Assessment of Depression & Suicide
Risk: Strategies for Matching Youths
to Optimal Interventions
Joan Rosenbaum Asarnow, Ph.D.
University of California, Los Angeles
Melissa Institute
Some slides adapted from M Kovacs and J. McCracken
Disclosures: Joan Rosenbaum
Asarnow, Ph.D.
Source
Consult/Honorarium
California Institute of Mental
Health
Depression Treatment
Quality Improvement (DTQI)
Casa Pacifica
CBT Training
Los Angeles County DMH
and sites
CBT Training, DTQI
Phillip Morris
Research Grant
Unrestricted
American Foundation for
Suicide Prevention
X
X
NIMH
X
X
SAMHSA
X
X
SanofilAventis
Spouse
Depression
Presentation Goals
• Why assess depression?
– Review current evidence on rates of depression
and course of depression in youths
• Do we have effective treatments for
depression in youths?
– Review evidence supporting CBT as evidencebased practice
• How can we improve care for depression?
Depression Facts
• Over 18 million Americans are depressed
• As many as 2 million of these are adolescents
Defining Depression
Dep Symptoms
D
Dep
Disorder
Mary
•
•
•
•
•
•
Presents with frequent school absences
Stomach aches
Difficulty sleeping due to stomach pain
Missing school frequently
Sad nearly all the time
Recent onset of the following symptoms
– Can’t sleep at night
– Not eating well
– Can’t concentrate at school, drop in grades
– Tired
– Feels worthless
– Thoughts of death and suicide
Clinical Depression: Major Depression
Duration
≥ 2 weeks
Critical Symptoms
Depressed, irritable , or anhedonic mood
nearly all the time
# Symptoms- 5 of 9 symptoms must include
depressed/irritable mood or anhedonia
Depressed/Irritable Mood
Anhedonia
Insomnia or hypersomnia
Appetitie disturbance
Concentration problems/indecision
Low energy or fatigue
Worthlessness or guilt for no reason
Agitation or moves more slowly than usual
Thoughts of death or suicide
Severity
Distress or functional impairment
EXCLUSION
Not due to drugs/medication/medical
disorder. Not bereavement, not a mixed
episode
Danny
• Getting into trouble at school
• Irritable and crabby at home, been generally
unhappy for past year
• Complains of being bored all of the time
• Feels like not as good as other kids
• Can’t concentrate in school, drop in grades
• Says his life is awful, no reason to think it will get
any better, feels like giving up
Clinical Depression: Dysthymic Disorder
Duration
≥1 year for children
Critical Symptoms
Depressed/ irritable mood most of the time
more days than not
# Symptoms- 2 of 6 symptoms, must include
depressed/irritable mood
Either overeating or lack of appetite.
Sleeping too much or having difficulty
sleeping.
Fatigue, lack of energy.
Poor self-esteem.
Difficulty with concentration or decision
making.
Feeling hopeless.
Severity
Distress or functional impairment
EXCLUSION
No MDD in Year 1.
Never manic/hypomanic/mixed/
cyclothymicNot due to psychosis,
drugs/medication/medical disorder. Not
bereavement
Ana
Presents to ER with suicide attempt, serious overdose
Boyfriend broke up with her
Hasn’t been able to stop crying since break-up 5 days
ago
Feels worthless
Can’t sleep
Doesn’t feel like eating
Worried that she is pregnant, feels nauseous
Children do suffer from depressive disorders:
Pediatric depression is a prevalent condition
• Rates increase with age; pattern differs by gender
<13 yrs: 2.8% (+ .5)
13-18 yrs 5.6% (+ .3)
• 1:1 sex ratio (or more boys) prior to adolescence
• Increased frequency in girls during adolescence
13-18 yrs girls 5.9%
13-18 yrs boys 4.6%
Rates approach adult prevalence by end of
adolescence
THE EPIDEMIOLOGY OF YOUTH DEPRESSION:
THE FINDINGS
PREVELENCE/INCIDENCE NOT YET RELIABLY ESTABLISHED
Age 9-16
3-mo prev.
cumulative/
By age 16
predicted
Age 14-18 (T1) lifetime
any dep d/o
2.2%a
any dep d/o
9.5%a
major dep d/o
20.4%b
Age 15-19 (T2 ) lifetime
By age 19
prorated
major dep d/o
major dep d/o
24.0%b
28.0%b
Age 18
lifetime
major dep d/o
9.4%c
Age 15-16
Age 17-18
lifetime
lifetime
major dep d/o
major dep d/o
14.6%d
13.5%d
aCostello
et al., 2003; bLewinson et al., 1998; cReinherz et al., 1993; dKessler & Walters, 1998
Pediatric Depression Not Benign Condition






Depression recurrent (in up to ~60-75% of cases),
One year recurrence greater than adults (40% vs. 24%)
20% have persistence >2yrs
40-60% relapse after successful treatment
70% have adult depression
Episodes are lengthy: MDD (7-9 mos) in clinical cases; DD
(~3yrs)
 Associated with significant impairment in school, with family,
and peers
 Suicide risk in adults with history of adolescent MDD is 5x
adults with late onset
Asarnow et al., 1994; Kovacs et al., 1984a, 1994,1997; Lewinson et al., 1994; McCauley et al., 1993; PuigAntich et al., 1989; Rao et al., 1995; Weissman et al., 1999 a,b
Pediatric Depression: Associated
With High Risk of Suicidality
9 year follow up
of prepubertal
children
90
80
74
78
70
%
60
50
Major Depression
Dysthymia
Adj D/O Depressed
No Mood D/O
