1. Joan Rosenbaum Asarnow, Ph.D. University of California, Los Angeles
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

2. Disclosures: Joan Rosenbaum Asarnow, Ph.D.
Source
Consult/Honorarium
Research Grant
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
Unrestricted
American Foundation for Suicide Prevention X
NIMH
SAMHSA
Sanofil-
Aventis
Spouse

3. Depression

4. 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 evidence-based practice
How can we improve care for depression?
Why CBT within the context of an overall Depression Treatment Quality Improvement Program

5. Depression Facts Over 18 million Americans are depressed
As many as 2 million of these are adolescents

6. Defining Depression D
Dep Symptoms
Dep Disorder

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. THE EPIDEMIOLOGY OF YOUTH DEPRESSION: THE FINDINGS
PREVELENCE/INCIDENCE NOT YET RELIABLY ESTABLISHED
Age 9-16
3-mo prev.
any dep d/o
2.2%a
By age 16
cumulative/ predicted
9.5%a
Age (T1)
lifetime
major dep d/o
20.4%b
Age (T2 )
24.0%b
By age 19
prorated
28.0%b
Age 18
9.4%c
Age 15-16
Age 17-18
14.6%d
13.5%d
aCostello et al., 2003; bLewinson et al., 1998; cReinherz et al., 1993; dKessler & Walters, 1998

14. 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; Puig-Antich et al., 1989; Rao et al., 1995; Weissman et al., 1999 a,b

15. Pediatric Depression: Associated With High Risk of Suicidality
9 year follow up of prepubertal
children
Kovacs et al. J Am Acad Child Adolesc Psychiatry 1993
38% of depressed youths had made attempt by age 17

16. 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

17. 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

18. 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

19. 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;

20. TREATMENT
Do we have effective treatments?

21. Treatment for Depression in Children and Adolescents
Psychotherapy
Pharmacotherapy
Combination psychotherapy and pharmacotherapy

22. Fluoxetine Treatment of Major Depression Response (CGI 2)60 50 40 30 20 10
Fluoxetine (N=48)
Placebo (N=48)
p=0.02; Emslie GJ, Rush AJ, Weinberg WA, et al. Arch Gen Psychiatry. 1997;54(11):

23. Fluoxetine in Juvenile Depression
219 outpatients with MDD, Ages 8-17
8 week trial 20 mg
CGI ≤ 2 *
N=109
N=110
Emslie G et al. J Am Acad Child Adolesc Psychiatry 2002

24. Fluoxetine Treatment for Depression in Children and Adolescents
Remission Rates
Fluoxetine 41%
Placebo %
p<0.01; Emslie GJ, Heiligenstein JH, Hoog S, et al. J Am Acad Child Adolesc Psychiatry. 2000

25. 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
A * *
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 >
Adapted from Jobson KO, Potter WZ. Psychopharmacol Bull. 1995;31:457–459.
Adapted from McCracken, 2009

26. 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.

27. 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

28. What kind of depression treatment do teens prefer?
21%
27%
52%
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 Health 33,
© Joan R. Asarnow for YPIC Team

29. 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 60-66% (vs % in comparison conditions)

30. THE STRESS SPIRAL Stressors School/Work Problems Problems with Friends
Family Problems
Medical Illness
Losses
THE STRESS SPIRAL
Actions/
Behaviors
Withdrawal
Decreased activity
Irritable with others
Thoughts
Negative thoughts
Low self-esteem
Pessimistic
Hopeless
Feelings
Sad
Crabby
Don’t enjoy anything
Bored

31. Psychotherapy Trial: MDD Remission (No MDD + BDI <9 for 3 Weeks)60 50 40 30 20 10
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):
Courtesy, McCracken, 2009

32. 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

33. 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 single-parent families) to be addressed in the remainder of therapy.
Mufson L, Weissman MM, Moreau D, Garfinkel R. Arch Gen Psychiatry. 1999(Jun);56(6):

34. IPT for Depressed Adolescents
48 adolescent outpatients, ages 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):

35. IPT: MDD Response (HDRS 6 and/or BDI 9)80 70 60 50
Percent 40 30 20 10
IPT (N=24)
Control (N=24)
Mufson L, Weissman MM, Moreau D, Garfinkel R. Arch Gen Psychiatry. 1999(Jun);56(6):

