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Assessing the Impact of Childhood Interventions
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skip navigation About the Conference
Agenda
Commissioned Papers
Barbara J. Burns, Ph.D.
Scott N. Compton, Ph.D.
Helen L. Egger, M.D.
Elizabeth M.Z. Farmer, Ph.D.
E. Jane Costello
Tonya D. Armstrong
Alaattin Erkanli
Paul E. Greenbaum
Chi-Ming Kam
Linda M. Collins
Selected Bibliography
Program Contacts
An Annotated Review of the Evidence Base for Psychosocial and Psychopharmacological Interventions for Children with Attention-Deficit/Hyperactivity Disorder, Major Depressive Disorder, Disruptive Behavior Disorders, Anxiety Disorders, and Posttraumatic Stress Disorder

Burns, Compton, Egger & Farmer

Part 3: Studies of Childhood Depression

Links to other parts of this paper:


Studies of Childhood Depression

A review of the literature was conducted to identify empirical studies of psychosocial and pharmacological treatments of children with depression. This review was conducted in two stages. First, systematic computerized literature searchers were conducted on PsycINFO and Medline databases, with keywords depression and major depression. The resulting list of references was reduced to include only those studies that: (1) were identified in the electronic database by one or more of the following study descriptors: treatment outcome study, clinical trial, controlled clinical trial, or randomized controlled trial; (2) included subjects between the ages of 6 and 12 as the primary treatment target population, although studies that included younger children and adolescents were not excluded; (3) were published between 1985 and 1999; and (4) were published in the English language. Second, reference lists obtained from review articles and book chapters were searched to ensure that all of the relevant studies had been identified. This search strategy resulted in 28 potential studies. This list was further reduced by excluding studies for the following reasons: depression was a secondary comorbid diagnosis (e.g., mentally retarded children, socially anxious children, medically ill children; = 4); the study focus was other than treatment outcome (e.g., effects of extended evaluation on symptoms of depression, factors related to correspondence to teacher and child ratings, information processing in recovered depressed children; n = 4); or subjects were not randomly assigned to treatment conditions (n = 1). This process identified 19 peer-reviewed controlled studies of children with either depression or depressive symptoms. These studies are presented and described in table 2.

Perhaps the most striking conclusion that can be drawn from the current review of empirical studies of childhood depression is the relative paucity of well-controlled outcome studies with this population. Psychosocial and pharmacological interventions are the two primary treatment modalities that have been studied. The psychosocial interventions investigated include individual and group cognitive behavior therapy, self-control training, and problem-solving and social skills training. The pharmacological interventions include tricyclic antidepressants (imipramine, nortriptyline), selective serotonin reuptake inhibitors (fluoxetine), and phenethylamine monoamine reuptake inhibitors (venlafaxine).

Generally, it can be concluded that both cognitive behavior therapy and self-control therapy are efficacious treatments for children with symptoms of depression. However, with few exceptions, the inclusion criteria for psychosocial treatments were based on depressive symptoms rather than a diagnosis of depression, and treatments usually occurred in school settings with an average of 12 sessions. Few of these studies reported followup data. In the few studies reporting longitudinal data, treatment gains were maintained at followup.

Research addressing the efficacy of tricyclic antidepressants for the treatment of childhood depression failed to find superiority for its use over placebo. Thus, there is no evidence to suggest that tricyclic antidepressants should be used in the treatment of children with depression. However, studies investigating the effectiveness of selective serotonin reuptake inhibitors are promising. One recent double-blind, placebo-controlled study of fluoxetine for childhood depression reported significant treatment effects relative to placebo. A second new generation antidepressant venlafaxine (a phenethylamine monoamine reuptake inhibitor) has not been found beneficial for this population. Well designed studies regarding the safety, efficacy, and long-term use of antidepressant medication need to be conducted before strong statements can be made regarding their overall efficacy in the treatment of childhood depression.