50 48
40
28
30
17
20
6
10
8
0
Suicidal Ideation
Suicide Attempt
Kovacs et al. J Am Acad Child Adolesc Psychiatry 1993
38% of depressed youths had made attempt by age 17
Elevated rates of Suicide & Suicide
Attempts in Adolescent-Onset MDD by
Early Adulthood
From Weissman et al. (1999). Depressed Adolescents Grown Up. JAMA
Mean age at follow-up 26 yrs, follow-up period ≈10 years
Burden of Pediatric Depression:
Additional Consequences
 Eventual substance use/abuse disorders: 15% to
45%a
 Persistence of functional impairment: social
dysfunction, work difficulties, low employment
rateb
 Depressive episode recurrence of ~60%-69% into
young adulthoodc
a)Geller et al., 2001; Harrington et al., 1990; Rao et al., 1995; Weissman et al., 1999
b) Fergusson & Woodward, 2002; Fombonne et al., 2001; Garber et al., 1988; Geller et al., 2001;Harrington et al.,
1991; Rao et al., 1995; Weissman et al., 1999 a,b; c)Harrington et al., 1990; Weissman et al., 1999 b; Rao et al.,
1995
Comorbidity/Co-Occurring Disorders:
High Across Range of Disorders
 Most youths present with another diagnosis, ~80-90%
 40-50% have an anxiety disorder, anxiety disorders often
precede the onset of depressive disorders
 Double depression common, ~ 20% DD/MDD
 ADHD comorbid in ~ 20%
 Conduct disorder in ~ 50% of school age depressives
 Increased risk for bipolar disorder (8%-49%)
 Common overlap with PTSD, OCD
Baji et al., in press; Biederman et al., 1995; Carlson & Kashani, 1988; Ferro et al., 1994; Fombonne et al., 2001; Geller et al., 2001;
Goodyer et al., 1997; Kovacs et al., 1988/89, 1994, 1997 and Unpub; McCauley et al., 1993; Mitchell et al., 1988; Rao et al., 1995;
Ryan et al., 1987; Shain et al., 1991; Strober & Carlson, 1982; Strober et al., 1993; Weiss & Garber, 2003; Weissman et al., 1999a,b
INTERIM CONCLUSION
 Depression in children is a serious condition
 Course is often protracted
 Presentation is complicated, often with other co-occurring mental health
problems
 While most youth recover (80%), risk of recurrence is high (around 50%
or higher)
 Associated with long-term disorder + functional impairment, often
persisting into adulthood
 Recent results suggest that earlier onset MDD (child and
adolescent-onsets) tends to be more severe, recurrent, and
impairing than later adult-onset MDD*
 Most adult depressions begin during childhood-adolescent
years
*Zisook et al., 2007;
TREATMENT
Do we have effective treatments?
Treatment for Depression in
Children and Adolescents
• Psychotherapy
• Pharmacotherapy
• Combination psychotherapy and
pharmacotherapy
Fluoxetine Treatment of
Major Depression Response (CGI 2)
60
50
40
30
20
10
0
Fluoxetine (N=48) Placebo (N=48)
p=0.02; Emslie GJ, Rush AJ, Weinberg WA, et al. Arch Gen Psychiatry. 1997;54(11):1031-1037
Fluoxetine in Juvenile Depression
60
* p=.03
% CGI Responders
50
40
219 outpatients with
MDD, Ages 8-17
8 week trial 20 mg
CGI ≤ 2
*
Fluoxetine
Placebo
30
20
10
0
N=109
Emslie G et al. J Am Acad Child Adolesc Psychiatry 2002
N=110
Fluoxetine Treatment for
Depression in Children and Adolescents
Remission Rates
• Fluoxetine
• Placebo
41%
20%
p<0.01; Emslie GJ, Heiligenstein JH, Hoog S, et al. J Am Acad Child Adolesc Psychiatry. 2000
Drug Treatments for Child and Adolescent
Depression: Levels of Evidence
Short-Term
Efficacy
Fluoxetine
Sertraline
Fluvoxamine
Paroxetine
Citalopram/Escitalopram
TCAs
Venlafaxine
Duloxetine
A *
B
C
B
A *
C
B
C
A = >2 randomized, controlled studies; B = 1 randomized, controlled study; C = Clinical experience (open studies, case reports,
etc)
*-- fluoxetine FDA approved for depression ≥ 8 yrs; Escitalopram > 12-17.
Adapted from McCracken, 2009
Adapted from Jobson KO, Potter WZ. Psychopharmacol Bull. 1995;31:457–459.
FDA Public Health Advisory
March 2004
Suicidality in Children and Adolescents
Treated With Antidepressant Medications
Today the Food and Drug Administration (FDA) directed
manufacturers of all antidepressant drugs to revise the labeling for
their products to include a boxed warning and expanded warning
statements that alert health care providers to an increased risk of
suicidality (suicidal thinking and behavior) in children and
adolescents being treated with these agents, and to include
additional information about the results of pediatric studies.
Treatments Not So Robust?
“The evidence for effectiveness of SSRIs
compared with placebo in the treatment of
depressive disorders in children and
adolescents is far from compelling.”
Cochrane 2007 Review of SSRIs and Child and
Adolescent Depression
Herrick SE, Cochrane Database of Sys Rev. July 18
McCracken, 2009
What kind of depression treatment
do teens prefer?
21%
27%
Wait & Watch
Therapy
52%
Medication
Jaycox, L.H., Asarnow, J.R, Sherbourne, C.D., et al. (2006). Adolescent Primary Care
Patients’ Preferences for Depression Treatment. Administration and Policy in Mental
© Joan R. Asarnow for YPIC Team
Health 33, 198-207.
