craighead fri 8.30 am ga psych 2 25-26-11 - …c.ymcdn.com/sites/ subjects identified by the cdi and...

Preven&on of Depression Among YoungPeople: A Developmentally‐Based CBT

Approach

W. Edward Craighead, PhD

J. Rex Fuqua Professor

Departments of Psychiatry and BehavioralSciences and Psychology

Emory University

Supported by NIMH Grant R21 MH59629, NIMH R03 066207,NIMH RO1 MH080880, Icelandic Research Council, and University

of Colorado

Financial Disclosures

Craighead receives support from the NIHfor his research, and he receives bookroyalties from John Wiley & Sons. He isa Senior Fellow, Center for the Studyof Law and Religion, Emory University.He is an officer of Hugarheill enf, anIcelandic non-profit companydedicated to prevention of depression.He owns stock in Novadel Pharma,IVAX Diagnostic, and Neoprobe Corp.

• At least 5 of the following nearly every day for at least 2 weeks(At least one symptom is (1) or (2)).

1. Depressed mood2. Markedly diminished interest/pleasure in activities

3. Weight change4. Sleep changes5. Psychomotor agitation or retardation6. Fatigue or loss of energy7. Feelings of worthlessness or guilt8. Poor concentration or indecisiveness9. Thoughts of death or suicidal ideation/attempt

• Clinically significant distress or impairment in important area of functioning

Source: DSMIV

Diagnosis of Major Depression

Hankin et al., 1998

0

5

10

15

20

25

11 12 13 14 15 16 17 18 19 20 21Age

Perc

ent C

linic

ally

Dep

ress

ed

TotalMaleFemale

Lewinsohn et al. (1993). J. Abn. Psych., 102, 133-144.Hankin et al. (1998). J. Abn. Psych., 107, 128-140.Fergusson et al. (2002). Arch. Gen. Psych., 59, 225-231.

Outline of TalkI. Model Guiding Research

II. Prevention of Relapse and PD

III. Prevention Studies in Iceland

Cognitive Model of Depression

Depression Among CollegeStudents

62% matriculate for higher educationa. Only 30% graduateb. Dropout--Mental Health (Depression)

Negative impact on academic performance

Poor social life (even at University of Colorado)

Comorbid a. Anxiety

b. Eating Disorders c. Substance Abuse

Prevention of RelapseStudies

Recurrence of MDD

• Greater risk of recurrence for individuals withearly onset of depression (Lewinsohn et al., 1993)

• Estimate between 45% and 66% recurrence rateby early adulthood (Lewinsohn et al., 1999;Fergusson & Woodward, 2002)

• Increased risk for future episodes indicates aneed for further research on predictors ofrecurrence and prevention of recurrence

Comorbid Personality Disorders

• Greater number of depressive episodes (Melartin etal., 2004)

• Longer duration of depressive episodes (Shea et al.,1987; Bell et al., 1988; Rothschild & Zimmerman, 2002;Melartin et al., 2004)

• More frequent suicidal ideation and suicideattempts (Bell et al., 1988)

• Poor treatment prognosis (Ilardi & Craighead, 1995;Mulder, 2002)

• Related to Cognitive Distortions in MDD Relapse(Craighead et al., in press)

Prevention of Relapse/Recurrence

• Maintenance

• Booster Sessions

• Prevention Programs

Model of Depression

Baseline Procedures

• Baseline Session 1: Assessment ofcurrent depressive symptomatology, MDDdiagnosis, other Axis I diagnoses, andother clinical descriptors

• Baseline Session 2: Assessment of Axis IIpersonality pathology

• Participants were paid $40 for completingthe baseline assessment(s)

Inclusion Criteria

• First-year freshman at University of Colorado• History of remitted DSM-IV MDD• No current DSM-IV MDD or dysthymia• No bipolar disorder• No primary psychotic disorder• No current substance dependence• No current psychotherapy or antidepressant

treatment

Measures

• Beck Depression Inventory (BDI; Beck et al., 1996)

• Structured Clinical Interview for DSM-IV,Research Version (SCID; First, Spitzer, Gibbon, &Williams, 1995)

• International Personality Disorder Examination(IPDE; World Health Organization, 1996)

• Longitudinal Interval Follow-up Evaluation –Modified (LIFE; Keller et al., 1987)