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Table 2.1 Psychosocial Studies of Childhood Depression
Study Citation(s) Study Design/
Description
Target Population Demographic Characteristics Outcomes Notes
Butler, Miezitis, Friedman, & Cole, 1980 Quasi-experimental design; 10-session school-based group treatment for depression; role-playing (n = 14) vs. cognitive restructuring
(n = 14) vs. attention-placebo (= 13) vs. classroom control (n = 14)
Nondiagnosed schoolchildren with mild to moderate depressive symptoms; subjects selected on the basis of self-report and teacher referral Age: 11 – 12

Gender:
63% boys
37% girls

Race/Ethnicity: DK

Role-playing and cognitive restructuring groups showed most improvement No followup data; method of assignment to groups unspecified; no standard diagnostic criteria
Jaycox, Reivich, Gillham, & Seligman, 1994; Gillham, Reivich, Jaycox, & Seligman, 1995 Quasi-experimental design; 12 session school-based group treatment; cognitive training and social problem-solving (n = 69) vs. wait-list and no participation control (n = 74) Non-diagnosed school children identified as at-risk (current level of depressive symptoms and parental conflict) on the basis of self-report measures Age: 10 – 13

Gender:
54% boys
46% girls

Race/Ethnicity:
83% White
11% African American
6% Other

Treatment group showed significant decrease in and prevention of depressive symptoms relative to control group; no between-group differences in internalizing and externalizing behavioral problems and explanatory style Treatment gains maintained at 6-month followup; treatment effects grew larger at 2-year followup; no standard diagnostic criteria
Kahn, Kehle, Jenson, & Clark, 1990 RCT; 12-session school-based group treatment; cognitive-behavioral therapy (= 17) vs. relaxation training (n = 17) vs. self-modeling treatment (= 17) vs. wait-list control Nondiagnosed schoolchildren with mild to moderate depressive symptoms; subjects selected on the basis of self-report measures and structured clinical interview Age: 10 – 14

Gender:
48% boys
52% girls

Race/Ethnicity: DK

All active treatment conditions showed decrease in depressive symptoms and increase in self-esteem relative to wait-list control Treatment effects maintained at 4-week followup; subjects in cognitive-behavioral group showed most improvement; subjects in self-modeling group more likely to relapse; small sample size
Liddle & Spence, 1990 RCT; 8-session school-based group treatment; social competence training (n = 11) vs. attention placebo
(n = 10) vs. wait-list control (n = 10)
Nondiagnosed schoolchildren with mild to moderate depressive symptoms; subjects selected on the basis of self-report measures and nonstandardized clinical interview Age: 7 – 11

Gender:
68% boys
32% girls

Race/Ethnicity: DK

All groups showed decrease in depressive symptoms; no significant between-group differences Treatment effects maintained at 8-week followup; no standard diagnostic criteria; small sample size
Stark, Reynolds, & Kaslow, 1987 RCT; 12-session school-based group treatment; self-control training (n = 9) vs. behavioral problem-solving (n = 10) vs. wait-list control (n = 9) Nondiagnosed schoolchildren with mild to moderate depressive symptoms; subjects selected on the basis of self-report measures and semi-structured interview Age: 9 – 12

Gender:
57% boys
43% girls

Race/Ethnicity: DK

Both active treatments showed significant improvement relative to wait-list control Treatment effects maintained at 8-week followup; small sample size; no standard diagnostic criteria
Stark, Rouse, & Livingston, 1991 RCT; 24- to 26-session school-based group and home treatment; cognitive-behavioral group treatment (n = 12) vs. traditional group counseling (= 12) Nondiagnosed schoolchildren with mild to moderate depressive symptoms; subjects selected on the basis of self-report measures Age: 9 – 13

Gender: DK

Race/Ethnicity: DK

Within-group analyses showed a reduction in depressive symptoms in both treatment groups; between-group analyses showed that cognitive-behavioral group was superior to traditional group counseling No between-group differences at 7-month followup; no standard diagnostic criteria
Vostanis, Feehan, Grattan, & Bickerton, 1996; Vostanis, Feehan, Grattan, & Bickerton, 1996; Vostanis, Feehan, & Grattan, 1998 RCT; 9-session outpatient clinic-based individual treatment; cognitive-behavioral (n = 29) vs. nonfocused intervention
(n = 28)
Inpatient depressed children; subjects selected on the basis of self-report measures and semi-structured interview Age: 8 – 17

Gender:
44% boys
56% girls

Race/Ethnicity:
88% White
9% Asian
3% African American

Both groups showed decrease in depressive symptoms and improvement in social functioning Treatment gains for both groups were maintained at 9-month and 2-year followup; same therapists presented both treatments; no measure of treatment adherence
Weisz, Thurber, Sweeney, Proffitt, & LeGagnoux, 1997 RCT; 8-session school-based group treatment; cognitive-behavioral treatment (n = 16) vs. no treatment control (= 32) Nondiagnosed schoolchildren with mild to moderate depressive symptoms; subjects selected on the basis of self-report measures and semi-structured interview Age: 8 – 12