Cognitive Behavior Therapy (CBT)
• Established psychosocial treatment for adolescent
depression with evidence based supporting efficacy
• Acute treatment studies demonstrate greater efficacy
for CBT (12-16 sessions) as compared to alternative
psychosocial interventions and waitlist conditions
• Response rates for CBT appear to be between 6066% (vs. 38-48% in comparison conditions)
Stressors
• School/Work Problems
• Problems with Friends
• Family Problems
• Medical Illness
• Losses
THE STRESS
SPIRAL
Feelings
• Sad
• Crabby
• Don’t enjoy anything
• Bored
Actions/
Behaviors
• Withdrawal
• Decreased activity
• Irritable with others
Thoughts
• Negative thoughts
• Low self-esteem
• Pessimistic
• Hopeless
Psychotherapy Trial: MDD Remission
(No MDD + BDI <9 for 3 Weeks)
60
50
40
30
20
10
0
CBT (N=35)
Family (N=31)Supportive (N=33)
Overall p=0.05; CBT vs. family p=0.03; CBT vs. supportive p=0.04
Brent DA, Holder D, Kolko D, et al. Arch Gen Psychiatry. 1997(Sep);54(9):877-885
Courtesy, McCracken, 2009
Interpersonal Psychotherapy (IPT)
• Psychosocial treatment for adolescent depression
with evidence based supporting efficacy, but newer
with fewer efficacy studies as compared to CBT
• Response rates for IPT appear to be similar to those
for CBT
• Data support improvements in social functioning
IPT for Depressed Adolescents (IPT-A)
• Focuses on interpersonal relationships and roles and
the ways in which a person’s current relationships and
social context cause or maintain symptoms
• Initial 3 sessions focus on (in adolescents- client's
authority in relationship to parents; the development of
new interpersonal relationships; first experiences of the
death of a relative or friend; peer pressure; and singleparent families) to be addressed in the remainder of
therapy.
Mufson L, Weissman MM, Moreau D, Garfinkel R. Arch Gen Psychiatry. 1999(Jun);56(6):573-579
IPT for Depressed Adolescents
• 48 adolescent outpatients, ages 12-18 years, with
major depression
• Randomly assigned to 12-week IPT or clinical
monitoring (telephone contact)
• Results with IPT
– Greater decrease in depressive symptoms
– Improvement in social functioning
– Improved problem-solving
Mufson L, Weissman MM, Moreau D, Garfinkel R. Arch Gen Psychiatry.
1999(Jun);56(6):573-579
IPT: MDD Response
(HDRS 6 and/or BDI 9)
80
70
Percent
60
50
40
30
20
10
0
IPT (N=24)
Control (N=24)
Mufson L, Weissman MM, Moreau D, Garfinkel R. Arch Gen Psychiatry. 1999(Jun);56(6):573-579
Adolescent Depression
Combined CBT + Medication Treatment of Choice for
Moderate to Severe Major Depression
100
80
71%
60
61%
43%
40
35%
20
0
COMB
FLX
CBT
PBO
N=439, Treatment of Adolescent Depression Study (TADS); Week 12 Acute
Treatment Response
TADS Recovery Incomplete: Low Remission Rates &
50% of Remitted Youths Had Residual Symptoms
*CDRS-R total score ≤28 as the criterion for remission. COMB> FLX,CBT, PBO, P=.0009; FLX=CBT=PBO
Kennard et al. Remission and residual symptoms after short-term treatment in the Treatment of Adolescents
with Depression Study (TADS). J Am Acad Child Adolesc Psychiatry. 2006 Dec;45(12):1456-60
6-Site NIMH Study
MH61835 Pittsburgh, Brent
MH61864 UCLA, Asarnow
MH61856 Galveston, Wagner
MH61869 Portland, Clarke
MH61958 Dallas, Emslie
MH62014 Brown, Keller
334 outpatient adolescents, ages 1217 years, with diagnosis of major
depression
Depression persists despite at least 6
weeks of SSRI treatment
Acute phase 12-week trial
JAMA Feb 27, 2008
Asarnow J.R., APA, 2009,
Toronto
TORDIA: Evaluate Step-2 Treatment
Strategies After Step-1 SSRI Treatment
• SSRI response rate around 50-60%, often with
incomplete remission
• No empirical studies to guide clinicians on the
management of the roughly 50% of patients who
fail to respond to initial SSRI treatment
Asarnow JR, APA 2009,Toronto
TORDIA Supports Value of CBT-Clinical
Response by Treatment Group
80
N= 334
70
60
%
SSRI
SSRI & CBT
VLX
VLX & CBT
50
40
30
20
10
JAMA Feb 27, 2008
0
Treatment Group
CBT vs none, 54.8% vs 40.5%, p<0.009
Effectiveness Trials:
Strategies for Improving Community
Treatment & Services
Asarnow J.R., APA, 2009, Toronto
Y
P IC
Youth Partners in Care
Effectiveness of a Quality Improvement Intervention
for Adolescent Depression in Primary Care Clinics:
A Randomized Controlled Trial
Asarnow, Jaycox, Duan, LaBorde, Rea, Anderson,
Murray, Tang, Wells
Journal of the American Medical Association
2005 Jan 19; 293 (3):311-319.
Sponsored by the Agency for Healthcare Research and Quality (AHRQ;
Joan Asarnow, PI). Additional support from UCLA- RAND Health
Services Research Center (NIMH, Ken Wells, PI)
YPIC Goal

To test an innovative model for delivering
evidence based treatments for depression
through primary care
© Joan R. Asarnow for YPIC Team
YPIC: Participating Sites

Academic Medical Centers
 UCLA Mattell Children’s Hospital & Satellite Clinics
 University of Pittsburgh Children’s Hospital
 Managed Care Clinics
 Kaiser Permanente Los Angeles Medical Center
 Family Practice & Pediatric Departments
 Sunset & East LA Sites

Public Sector Clinics
 Ventura County Medical Center-Family Practice &
Pediatrics
 Venice Family Clinic
© Joan R. Asarnow for YPIC Team
© Joan R. Asarnow for YPIC Team
YPIC Design
Screened in Primary Care
N=4002
Eligible Screened Youth
N=1034
Baseline Assessment, N=418
Randomized to Treatment
N=418
QI (n=211)
UC (n=207)
6-Month Follow-Up
N=344
Asarnow, J.R., Jaycox, LJ, Duan, N., et al. (2005). JAMA, 2005, 293, 311-319.
