Developing an Integrated CBT Program for
Pediatric Depression, Anxiety, or Their Combination
V. Robin Weersing, Ph.D.
Yale University School of Medicine
Overview of Project
Adapt CBT into brief “core component” interventions
Depression protocol Anxiety protocol Parallel structure and content with goal of full integration
Pilot test in primary care Aims
Creation of draft materials Feasibility of recruitment and retention Assessing signal to noise in outcomes
Rationale
Why anxiety and depression?
Why primary care?
Why anxiety and depression IN primary care?
Rationale
Why anxiety and depression?
Prevalent and co-occurring Impairing Treatable
Why primary care?
Why anxiety and depression IN primary care?
Rationale
Why anxiety and depression?
Why primary care?
Access Central focus on health and disease Existing role (and staff) in behavioral health
Why anxiety and depression IN primary care?
Why Anxiety and Depression IN Pediatric Primary Care?
Connection to somatic symptoms
Recurrent abdominal pain Headache Chronic pain
Why Anxiety and Depression IN Pediatric Primary Care?
Connection to somatic symptoms
Recurrent abdominal pain Headache Chronic pain
Disorders impact pediatric practice
Increased use of services Increased health risk behaviors Non-compliance with physical health treatment
Why Anxiety and Depression IN Pediatric Primary Care?
Connection to somatic symptoms
Recurrent abdominal pain Headache Chronic pain
Disorders impact pediatric practice
Increased use of services Increased health risk behaviors Non-compliance with physical health treatment
Brief evidence-based treatments available
Cognitive behavioral therapy (CBT) Selective serotonin reuptake inhibitors (SSRIs)
Overview of Intervention
Evidence-based psychosocial base model Length adapted for primary care
8 sessions delivered in 12 weeks
CBT core components selected
Literature review and meta analysis Expert survey Analog training studies Practitioner surveys
Content of Parallel CBT Protocols for Anxiety and for Depression
Session 1 2 3 4 5 6 7 8 Biological sensitivity Stressful life events Maladaptive responses Maladaptive responses Maladaptive responses Maladaptive responses Maladaptive responses Target area Anxiety protocol Psychoeducation (fight or flight) Relaxation Distraction Problem solving skills (reducing avoidance) Exposure Problem solving skills Exposure Problem solving skills Exposure Problem solving skills Exposure Problem solving skills Relapse prevention Depression protocol Psychoeducation (mood spirals) Relaxation Distraction Problem solving skills (reducing avoidance) Behavioral activation Problem solving skills Behavioral activation Problem solving skills Behavioral activation Problem solving skills Behavioral activation Problem solving skills Relapse prevention
Study Design
Recruitment
Referred by primary care staff (physicians, nurses) Recruited from two large practices Based in rural area, low SES and minimal access to mental health
Random assignment
CBT delivered on-site by primary care staff Enhanced referral to local outpatient mental health Balanced on primary diagnosis, severity, gender
Participants
Inclusion
Research diagnosis of depression or anxiety Age 8 to 17
Exclusion
Serious, unstable medical illness Alternate active intervention for internalizing problems Requires psychiatric treatment other than BCBT (PTSD, psychosis, active suicidality, bipolar, addiction)
Enrollment
87% accepted referral to study 88% met inclusion 100% consented to randomization 23 youths enrolled between January and July 2005
Data for Interim Analyses
Assessment Week 0 Week 8 (phone) Week 12 Week 16 (phone) Week 24
Demographic information Diagnostic interview (K-SADS) Clinical Global Impression Scale (improvement; CGI-I)
X X X X X
Screen for Anxiety and Related Disorders (parent, youth)
Children’s Depression Inventory (parent, youth)
X
X
X
X
X
X
X
X
X
X
Children’s Depression Rating Scale
Child Behavior Checklist Parental Beck Depression Inventory Family Assessment Device
X
X X X
X
X
Columbia Impairment Scale
Consumer satisfaction Child and Adolescent Services Assessment Insurance claims for mental and physical health services
X
X
X X
X
X X
Computed indices of cost-effectiveness
X
Global Outcomes at Week 12
100
% improved (CGI-I < 2)
80
Primary depression
60
40
20
Primary anxiety
BCBT in primary care Referral to SMHC
0
Percent Receiving Services by Week 12
100
80
Primary depression
60
40
20
Primary anxiety
BCBT in primary care Referral to SMHC
0
Percent Improved (of those receiving services)
100
% improved (CGI-I < 2)
80
Primary depression
60
40
20
Primary anxiety
BCBT in primary care Referral to SMHC
0
Symptom Trajectories for Depression Arm
25
CDI-P total scores
20
DEP CBT CDI-P
15
10
5
DEP SMHC CDI-P
0 Intake 8 weeks 12 weeks
Time
Depression Symptom Trajectories for Combined Sample by Primary Diagnosis
25
DEP CBT CDI-P
CDI-P total scores
20
DEP SMHC CDI-P
15
10
ANX CBT CDI-P
5
0 Intake 8 weeks 12 weeks
ANX SMHC CDI-P
Time
Symptom Trajectories for Anxiety Arm
35
SCARED-P total score
30
ANX CBT SCARED-P
25
20
15
ANX SMHC SCARED-P
10 Intake 8 weeks 12 weeks
Time
Anxiety Symptom Trajectories for Combined Sample by Primary Diagnosis
35
SCARED-P total score
DEP CBT SCARED-P
30
DEP SMHC SCARED-P
25
20
ANX CBT SCARED-P
15
ANX SMHC SCARED-P
10 Intake 8 weeks 12 weeks
Time
Summary and Next Steps
Overall project appears feasible
Successful recruitment procedures Acceptable treatment protocol and manuals Promising outcomes
Develop integrated anxiety and/or depression program
Anxiety common in all youths Adapt psychoeducation for broad, internalizing problems Craft combined “graded engagement” procedures
CBT Clinical Trials vs. Community Care for Pediatric Depression and Anxiety
100
% responding at 6 months
80 60 40 20 0 CBT in clinical trials Primary depression Community SMHC Primary anxiety