Gender:
54% boys
46% girls

Race/Ethnicity:
63% White
37% African American

Treatment group showed significant decrease in depressive symptoms relative to no treatment control Treatment effects maintained at 9-month followup; small sample size; no attention placebo control group
Wood, Harrington, & Moore, 1996 RCT; outpatient clinic-based individual treatment; cognitive-behavioral treatment (n = 24) vs. relaxation training control
(n = 24)
Outpatient depressed children; subjects selected on the basis of standardized semi-structured interview Age: 9 – 17

Gender:
31% boys
69% girls

Race/Ethnicity: DK

Treatment group showed significant decrease in depressive symptoms relative to relaxation training control; no between-group differences on measures of anxiety and conduct symptoms Between-group differences were smaller at 3-month followup; groups did not differ at 6-month followup


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Table 2.2 Psychopharmacological Treatments of Childhood Depression
Study Citation(s) Study Design/
Description
Target Population Demographic Characteristics Outcomes Notes
Emslie, Rush, Weinberg, Kowatch, Hughes, Carmody, & Rintelmann, 1997; Emslie, Rush, Weinberg, Kowatch, Carmody, & Mayes, 1998 Double-blind, placebo-controlled RCT; 8-week fluoxetine (n = 48) vs. placebo (n = 48) Outpatient depressed children and adolescents; subjects selected on the basis of standardized semi-structured interview Age: 7 – 17

Gender:
54% boys
46% girls

Race/Ethnicity:
73% White
27% Other

Significant decrease in depressive symptoms for fluoxetine vs. placebo; differences were evident at week 5 Between-group differences were less evident on self-report measures
Geller, Cooper, McCombs, Graham, & Wells, 1989 Double-blind, placebo-controlled RCT; 8-week nortriptyline (n = 26) vs. placebo (n = 24) Outpatient depressed children; subjects selected on the basis of standardized semi-structured interview Age: 5 – 12

Gender:
70% boys
30% girls

Race/Ethnicity:
90% White
10% Other

No significance difference in response rate between nortriptyline and placebo groups No followup data; small sample size
Hughes, Preskorn, Weller, Weller, Hassanein, & Tucker, 1990 Double-blind, placebo-controlled RCT; 6-week imipramine in children with pure depression or depression plus anxiety (n = 14) vs. children with depression plus conduct/oppositional disorder (n = 17) vs. placebo Inpatient depressed children with comorbid anxiety or conduct/oppositional disorder; subjects selected on the basis of consensus diagnosis using self-report measures and a semi-structured interview Age: 6 – 12

Gender: DK

Race/Ethnicity: DK

Both depression groups improved; higher placebo response rate among depressed children with conduct/oppositional disorder No followup; small sample size
Mandoki, Tapia, Tapia, Sumner, & Parker, 1997 Double-blind, placebo-controlled RCT; 6-week venlafaxine and psychotherapy (n = 16) vs. placebo and psychotherapy (n = 17) Outpatient depressed children and adolescents; subjects selected on the basis of clinician interview Age: 8 – 18

Gender:
25% boys
75% girls

Race/Ethnicity: DK

No significance difference in response rate between the two treatment groups No followup data; no standard diagnostic criteria; small sample size
Preskorn, Weller, Hughes, Weller, & Bolte, 1987 Double-blind, placebo-controlled RCT; 6-week imipramine (n = 10) vs. placebo (n = 12) Inpatient depressed children; subjects selected on the basis of unstructured and standardized clinical interviews Age: 6 – 12

Gender: DK

Race/Ethnicity: DK

Significant reduction in depressive symptoms for imipramine group relative to placebo group Treatment effect detected within 3 weeks of starting drug therapy; no followup data; small sample size
Puig-Antich, Perel, Lupatkin, Chambers, Tabrizi, King, Goetz, Davies, & Stiller, 1987 Double-blind, placebo-controlled RCT; 5-week imipramine (n = 16) vs. placebo (n = 22) Outpatient depressed children; subjects selected on the basis of standardized semi-structured interview Age: M = 9.11, SD = 1.43

Gender:
61% boys
39% girls

Race/Ethnicity:
42% White
37% African American
21% Hispanic

No significance difference in response rate between imipramine and placebo groups Study terminated early due to imipramine nonresponse; high placebo response rate; small sample size

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References
Studies of Childhood Depression

Butler, L., Miezitis, S., Friedman, R., & Cole, E. (1980). The effect of two school-based intervention programs on depressive symptoms in preadolescents. American Educational Research Journal, 17, 119.