© Joan R. Asarnow for YPIC Team
© Joan R. Asarnow for YPIC Team
Definition of Depression Positive
• Endorsed stem items for major depression or
dysthymic disorder on CIDI, plus depressed mood
for a minimum of 1 week during past month, plus
CES-D ≥ 16
• CES-D ≥ 24
© Joan R. Asarnow for YPIC Team
YPIC Intervention Goals

To improve initiation of and adherence to evidence based
treatments
–
Psychotherapy (CBT)
–
Antidepressant medication

To support patients and parents in making choices regarding
treatment with their providers

To enhance the relationship between the youth, parents, and
primary care provider

To test the intervention under real-world practice conditions
© Joan R. Asarnow for YPIC Team
Intervention Components





Provider education
Care managers to support primary care
clinicians and provide cognitive-behavior
therapy in primary care clinics
Patient & family education
Emphasis on patient, parent and provider
choice
Local expert teams to tailor the depression
management model to each system
© Joan R. Asarnow for YPIC Team
Screener indicates high levels of
depressive symptoms
Initial Patient Visit with Care Manager (45 min)
 Structured Evaluation
 Basic Patient and Family Education
Primary Care Provider (PCP, 15 min)
 Develop PCP Management Plan
 Consider specialty mental health consultation
Medication or
Medication +
psychotherapy is
prescribed
Follow-up visits/phone calls by
CM and/or clinicians
Psychotherapy is
prescribed
Patients not started
on treatment
CBT is initiated and
primary care/CM followup arranged
© Joan R. Asarnow for YPIC Team
CM Follow-Up
Effectiveness of a Quality Improvement Intervention
for Adolescent Depression in Primary Care Clinics:
A Randomized Controlled Trial
Asarnow JR, Jaycox L, Duan N, et al.
Journal of the American Medical Association
2005 Jan 19; 293 (3):311-319.
© Joan R. Asarnow for YPIC Team
Study Elements
Efficacy
TADS, TORDIA
Effectiveness
YPIC
Dissemination
CIMH Partnership
Sample
Selected
Strict Inclusion/Exclusion Criteria
Heterogeneous
Minimal Exclusions
Heterogeneous
Usual patient population
Setting
Lab
Usual clinics
Usual Clinic
Providers
Research
Usual Trained + QA
Usual Trained + QA
Treatment
Structured, Manual driven
Guidelines, resources,
manuals, algorithms,
complex treatment
decisions, evidence
informed
Guidelines, resouces,
manuals, algorithms,
complex treatment decisions,
evidence informed
Choice
None, randomized
Enhanced , patient and
provider choice
Enhanced, Provider choice
Financing
Study supported
Enhanced by study
resources
Usual
© Joan R. Asarnow
Demographic characteristics of subjects at baseline
Female
Age, Mean Yrs.
Total
UC
QI
78%
17
77%
17
79%
17
13%
1%
12%
56%
14%
3%
13%
.5%
13%
55%
15%
3%
14%
2%
11%
57%
13%
3%
Ethnicity:
African American
Asian
Caucasian
Hispanic/Latino
Mixed
Other
© Joan R. Asarnow for YPIC Team
Demographic characteristics of subjects at baseline
At least 1 parent employed
Language other than English at
home
Total
UC
QI
89%
64%
89%
62%
88%
67%
43%
42%
2%
19.2
38.5
28%
41%
41%
2%
19.5
39.5
27%
44%
43%
2%
18.9%
37.5
29%
Baseline Depression Status: (CIDI
Diagnosis)
Diagnosis of Depression
Major Depression
Dysthymia
MHI-5 score, mean
MCS-12 score, mean
Externalizing Symptoms/ conduct
problems, YSR T>63
© Joan R. Asarnow
Demographic characteristics of subjects at baseline
Total
UC
QI
Patients endorsing >2 PTSD
symptoms
22%
25%
19%
POSIT-defined substance use,
problematic
25%
27%
23%
Suicidal Ideation, YSR item score>0
27%
13%
25%
12%
29%
14%
Suicide attempts/deliberate selfharm, YSR item score >0 for
suicidal ideation and deliberate selfharm
© Joan R. Asarnow for YPIC Team
Depression Outcomes: Lower
Rates of Severe Depression in QI
vs. UC Group
% CES-D >
24
42%
31%
© Joan Asarnow for YPIC Team 2008
Mental Health & Quality of Life Outcomes:
Greater Improvement in QI vs. UC Group
QI
UC
Between Group
Difference
Significance
P
MCS-12
44.6
42.8
2.6
(0.3 to 4.8)
2.19
.03
Satisfaction with
mental health
care*
3.8
3.5
0.3
0.1 to 0.5)
2.92
.004
*0-5 scale ranging from very dissatisfied (0)
© Joan R. Asarnow for YPIC Team
to very satisfied (5)
YPIC Intervention Associated
With >50% Reduction in
Suicide Attempt Rates
Baseline
6-Months
QI
14.2%
6.4%
UC
11.6%
9.5%
© Joan Asarnow for YPIC Team 2008
Mental Health Care: Higher Rate in QI Group
vs. UC
© Joan R. Asarnow for YPIC Team
QI
UC
OR
P
Any specialty mental health
care
32%
17%
2.8
(1.6 to 4.9)
<.001
Any psychotherapy/
counseling
32%
21%
2.2
(1.3 to 3.9)
.007
Medication
13%
16%
.74
Mental Health treatment by
primary care physician
21%
19%
0.9
(0.4 to 1.9)
1.2
(0.7 to 2.0)
.63
Medication: No Group Differences
QI
UC
Baseline
14%
18%
6 mos.
13%
16%
© Joan R. Asarnow for YPIC Team
Psychotherapy: Higher Rate in QI Group
QI
UC
Baseline
22%
23%
6 mos.
32%
21%
Difference
10%
-2%
© Joan R. Asarnow for YPIC Team
What kind of depression treatment
do teens prefer?
21%
27%
Wait & Watch
Therapy
52%
Medication
Jaycox, L.H., Asarnow, J.R, Sherbourne, C.D., et al. (2006). Adolescent Primary Care
Patients’ Preferences for Depression Treatment. Administration and Policy in Mental
© Joan R. Asarnow for YPIC Team
Health 33, 198-207.
Conclusions: 6 Month
Outcomes
• A quality improvement intervention delivered in primary
care settings has promise for increasing rates of care and
improving youth outcomes
• Youth tend to prefer psychotherapy/counseling to
medication and when given their choice of treatment tend
to choose psychotherapy
• Preliminary comparisons suggest intervention effects
similar to those seen in adults at 6 months using similar
quality improvement model (Partners in Care, Wells et
al. 2000)
© Joan R. Asarnow for YPIC Team
Effects appear similar to those in adult study (Partners in
Care, Wells et al. 2000)
PIC
YPIC
QI
UC
QI
UC
Baseline
30%
27%
20%
24%
6-Months
40%
27%
32%
17%
Difference
10%
0
12%
-7%
MH Care
* Tentative comparisons due to variations across studies in procedures for deriving
estimates
© Joan R. Asarnow for YPIC Team
Youth vs. Adults
Antidepressant medication use was lower in YPIC
PIC
YPIC
QI
UC
QI
UC
Baseline
28%
27%
14%
18%
6-Months
35%
25%
13%
16%
Difference
7%
-2%
-1%
-2%
Medication
* Tentative comparisons due to variations across studies in procedures for deriving
estimates
© Joan R. Asarnow for YPIC Team
Y
P IC
Youth Partners in Care
Long-term benefits of short-term quality
improvement interventions for depressed
youths in primary care
Asarnow JR, Jaycox LH, Tang L, Duan N, LaBorde AP,
Zeledon LR, Anderson M, Murray PJ, Landon C, Rea MM,
Wells KB
Am J Psychiatry. 2009 Sep;166(9):1002-10
QI Intervention Associated With Shorter Time
To First Recovery
Wilcoxon X2 = 3.60, p=.058; 6-months, z=2.03, p=.042; . Mean times to first recovery were: QI 8.76 months (SE, 0.35);
UC 9.65 months (SE, 0.37); diff ≈27 days. Asarnow et al, American Journal of Psychiatry, 2009
Strongest Intervention Effect Seen
At 6-Months
Table 1. Intervention Effects Over 18 Months of Follow-Up*
Adjusted Analysis for
Unadjusted Estimates
Intervention vs. Usual Care*
UC
N(%)
Severe
Depression
CES-D ≥ 24
6-Mo
12-Mo
18-Mo
QI
N(%)
Odds Ratio
(95% C.I.)
t
70 (40.23%) 52 (30.59) 0.55(0.34, 0.89) -2.44
50 (30.49%) 44 (26.99) 0.81(0.48, 1.34) -0.83
44 (27.67%) 34 (20.86) 0.59(0.34, 1.02) -1.88
P-value
0.015
0.407
0.060
*We fit a mixed-effects logistic regression model using follow-up data at 6, 12, 18 months with regression adjustment for age, gender, ethnicity, the baseline measure for
the same outcome, and study sites. \
Asarnow et al, American Journal of Psychiatry, 2009
Early Intervention Effects Shifted Youths Towards
Healthier Pathways Through 18-Month Follow-Up
Baseline
6-month
12-month
18-month
QIIntervention
-0.18(0.19)
-0.39(0.15)
0.64(0.13)
Depression
0.46(0.12)
Depression
Depression
-0.01(0.01)
-0.03(0.01)
-0.01(0.08)
Depression
(MHI-5)1
Asarnow et al, American Journal of
Psychiatry, 2009
Asarnow J.R., APA, 2009, TorontoN=418
N=418
Conclusions: Longer Term Outcomes
Through 18 Months
• Youths who benefited from the intervention at 6
months tended to do better over the course of the
18-month follow-up period
• Depression is a relapsing condition, 18-month data
suggest some protection against relapse at 18
months among youths receiving intervention
• Early intervention-related improvements conferred
additional long-term protection through a favorable
shift in illness course through 12 and 18 months.
© Joan R. Asarnow for YPIC Team
Y
P IC
Youth Partners in Care
• UCLA
Joan Asarnow, Ph.D.
• RAND
Kenneth Wells, M.D., M.P.H.
Lisa Jaycox, Ph.D.
Naihua Duan, Ph.D.
Cathy Sherbourne, Ph.D.
Martin Anderson, M.D., M.P.H.
Michael Schoenbaum, Ph.D.
Bonnie Zima, Ph.D., M.P.H.
Mark Schuster, MD, MPH
Arleen Leibowitz, Ph.D.
Jeanne Miranda, Ph.D.
• KAISER PERMANENTE
Emily McGrath, Ph.D.
Anne LaBorde, Psy.D.
Margaret Rea, Ph.D.
Robert Zeledon, M.D.
Angela Albright, Ph.D.
Michael Wilkes, M.D., M.P.H.
Diane Morrison, M.S.W.
Beth Tang, M.A.
Jim Carter, L.M.F.T.
Diana Polo, B.A.
Jan Dils, L.M.F.T.
James McKowen, B.A.
John Tsilimparis, L.M.F.T.
Samantha Fordwood, M.A.
Joan Mueller
Eunice Kim, Ph.D
Geoff Collins, M.B.A.
Rochelle Noel, B.A.
© Joan R. Asarnow for YPIC Team
Ari Stern, M.A.
• VENTURA COUNTY MEDICAL
CENTER
Chris Landon, M.D.
Eleanor Fritz, R.N., Ph.D.
Miguel Cervantes, M.D.
Ken Saum, M.S.W.
Fabiola Macias, B.A., M.F.T.
Arlene Altobelli, Psy.D.
• CHILDREN’S HOSPITAL
PITTSBURGH-WPIC
Pamela Murray, M.D.
Frances Wren, M.D.
David Brent, M.D.
Kelly Kelleher, M.D.
Brian McCain, M.S.W.
• VENICE FAMILY CLINIC
Martin Anderson, M.D., M.P.H.
Michael Wilkes, M.D., M.P.H.
Blanca Andres, M.D.
Janeen Armm, Ph.D.
Juan Carlos Aguila, M.A.
STONY BROOK-STATE UNIV OF NY
Gabrielle Carlson, M.D.
© Joan R. Asarnow for YPIC Team
Challenge: Personalized Treatment
Our current treatments leave a substantial
proportion of patients with residual or fullblown depressions
Can we improve our ability to match patients to
optimal treatments?
Can we improve patient outcomes by matching
patients to the treatment strategies that are most
likely to be beneficial?
Predictors of Poor Outcome Across
Treatment Groups – Acute Treatment
(TADS, TORDIA)
•
•
•
•
•
•
More Chronic Depression (a) (b+)
Severe Suicidal Ideation (a) (b)
Comorbidity (a)
Functional Impairment (a) (b)
Hopelessness (a) (b)
Lower Expectancies For Treatment Benefits (a)
(a) Curry J, Rohde P, Simons A et al. (2006) Predictors and Moderators of acute outcome in the Treatment for Adolescents with Depression
Study (TADS). Journal of the American Academy of Child and Adolescent Psychiatry, 2006; 45: 1427-1439.
(b) (b) Asarnow, JR, Emslie, G., Clarke, G. Wagner, K, Spirito, A., Vitiello, B, Iyengar, S, Shamseddeen, W, Ritz, L, Birmaher, B, Ryan, N,
Kennard, B, Mayes, T, DeBar, L, McCracken, J, Strober, M, Suddath, R, Leonard, H, Porta, G, Keller, M, Brent, D.(2009) Treatment of
SSRI-Resistant Depression in Adolescents: Predictors and Moderators of Treatment Response. Journal of the American Academy of
Child and Adolescent Psychiatry, 2009; 48 (3):331-340.
Additional Predictors of Poor OutcomeStep 2 Treatment (TORDIA)
•
•
•
•
•
More Severe Depression (b)
History Of NSSI (b)
More Severe Family Conflict (b)
Drug Use (b+, youths excluded for abuse/dep)
Abuse History (b+)
(b) Asarnow, JR, Emslie, G., Clarke, G. Wagner, K, Spirito, A., Vitiello, B, Iyengar, S, Shamseddeen, W, Ritz, L, Birmaher, B, Ryan, N, Kennard,
B, Mayes, T, DeBar, L, McCracken, J, Strober, M, Suddath, R, Leonard, H, Porta, G, Keller, M, Brent, D.(2009) Treatment of SSRI-Resistant
Depression in Adolescents: Predictors and Moderators of Treatment Response. Journal of the American Academy of Child and Adolescent
Psychiatry, 2009; 48 (3):331-340.
Who Benefits the Most From
Medication Treatment?
•Lower Depression Severity
•Family Discord
•Comorbity
Similar to Overall Predictors
Emslie GJ. Fluoxetine in child and adolescent depression: acute and maintenance
treatment. Depression Anxiety. 1998;7:32-39.
Who Benefits the Most From
CBT/Psychosocial Treatment?
•
•
•
•
Suicidal ideation: CBT > Supportive (b)
Comorbid Anxiety: CBT > Supportive (a)
Abuse History: No diff (c)
Maternal Depression: No diff (c)
(a) Brent et al. Predictors of treatment efficacy in a clinical trial of three psychosocial treaatments for adolescent depression. J Am Acad
Child Adolesc Psychiatry, 1998:;7;906-914.
(b) Barbe RP, Bridge J, Birmaher B et al. Suicidality and its relationship to treatment outcome in depressed adolescents. Suicide Life
Threat Behav. 2004:34:44-45
(c ) Barbe RP, Bridge J, Birmaher B et al. Lifetime history of sexual abuse, clinical presentation, and outcome in a clinical trial for
adolescent depression. J Clin Psychiatry. 2004: 65:77-83.
Who Benefits the Most From
CBT/Combined Treatment?
•Mild to moderate depression severity vs. severe
•Mild-Mod Severity: Combined > fluoxetine alone
•Severe Dep: Combined=fluoxetine alone
•More cognitive distortion
•More distortion: Combined > fluoxetine alone
•Income level associated with better response to CBT
vs placebo
Moderators of CBT/Combined
Treatment at Step 2 Treatment:
Who Benefits the Most From Combined CBT +
Medication Switch Vs. Medication Switch Alone?
Significant Treatment X Baseline Variable Interaction
Backward binary logistic regression, including baseline variable, medication type,
CBT/combined treatment, and interaction terms.