Enrollment FlowchartScreens Mailed

n ≈ 17,000

Phone Screensn = 634

Interviewedn = 222

Random Assignmentn = 100

Controlsn = 50

Screens Returnedn = 1473

Intervention Groupn = 50

Procedures for Follow-up

• Follow-up assessments occurred 6, 12, and18 months after the first baseline session

• Follow-up Sessions: Assessment of thecourse of Axis I disorders over the previous 6months

• Phone interviews with participants that movedout of the Boulder area

• Participants were paid $30 for completingeach of the follow-up assessments

SCID IPDE 6 Mo. LIFE 12 Mo. LIFE 18 Mo. LIFE

Demographic SampleCharacteristics

• Gender:75.2% female24.8% male

• Race:71.0% White7.8% Asian7.8% Latino1.4% Native American0.9% African-American11.1% Did not identify his/her race

Clinical Sample Characteristics• 78.9% experienced one MDE in high school;

21.1% experienced 2+ MDEs• 64.7% experienced suicidality during an MDE in

high school• 40.1% received prior treatment for depression• 22.5% had a comorbid Axis I disorder at study

entry• 58.3% had a lifetime history of another Axis I

disorder

Intervention Program

• Introduction• Explanation of the Model• Techniques• Prevention Skills

Interpersonal situations frequentlyleading to depression

• Transitions-changes in the roles you are expected to fill: mayrequire new skills or lead to role conflict

• Losses-loss of social support and meaningful social roles: mayinvolve guilt or anger toward self or others

• Role Disputes-when differences in expectations are irreconcilable orthe resolution of differences stall so they are a continuous source ofconflict: feel loss of control and threat of loss of relationship

• Interpersonal Skill Difficulties-problems such as initiatingor maintaining relationships: poor communication skills (e.g.overly aggressive or unassertive): social isolation (lack of socialsupport): difficulties can lead to losses (e.g. personal & workroles) and less ability to recover from such losses

Types of cognitions frequentlyleading to depression

• Catastrophizing-assuming the worst is likely to happen and exaggerating the significance of negative events: over- generalizing

• Pessimistic explanatory style-excessive self blame for negative events and not taking adequate credit for positive events

• Dichotomous thinkingA. Perfectionism—setting rigid and unrealistically high standards and

concluding one is a failure when standards not met

B. Need for approval—difficulty accepting disappointing anyone orbeing criticized by anyone: concluding one is a bad person whendo not receive other’s approval

• Mind reading-assuming you can figure out what others want or arethinking without explicit information: and assuming others should beable to figure out what you want or are thinking

Assessment Program

• Same procedures asIntervention Study

• Only participated inAssessments

• Screened about 25,000• N = 218

Procedures for Follow-up

• Follow-up assessments occurred 6, 12, and18 months after the first baseline session

• Follow-up Sessions: Assessment of thecourse of Axis I disorders over the previous 6months

• Phone interviews with participants that movedout of the Boulder area

• Participants were paid $30 for completingeach of the follow-up assessments

SCID IPDE 6 Mo. LIFE 12 Mo. LIFE 18 Mo. LIFE

Personality Factors Related toSocial Competence and MDD

Relapse

Interpersonal Conduct Disorder Social AnxietyHypersensitivity

Impaired Social Competence

Major Depression Relapse

Personality Factors and Stress asPredictors of MDD Recurrence

• Interpersonal Conduct Disorder Social AnxietyHypersensitivity

• Interpersonal Stress

• MDD Recurrence

Collaborators

Linda W. CraigheadErin S. SheetsAlisha L. BrosseJoshua W. MadsenAlinne Z. BarreraMonika HauserAndri BjornssonLaramie Duncan

Prevention Studies

Efficacy of Group Cognitive Intervention inPreventing Depression in Adolescents withDepressed Parents

Clarke, Hornbrook, Lynch, Polen, Gale,Beardslee, O’Connor, & Seeley (2001)

Groups:• “usual care” + Cognitive Therapy Prevention

Program (15-sessions; n = 45)• “usual care” control (n = 49)

Behavioral Measure:• Incidence of major depressive episodes at

15-mo.

Clarke et al. (2001). Arch. Gen. Psych., 58, 1127-1134.

LANDSPÍTALI – UNIVERSITY HOSPITAL Psychological Health Services

Background and significance

■ Increased medical use■ Increased substance abuse■ Increased suicide■ Poorer academic performance■ Poor social and family adjustment


Goal■ The primary goal of the research is to prevent

the occurrence of the first depressive episodeamong adolescents exhibiting severaldepressive symptoms and depressogeniccognitive style.