Emslie, G. J., Rush, A. J., Weinberg, W. A., Kowatch, R. A., Hughes, C. W., Carmody, T., & Rintelmann, J. (1997). A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Archives of General Psychiatry, 54, 1031-1037.

Emslie, G. J., Rush, A. J., Weinberg, W. A., Kowatch, R. A., Carmody, T., & Mayes, T. L. (1998). Fluoxetine in child and adolescent depression: Acute and maintenance treatment. Depression and Anxiety, 7, 32-39.

Geller, B., Cooper, T. B., McCombs, H. G., Graham, D., & Wells, J. (1989). Double-blind, placebo-controlled study of nortriptyline in depressed children using a "fixed plasma level" design. Psychopharmacology Bulletin, 25, 101-108.

Gillham, J. E., Reivich, K. J., Jaycox, L. H., & Seligman, M. E. (1995). Prevention of depressive symptoms in schoolchildren: Two-year follow-up. Psychological Science, 6, 343-351.

Hughes, C. W., Preskorn, S. H., Weller, E., Weller, R., Hassanein, R., & Tucker, S. (1990). The effect of concomitant disorders in childhood depression on predicting treatment response. Psychopharmacology Bulletin, 26, 235-238.

Jaycox, L. H., Reivich, K. J., Gillham, J., & Seligman, M. E. (1994). Prevention of depressive symptoms in school children. Behaviour Research and Therapy, 32, 801-816.

Kahn, J. S., Kehle, T. J., Jenson, W. R., & Clark, E. (1990). Comparison of cognitive-behavioral, relaxation, and self-modeling interventions for depression among middle-school students. School Psychology Review, 19, 196-211.

Liddle, B., & Spence, S. H. (1990). Cognitive-behaviour therapy with depressed primary school children: A cautionary note. Behavioural Psychotherapy, 18, 85-102.

Mandoki, M. W., Tapia, M. R., Tapia, M. A., Sumner, G. S., & Parker, J. L. (1997). Venlafaxine in the treatment of children and adolescents with major depression. Psychopharmacology Bulletin, 33, 149-154.

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Preskorn, S. H., Weller, E. B., Hughes, C. W., Weller, R. A., & Bolte, K. (1987). Depression in prepubertal children: Dexamethasone nonsuppression predicts differential response to imipramine vs. placebo. Psychopharmacology Bulletin, 23, 128-133.

Puig-Antich, J., Perel, J. M., Lupatkin, W., Chambers, W. J., Tabrizi, M. A., King, J., Goetz, R., Davies, M., & Stiller, R. L. (1987). Imipramine in prepubertal major depressive disorders. Archives of General Psychiatry, 44, 81-89.

Stark, K. D., Reynolds, W. M., & Kaslow, N. J. (1987). A comparison of the relative efficacy of self-control therapy and a behavioral problem-solving therapy for depression in children. Journal of Abnormal Child Psychology, 15, 91-113.

Stark, K. D., Rouse, L. W., & Livingston, R. (1991). Treatment of depression during childhood and adolescence: Cognitive-behavioral procedures for the individual and family. In P. C. Kendall (Ed.), Child and Adolescent Therapy: Cognitive-Behavioral Procedures (pp. 165-206). New York: The Guilford Press.

Vostanis, P., Feehan, C., & Grattan, E. (1998). Two-year outcome of children treated for depression. European Child and Adolescent Psychiatry, 7, 12-18.

Vostanis, P., Feehan, C., Grattan, E., & Bickerton, W. L. (1996). A randomised controlled out-patient trial of cognitive-behavioural treatment for children and adolescents with depression: 9-month follow-up. Journal of Affective Disorders, 40, 105-116.

Vostanis, P., Feehan, C., Grattan, E., & Bickerton, W.-L. (1996). Treatment for children and adolescents with depression: Lessons from a controlled trial. Clinical Child Psychology and Psychiatry, 1, 199-212.

Weisz, J. R., Thurber, C. A., Sweeney, L., Proffitt, V. D., & LeGagnoux, G. L. (1997). Brief treatment of mild-to-moderate child depression using primary and secondary control enhancement training. Journal of Consulting and Clinical Psychology, 65, 703-707.

Wood, A., Harrington, R., & Moore, A. (1996). Controlled trial of a brief cognitive-behavioural intervention in adolescent patients with depressive disorders. Journal of Child Psychology and Psychiatry and Allied Disciplines, 37, 737-746.

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