From Asarnow J.R.,JAACAP, 2008
Greater Comorbidity Associated With Stronger
CBT/Combined Treatment Effect
80
Response Rate
70
60
50
No CBT
40
CBT
30
20
10
0
0
1
≥2
From Asarnow J.R.,JAACAP, 2009 © 2009 AACAP
Total
CBT/Combined Treatment Less Effective
in Abused Youth
70
p<0.05
Response Rate
60
p= 0.06
50
40
No CBT
30
CBT
20
10
0
No (N=246)
Yes (N=81)
Total
History of Abuse
From Asarnow J.R.,JAACAP, 2009 © 2009 AACAP
CBT/Combined Treatment Most Beneficial
With Lower Hopelessness
80
Response Rate
70
60
50
No CBT
40
CBT
30
20
10
0
<13 (N=198)
≥13 (N=133)
Total
BHS
From Asarnow J.R.,JAACAP, 2009 © 2009 AACAP
Depression:
Conclusions
• Treatments with evidence for efficacy exist
• Evidence-based treatments can be transported to
community settings and yield improved outcomes
• Choice of treatment guided by youth and family
preference, availability of treatments, and
characteristics of youths and families
Leading causes of death for selected age groups – United
States, 2004
Rank
10-14 years
15-19 years
20-29 years
30-39 years
40-49 years
50-59 years
1
Unintentional
Injuries
Unintentional
Injuries
Unintentional
Injuries
Unintentional
Injuries
Malignant
Neoplasms
Malignant
Neoplasms
2
Malignant
Neoplasms
Homicide
Homicide
Malignant
Neoplasms
Heart
Disease
Heart
Disease
3
Suicide
Suicide
Suicide
Heart
Disease
Unintentional
Injuries
Unintentional
Injuries
4
Homicide
Malignant
Neoplasms
Malignant
Neoplasms
Suicide
Suicide
Diabetes
Mellitus
5
Congenital
Malformations
Heart
Disease
Heart
Disease
Homicide
HIV
Cerebrovascular
6
Heart
Disease
Congenital
Malformations
HIV
HIV
Liver
Disease
Liver
Disease
7
Chronic
Lower Respiratory
Ds
Chronic
Lower
Respiratory Ds
Congenital
Malformations
Diabetes
Mellitus
Cerebrovascular
Chronic
Lower Respiratory
Ds
8
Influenza &
pneumonia
Cerebrovascular
Cerebrovascular
Cerebrovascular
Diabetes
Mellitus
Suicide
Source: CDC vital statistics
Healthy People 2010 & 2020
• Reducing suicide and suicide attempts in
adolescents.
• National Health Promotion Objectives 18.1 &
18.2
Why Suicide & Suicide Attempt
Prevention?
• Suicide is the third leading cause of death among
young people ages 10-24, accounting for 4,599
deaths (MMWR, Sept. 2007, 2004 Statistics)
• Among 15- to 24-year olds, suicide accounts for
12.9% of all deaths annually (CDC 2005).
• Almost 700,000 receive medical treatment for
suicide attempts
Evidence-Based Treatment: What works?
Emergency Interventions for Suicide &
Suicide Attempt Prevention
ED Visit: A Window of Opportunity to
Deliver an Effective Intervention
 Most suicidal adolescents have substantial need for
mental health services
 The ED visit is a major contact point for the large group
of youth who receive little to no follow-up care
 <50% receive referrals for follow-up care (Piacentini et al.,
1995; Spirito et al., 2000)
 A large proportion never attend any follow-up sessions (77%)
and many fail to complete a full course of treatment (RotheramBorus et al., 1996)
Means Restriction Education: Parents
Listed in Registry of Evidence-Based Suicide
Prevention Programs- 1 of 4 “effective practices.”
Parents informed that youth at risk for suicide and
why
Parents informed that risk can be reduced by
restricting access to lethal means
Education and problem-solving regarding how to
restrict access to lethal means
Kruesi, M. J. P., Grossman, J., Pennington, J. M., Woodward, P. J., Duda, D., and Hirsch, J. G. (1999). Suicide and violence prevention: Parent
education in emergency department. Journal of the American Academy of Child and Adolescent Psychiatry, 38(3), 250-255.
Kruesi, M. J. P., Grossman, J., and Hirsch, J. G. (1995). Five Minutes of Your Time May Mean a Lifetime to a Suicidal Adolescent. Chicago, IL:
Ronald McDonald House Charities, University of Illinois—Chicago.
Specialized ED Intervention for
Suicidal Adolescent Females
Listed in Registry of Evidence-Based Suicide
Prevention Programs (SPRC, 2/23/2005, Access
at:
www.sprc.org/featured_resources/ebpp/ebpp_fact
sheets.asp#type. ) One of 7 promising practices in
evidence-based registry.
Intervention Components: Specialized ED
Intervention
SEDI
ED Staff Training: enhance positive staff/patient interactions,
reinforce importance of outpatient treatment, recognize seriousness of
suicide attempts
Motivational video: 20 min, facilitate linkage to outpatient treatment
(highlight importance and facilitate realistic expectations)
ED Crisis session: discuss video, screen for suicide risk, conduct
therapy session, contract for outpatient treatment
Enhanced ED Care
Medical Evaluation & Clearance
Mental Health Safety Evaluation & Disposition
Suicidal
Adolescent
ED Patient
Family
Support & Protective
Monitoring
Linkage to
Family CBT
Treatment
Youth
1) Perceived support
3) Coping skills
4) Commitment safety
Based on Rotheram-Borus et al. 2000,
©Asarnow J.R., 2008
When Combined With Access To Structured Follow-up
Treatment, SEDI Associated With Improved Outcomes
(Rotheram-Borus et al., 2000)
1. Improved adherence to recommendation for
follow-up treatment
2. Youth reported less suicidal ideation and
depression at post-discharge assessment
3. Attended more follow-up treatment sessions
4. At 18 months, youth less depressed, mothers
reported higher family cohesion
Evidence-Based Treatment: What
works?