36. Adolescent Depression
Combined CBT + Medication Treatment of Choice for Moderate to Severe Major Depression
N=439, Treatment of Adolescent Depression Study (TADS); Week 12 Acute Treatment Response

37. 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 Dec;45(12):

38. 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 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

39. 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

40. TORDIA Supports Value of CBT-Clinical Response by Treatment Group%
JAMA Feb 27, 2008
CBT vs none, 54.8% vs 40.5%, p<0.009

41. Effectiveness Trials:
Strategies for Improving Community Treatment & Services
Asarnow J.R., APA, 2009, Toronto

42. A Randomized Controlled Trial
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):
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)

43. © Joan R. Asarnow for YPIC Team
YPIC Goal
To test an innovative model for delivering evidence based treatments for depression through primary care
© Joan R. Asarnow for YPIC Team

44. 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

45. © Joan R. Asarnow for YPIC Team

46. © 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
UC (n=207)
QI (n=211)
6-Month Follow-Up
N=344
Asarnow, J.R., Jaycox, LJ, Duan, N., et al. (2005). JAMA, 2005, 293,
© Joan R. Asarnow for YPIC Team

47. © Joan R. Asarnow for YPIC Team

48. 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

49. 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

50. 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

51. © 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
Psychotherapy is prescribed
CBT is initiated and primary care/CM follow-up arranged
Follow-up visits/phone calls by CM and/or clinicians
Medication or Medication + psychotherapy is prescribed
Patients not started on treatment
CM Follow-Up
© Joan R. Asarnow for YPIC Team

52. A Randomized Controlled Trial
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):
© Joan R. Asarnow for YPIC Team

53. Strict Inclusion/Exclusion Criteria Heterogeneous Minimal Exclusions
Study Elements
Efficacy
TADS, TORDIA
Effectiveness
YPIC
Dissemination
CIMH Partnership
Sample
Selected
Strict Inclusion/Exclusion Criteria
Heterogeneous
Minimal Exclusions
Usual patient population
Setting
Lab
Usual clinics
Usual Clinic
Providers
Research
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

54. Demographic characteristics of subjects at baseline
Total UC QI
Female
78%
77%
79%
Age, Mean Yrs. 17
Ethnicity:
African American
13%
14%
Asian 1%
.5% 2%
Caucasian
12%
11%
Hispanic/Latino
56%
55%
57%
Mixed
15%
Other 3%
© Joan R. Asarnow for YPIC Team

55. Demographic characteristics of subjects at baseline
Total UC QI
At least 1 parent employed
89%
88%
Language other than English at home
64%
62%
67%
Baseline Depression Status: (CIDI Diagnosis)
Diagnosis of Depression
43%
41%
44%
Major Depression
42%
Dysthymia 2%
MHI-5 score, mean
19.2
19.5
18.9%
MCS-12 score, mean
38.5
39.5
37.5
Externalizing Symptoms/ conduct problems, YSR T>63
28%
27%
29%
© Joan R. Asarnow

56. Demographic characteristics of subjects at baseline
Total UC QI
Patients endorsing >2 PTSD symptoms
22%
25%
19%
POSIT-defined substance use, problematic
27%
23%
Suicidal Ideation, YSR item score>0
29%
Suicide attempts/deliberate self-harm, YSR item score >0 for suicidal ideation and deliberate self-harm
13%
12%
14%
© Joan R. Asarnow for YPIC Team

57. © Joan Asarnow for YPIC Team 2008
Depression Outcomes: Lower Rates of Severe Depression in QI vs. UC Group
42%
% CES-D > 24
31%
© Joan Asarnow for YPIC Team 2008

58. Between Group Difference Satisfaction with mental health care*
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) to very satisfied (5)
© Joan R. Asarnow for YPIC Team

59. 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

60. Mental Health Care: Higher Rate in QI Group vs. UC© Joan R
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
21%
2.2
(1.3 to 3.9)
.007
Medication
13%
16%
0.9
(0.4 to 1.9)
.74
Mental Health treatment by primary care physician
19%
1.2
(0.7 to 2.0)
.63

61. Medication: No Group DifferencesQI UC
Baseline
14%
18%
6 mos.
13%
16%
© Joan R. Asarnow for YPIC Team

62. Psychotherapy: Higher Rate in QI GroupUC
Baseline
22%
23%
6 mos.
32%
21%
Difference
10%
-2%
© Joan R. Asarnow for YPIC Team

63. What kind of depression treatment do teens prefer?
21%
27%
52%
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 Health 33,
© Joan R. Asarnow for YPIC Team

64. 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

65. © 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
MH Care
Baseline
30%
27%
20%
24%
6-Months
40%
32%
17%
Difference
10%
12%
-7%
* Tentative comparisons due to variations across studies in procedures for deriving estimates
© Joan R. Asarnow for YPIC Team

66. Youth vs. Adults Antidepressant medication use was lower in YPICQI UC
Medication
Baseline
28%
27%
14%
18%
6-Months
35%
25%
13%
16%
Difference 7%
-2%
-1%
* Tentative comparisons due to variations across studies in procedures for deriving estimates
© Joan R. Asarnow for YPIC Team

67. Am J Psychiatry. 2009 Sep;166(9):1002-10
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 Sep;166(9):

68. 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 months (SE, 0.35); UC 9.65 months (SE, 0.37); diff ≈27 days. Asarnow et al, American Journal of Psychiatry, 2009

69. Strongest Intervention Effect Seen At 6-Months
*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

70. Asarnow J.R., APA, 2009, TorontoN=418
Early Intervention Effects Shifted Youths Towards Healthier Pathways Through 18-Month Follow-Up
QI-Intervention
Depression
12-month
Baseline
18-month
6-month
(MHI-5)1
0.64(0.13)
-0.01(0.08)
-0.03(0.01)
-0.39(0.15)
-0.18(0.19)
-0.01(0.01)
0.46(0.12)
Early effective treatment improves longer term outcomes.
Important to intervene early with a treatment that works.
Asarnow et al, American Journal of Psychiatry, 2009
N=418
Asarnow J.R., APA, 2009, TorontoN=418 70

71. 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

72. © Joan R. Asarnow for YPIC Team
UCLA
Joan Asarnow, Ph.D.
Kenneth Wells, M.D., M.P.H.
Naihua Duan, Ph.D.
Martin Anderson, M.D., M.P.H.
Bonnie Zima, Ph.D., M.P.H.
Arleen Leibowitz, Ph.D.
Jeanne Miranda, Ph.D.
Emily McGrath, Ph.D.
Margaret Rea, Ph.D.
Angela Albright, Ph.D.
Michael Wilkes, M.D., M.P.H.
Beth Tang, M.A.
Diana Polo, B.A.
James McKowen, B.A.
Samantha Fordwood, M.A.
Eunice Kim, Ph.D
Geoff Collins, M.B.A.
Rochelle Noel, B.A.
Ari Stern, M.A.
RAND
Lisa Jaycox, Ph.D.
Cathy Sherbourne, Ph.D.
Michael Schoenbaum, Ph.D.
Mark Schuster, MD, MPH
KAISER PERMANENTE
Anne LaBorde, Psy.D.
Robert Zeledon, M.D.
Diane Morrison, M.S.W.
Jim Carter, L.M.F.T.
Jan Dils, L.M.F.T.
John Tsilimparis, L.M.F.T.
Joan Mueller
© Joan R. Asarnow for YPIC Team

73. © Joan R. Asarnow for YPIC Team
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

74. Can we improve our ability to match patients to optimal treatments?
Challenge: Personalized Treatment Our current treatments leave a substantial proportion of patients with residual or full-blown 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? 74

75. 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)
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:
(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):

76. Additional Predictors of Poor Outcome- Step 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):

77. 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. 77

78. 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;
(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.

79. 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 79

80. 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 80

81. From Asarnow J.R.,JAACAP, 2009 © 2009 AACAP
Greater Comorbidity Associated With Stronger CBT/Combined Treatment Effect
From Asarnow J.R.,JAACAP, 2009 © 2009 AACAP 81

82. CBT/Combined Treatment Less Effective in Abused Youth
From Asarnow J.R.,JAACAP, 2009 © 2009 AACAP 82

83. CBT/Combined Treatment Most Beneficial With Lower Hopelessness
From Asarnow J.R.,JAACAP, 2009 © 2009 AACAP 83

84. 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

85. 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
Malignant
Neoplasms 2
Homicide
Heart
Disease 3
Suicide 4
Diabetes
Mellitus 5
Congenital
Malformations
HIV
Cerebro-
vascular 6
Liver 7
Chronic
Lower Respiratory Ds 8
Influenza & pneumonia
Source: CDC vital statistics

86. Healthy People 2010 & 2020
Reducing suicide and suicide attempts in adolescents.
National Health Promotion Objectives 18.1 & 18.2

87. 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

88. Evidence-Based Treatment: What works
Evidence-Based Treatment: What works? Emergency Interventions for Suicide & Suicide Attempt Prevention

89. 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 (Rotheram-Borus et al., 1996)

90. 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),
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.

91. Specialized ED Intervention for Suicidal Adolescent Females
Listed in Registry of Evidence-Based Suicide Prevention Programs (SPRC, 2/23/2005, Access at: ) One of 7 promising practices in evidence-based registry.

92. 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

93. Specialized ED Interveniton
Enhanced ED Care
Medical Evaluation & Clearance
Mental Health Safety Evaluation & Disposition
Family
Support & Protective Monitoring
Youth
1) Perceived support
3) Coping skills
4) Commitment safety
Suicidal Adolescent
ED Patient
Linkage to Family CBT Treatment
Based on Rotheram-Borus et al. 2000, ©Asarnow J.R., 2008

94. When Combined With Access To Structured Follow-up Treatment, SEDI Associated With Improved Outcomes (Rotheram-Borus et al., 2000)
Improved adherence to recommendation for follow-up treatment
Youth reported less suicidal ideation and depression at post-discharge assessment
Attended more follow-up treatment sessions
At 18 months, youth less depressed, mothers reported higher family cohesion

95. Evidence-Based Treatment: What works
Evidence-Based Treatment: What works? Outpatient Treatments for Suicide & Suicide Attempt Prevention

96. 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

97. Brief home based family intervention (Harrington et al., 1998)
Components
In home
Family problem-solving
Intervention (plus UC) associated with reductions in suicidal ideation at 2 and 6 month follow-up, relative to UC alone
Intervention effect not evident among youth with MDD

98. 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

99. 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).

100. 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.

101. 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

102. 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

103. DBT Addresses 5 functions
Increasing behavioral capabilities/skills
Improving motivation for skillful behavior (through contingency management and reduction of interfering emotions and cognitions)
Promoting generalization of gains to the natural environment
Structuring the treatment environment so that it reinforces functional rather than dysfunctional behaviors
Enhancing therapist capabilities and motivation to treat patients effectively

104. 4 Modes of Service Delivery
Weekly individual psychotherapy (1 hr/wk)
Group skills training (2 hrs/wk)
Telephone consultation (as needed within the therapist's limits to ensure generalization)
Weekly therapist consultation team meetings (to enhance therapist motivation and skills and to provide therapy for the therapists).

105. 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:
Hazard Ratio, 2.66, P = .005. CTBE indicates community treatment by experts
Copyright restrictions may apply.

106. DBT for Suicidal Adolescents Rathus and Miller (2002)
Subjects: Suicidal adolescents with BPD features, ages 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 non-significant.

107. 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

108. Community Partnerships: Improving Care & Developing “Effective”Treatments Easily Transportable to Community Settings
Community
Lab
©Asarnow J.R., 2008

109. Michigan- Depression Treatment Quality Improvement Project
Michigan DTQI Partnership: State-wide Training in Cognitive-Behavior Therapy for Adolescent Depression
Michigan- Depression Treatment Quality Improvement Project
Joan Rosenbaum Asarnow
Margaret Rea
Kay Hodges
Jim Wotring
Asarnow J.R., 2008

110. CIMH Dissemination Project
Joan Rosenbaum Asarnow
Margaret Rea
Bill Carter
Cricket Mitchell
Todd Sosna
Lynne Marsenich
Robert Suddath
California Depression Treatment Quality Improvement Project
DTQI
Promote High Quality Depression Treatment
CBT + Pharmacotherapy
Asarnow J.R., 2008