■ Utilize developmental level inintervention—Erikson’s theory,Developmental Psychopathology, CBT & IPT.


Procedure( subject selection)

■ Participants fulfilling the following criteria were invited toparticipate in the program:● grade 9 (ages 14-15)● many depressive symptoms: CDI score; 75th -89th percentile● attributional style: CASQ negative score of 16 or higher; 75th -99th

percentile

■ The subjects identified by the CDI and CASQ as havingsignificant depressive symptoms and a depressogeniccognitive style were invited to participate in the program,and parental consent was sought for those who expressedinterest in the program.

■ Randomly assigned to TAU or Prevention Group■ Followed for one year after end of intervention


Overview of Group■ Group met two times per week for three weeks

and once per week for eight weeks over the nextthree months.

■ Group meetings lasted 90 minutes.■ School psychologist led group.■ Group based on manual.■ Weekly meetings of investigator, assistant, and

school psychologists.


Predictors of MDE/DYS Predictors Entered Alone

CDI CASQ Negative CASQ Positive

Odds Ratio 1.12** 1.09 0.85*

p value 0.008 0.408 0.050


Predictors of MDE/DYS Predictors Entered Alone


Odds Ratio 1.12** 1.09 0.85*

p value 0.008 0.408 0.050

Predictors Entered Simultaneously


Odds Ratio 1.10* 1.05 0.91

p value 0.033 0.654 0.288

Risk of Incident Depression byInterven&on Condi&on

Garber, J. et al. (2009). Prevention of depression in at-risk adolescents.Journal of the American Medical Association, 301(21), 2215-2224.

CB indicates cognitive behavioral.

Risk of Incident Depression by Interven&onCondi&on and Baseline Parental Depression

Garber, J. et al. (2009). Prevention of depression in at-risk adolescents.Journal of the American Medical Association, 301(21), 2215-2224.


Future Directions

■ Implementation in all Secondary Schools inIceland

■ Development of Prevention Program in Portugal

Sociodemographic variables – Adolescents - Characterization

DescriptiveStatistics

Neitherdepressed

neither “at risk”N = 211

“at risk”

N = 142

Many depressivesymptoms (CDI)

N = 30Presence of

Parent’sdisease

Y 11.8%N 87.7%

Y 16.2%N 82.4%

Y 23.3%N 73.3%

Type ofparent’sdisease

Physical illnessfather 3.8 %Physical illnessmother 3.3 %

Depressionmother 1.4%Depressionfather 0.5 %

Physical illnessfather 3.5 %Physical illnessmother 4.9 %

Depressionmother 2.1 %Depression father 2.1 %

Father physicalillness 3.3 %Physical illnessmother 6.7

Depressionmother 13.3%Depression father 3.3 %

Sociodemographic variables – Adolescents - Characterization

DescriptiveStatistics

Neith depressedneither “at risk”

N = 211

“at risk”

N = 142

Many depressivesymptoms (CDI)

N = 30School

performanceA 10.4 %B 28.9 %C 0.9 %

A 2.1 %B 21.8 %C 6.3 %

A 0 %B 13.3 %C 10 %

CONCLUSIONS• MDD is a prevalent and burdensome

problem• CBT is effective to prevent relapse of

MDD• PD is a significant predictor of relapse of

MDD among young adults• CBT is prevent initial episode of MDD

among “at risk” adolescents


Collaborators since 2001Arnfríður Kjartansdóttir, Psychologist – Department of Family and

Educational Services, AkureyriRagnhildur S. Georgsdóttir, B.A. –assistant from 2006Margrét Ólafsdóttir, Psychologist - SeltjarnarnesInga Hrefna Jónsdóttir, Psychologist – Mosfellsbær / SeltjarnarnesHulda Sólrún Guðmundsdóttir, Psychologist - MosfellsbærÁgústa Gunnarsdóttir, Psychologist – ReykjanesbærHafdís Kjartansdóttir, Psychologist - ReykjanesbærBrynjólfur Brynjólfsson, Psychologist - GarðabærLára H. Halldórsdóttir, Psychologist – ReykjavíkJoshua Madsen & Erin Sheets, University of ColoradoDaniel Yoo, Emory University


The End

craighead fri 8.30 am ga psych 2 25-26-11 - …c.ymcdn.com/sites/ subjects identified by the cdi and...

Documents