Outpatient Treatments for Suicide
& Suicide Attempt Prevention
Multisystemic Therapy (MST): Adaptation for youth in
psychiatric crisis (intensive family and community based
treatment, Huey et al., 2004, Henggeler et al., 2003)
•
•
•
•
•
Intensive community based treatment aimed at mobilizing protective
factors and reducing risk factors in the youth’s ecological context
Based on “fit analysis” identifying risk and protective factors for
individual youth
Focuses on multiple systems- youth’s ecological niche (family, peers,
school, community)
Assisting responsible adults in the natural environment to monitor and
provide structure in a manner that is likely to reduce risk for suicide
More effective than emergency hospitalization and usual services at
reducing rates of suicide attempts, mental health symptoms, and out of
home placements and improving school attendance and family
functioning
Brief home based family intervention
(Harrington et al., 1998)
1. Components
•
•
In home
Family problem-solving
2. Intervention (plus UC) associated with
reductions in suicidal ideation at 2 and 6
month follow-up, relative to UC alone
3. Intervention effect not evident among youth
with MDD
Cognitive Therapy (Beck, Brown et al)
• Suicidal behavior is the primary target of treatment
• Maladaptive cognitions seen as the primary pathway to
suicidal behavior
• Treatment includes a set of cognitive-behavioral
interventions including:
–
–
–
–
–
Crisis plan
Cognitive conceptualization of the suicide attempt
Coping cards
Hope box
Relapse prevention task Developed by Aaron T. Beck and
colleagues at the University of Pennsylvania
Cognitive Therapy: Results
• A randomized controlled trial showed that
participants in the CT group had an approximately
50% lower reattempt rate at 18-month follow-up
than those in Usual Care.
• The CT group had lower rates of self-reported
depression and hopelessness across the 18-month
follow-up period (Brown et al., JAMA, 2005).
Dialectical Behavior Therapy (DBT)
• A cognitive behavioral treatment program
developed to treat suicidal clients meeting criteria
for Borderline Personality Disorder
• Directly targets (1) suicidal behavior, (2)
behaviors that interfere with treatment delivery,
and (3) other dangerous, severe, or destabilizing
behaviors.
Biosocial Theory of BPD
Biological Dysfunction in the
Emotion Regulation System
Invalidating Environment
Pervasive Emotion Dysregulation
BPD criterion behaviors function to regulate emotions or
are a natural consequence of emotion dysregulation
DBT: Conceptualization
• BPD symptoms develop due to limited behavioral skills
for regulating negative emotions.
• BPD patients are biologically predisposed to experience
intense emotions which were invalidated by caregivers.,
resulting in individuals with BPD not learning skills for
down-regulating and managing emotions.
• BPD symptoms are attempts to regulate emotions.
• DBT emphasizes behavioral interventions, such as skills
training and changing reinforcers as treatment
DBT Addresses 5 functions
1.
2.
Increasing behavioral capabilities/skills
Improving motivation for skillful behavior (through
contingency management and reduction of interfering
emotions and cognitions)
3. Promoting generalization of gains to the natural
environment
4. Structuring the treatment environment so that it
reinforces functional rather than dysfunctional behaviors
5. Enhancing therapist capabilities and motivation to treat
patients effectively
4 Modes of Service Delivery
1. Weekly individual psychotherapy (1 hr/wk)
2. Group skills training (2 hrs/wk)
3. Telephone consultation (as needed within the
therapist's limits to ensure generalization)
4. Weekly therapist consultation team meetings (to
enhance therapist motivation and skills and to
provide therapy for the therapists).
Survival analysis for time to first suicide attempt: DBT Group had half the rate of
suicide attempts (23%) vs CTBE group (46%), NNT= 4.24
Linehan, M. M. et al. Arch Gen Psychiatry 2006;63:757-766.
Hazard Ratio, 2.66, P = .005. CTBE indicates community treatment by experts
Copyright restrictions may apply.
DBT for Suicidal Adolescents
Rathus and Miller (2002)
• Subjects: Suicidal adolescents with BPD features, ages 12-19
years.
• Quasi-experimental design: DBT = 29, TAU = 82, pre/post
treatment assessments. More severe patients assigned to DBT.
• DBT subjects received 12 weeks of individual and group sessions.
• Modifications made for adolescents: including parents in therapy
and skills groups, focus on adolescent “dialectical dilemmas” (e.g.,
leniency v. control, autonomy v. dependence)
• Findings: DBT group showed fewer hospitalizations and greater
treatment completion than TAU. Significant pre/post decrease
within DBT group in suicidal ideation, psychiatric symptoms, and
BPD symptoms. Fewer suicide attempts in DBT group, but nonsignificant.
Conclusions: Suicide Prevention
• Assessing and treating suicidal behavior/suicide
risk is a major problem
• Promising data exist on effective treatments for
suicide prevention in adults
• In youths, most effective treatments appear to be
those that:
– Mobilize family and community supports
– Teach skills for regulating emotions
Community Partnerships:
Improving Care & Developing “Effective”Treatments
Easily Transportable to Community Settings
Community
Lab
©Asarnow J.R., 2008
Michigan DTQI Partnership: Statewide Training in Cognitive-Behavior
Therapy for Adolescent Depression
Michigan- Depression
Treatment Quality
Improvement Project
Asarnow J.R., 2008
Joan Rosenbaum Asarnow
Margaret Rea
Kay Hodges
Jim Wotring
CIMH Dissemination Project
California Depression
Treatment Quality
Improvement Project
DTQI
Joan Rosenbaum Asarnow
Margaret Rea
Bill Carter
Cricket Mitchell
Todd Sosna
Lynne Marsenich
Robert Suddath
Promote High Quality Depression Treatment
CBT + Pharmacotherapy
Asarnow J.R., 2008