms of depression, prevented depressive relapse, and also influenced connectivity patterns of the brain (specifically, decreased hyperconnectivity between regions involved in the default mode and cognitive control networks). I willl be presenting these findings this fall at the annual meetings of the American Academy of Child and Adolescent Psychiatry as well as the Association for Behavioral and Cognitive Therapies.
This research is being conducted at the University of Illinois at Chicago's Institute for Juvenile Research and has been funded by the Klingenstein Foundation, the UIC Center for Clinical and Translational Research, the UIC Campus Research Board, and the Mind and Life Institute. My mentor for this project is Dr. Scott Langenecker (pictured above).
This video describes research supported by the Mind and Life Institute. I received one of the Varela Awards to support my research examining the use of mindfulness to reduce risk for depressive relapse among teenagers (and they told me to be silly and do yoga poses when they were filming). Enjoy!
A topic that comes up frequently with families is whether or not medication is an appropriate part of treatment. This is a personal decision and it is important to take into account many factors. The additional complication of the stigma of mental illness, can make this decision even harder. The good news is that there is good research on what the combination of medication (such as a selective serotonin reuptake inhibitor; SSRI) and cognitive behavior therapy (CBT) can offer.
During graduate school, I worked on the largest clinical trial for adolescent depression to date: the Treatment for Adolescents with Depression Study (TADS). Northwestern was one of 13 sites in this clinical trial. 439 adolescents were randomized to receive fluoxetine (Prozac), CBT, the combination of CBT+fluoxetine, or a pill placebo. What we found is that the combo treatment was more efficient in reducing symptoms of depression and suicidality over the short-term (12-weeks). CBT alone caught up to medication and combo at 36 weeks, but it is important to remember that 36 weeks is a long time in the life of a teenager!
If there is functional impairment (meaning the symptoms are getting in the way of the teen's life, such as in school or socially) then it may be important to speed up time to improvement.
Interesting research with animals suggests that extra serotonin may help us learn better. CBT takes a lot of work and some of our mental habits may be very strong. My clinical observation is that medication can help loosen up some of the negative thinking, so that it is a little bit easier to try having the thought "I can do my best to approach this problem" as opposed to the old habit of "I can't do anything right."
Medication isn't necessarily right for everyone and particularly in mild cases it may not be necessary. On the other hand, it can be a very useful tool on the road to wellness.
Mark Reinecke, PhD was my graduate school advisor and the Principal Investigator at the Northwestern cite. You can read more about him here. TADS was funded by the National Institutes of Mental Health (NIMH). NIMH has resources regarding adolescent depression here.
Here are a few of the TADS papers if you are interested in doing some background reading: