Depression is one of the dark demons of adolescence. Up to 1 in 12 American teenagers is affected, according to the National Institute of Mental Health (NIMH), and three times as many will experience depression at some point by age 18. Studies show that at least 20% of teenagers with clinical depression will go on to develop chronic cases that will haunt them throughout adulthood. That is, if they reach adulthood. Suicide is a significant risk for depressed adolescents and the third leading cause of deaths among U.S. teenagers.
It's no wonder, then, that researchers are beginning to focus on preventing teenage depression in the first place. A new study in the current issue of the Journal of the American Medical Association (JAMA) is the largest to date showing that a relatively modest intervention goes a long way to prevent episodes of depression in high-risk teens. The authors hope it will provide a model that could be used widely in schools to protect kids from depression. (See pictures of teenagers in America.)
The study involved 316 adolescents, ages 13 to 17, in four cities. All of the teenagers had a history of depression or current symptoms that just fell short of a clinical diagnosis. The teens also had at least one parent who had been diagnosed with depression.
Half the teenagers were randomly assigned to a prevention program that consisted of eight weekly group sessions of cognitive behavioral instruction (CB) lasting 90 minutes each, plus six follow-up sessions that met once a month. The other half of the volunteers were assigned to a control group that got "usual care," meaning they were free to seek help from whatever resources were available to them in their community as were the teens in the experimental group. There were no differences between the groups in terms of the types of services they chose on their own. (Read "Talk Therapy for Kids: Better Than Pills?")
The teenagers were followed for nine months. Less than a quarter (21.4%) of those in the CB program went on to have an episode of depression, compared with about a third (32.7%) of those in the control group. The results were far more dramatic for teens whose parents were not actively suffering from depression: only 11.7% who went through the program had an episode of depression during the nine-month follow-up.
The CB sessions focused on teaching the kids to think more realistically and less catastrophically about their problems and experiences. "It's what we call the ABCD model," explains lead author Judy Garber, professor of psychology and human development at Vanderbilt University. Under the guidance of a social worker or other trained professional, the teens discuss A, an activating event, like a breakup with a boyfriend. Next they explore B, beliefs and thoughts about that event, like, "It's all my fault." Then they look at C, perceived consequences of the event: "I'll never find another boyfriend." And finally and critically, they engage in D, disputing their thoughts and assumptions by asking questions like, "Am I being realistic?" or "Would other people see it the same way?"
Working in small groups of three to 10 works well for adolescents, says psychologist Gregory Clarke, who pioneered the program and is a co-author of the study. "The group can be almost a Greek chorus to bounce ideas off of, " explains Clarke, who is a senior investigator at Kaiser Permanente's Center for Health Research in Portland, Ore.
The authors hope the program will become a model for interventions that could be implemented at a reasonable cost in schools or pediatric clinics. They note that school psychologists or social workers with a master's level of education could be trained to lead the groups.
The researchers hope to publish a cost-benefit analysis of the program sometime next year. Part of the equation, however, will be to show that the benefits are lasting. The team has just received NIMH funding to follow the adolescents in the current study through their early to mid-20s.
"We hope that the program will not only prevent depression, but also the impairments associated with it," says Garber. "We will be looking at alcohol and drug use, eating problems, anxiety and behavior problems and performance in school."
The researchers will also examine what can be done for the adolescents whose parents are in the grips of depression: this subset, which was 45% of the participants, did not benefit significantly from the cognitive behavioral program. "It's awfully hard to change your thinking habits if a parent is depressed and everything is so chaotic around you," observes Clarke. Future studies, says Garber, will look at whether treating the parent for depression makes a difference.
Because it focuses on prevention, the JAMA study "really moves the field forward," says child psychologist Anne Marie Albano, who directs the Clinic for Anxiety and Related Disorders at Columbia University Medical Center. Albano says that recent surveys showing rising rates of mental illness in college students have sounded the alarm about the need to intervene earlier to prevent the cascade of social, academic, economic and emotional woes that befall teens who slip into depression. "This study is telling us that if you get kids early in the cycle of depression when they have symptoms and are on the path, you can give them skills that manage those symptoms."