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Warwick BABCP conference: 1st afternoon - treating adolescent anxiety & depression, and depressive rumination (3rd post)

I have already written about the pre-conference workshop I went to on "Anger dysregulation" and the presentations on the first morning of this year's summer CBT conference in "Warwick BABCP conference: 1st morning - trauma memories & a master presentation on four decades of outcome research (2nd post)".  In the afternoon I attended a symposium on "Improving treatment of anxiety and depression in adolescence" and then went on to a keynote by the Australian professor Michelle Moulds entitled "Rumination and memory in depression".

Time in the symposium was pretty squeezed with five lectures in two hours.  Sue Spence talked about "The development and evaluation of a national, self-help, online CBT program for child and adolescent anxiety".  She pointed out that over 50% of mental health problems in adult life (excluding dementia) start by age 14 and 75% by age 18.  Apparently too, less than 25-35% of those with a diagnosable mental health condition access support (2005 UK national survey).  Sue underlined "We must make it much easier for a child or young person to seek help and support in non-stigmatised settings."  Polly Waite spoke on "The effectiveness of an internet-based treatment (BRAVE-Online) with adolescents with anxiety disorders: Does this work in routine clinical setting and do parent sessions improve treatment outcome?".  Katy Smart & Lydia Smith had put together a presentation on "Parent and adolescent experiences of an online CBT program for anxiety disorders".

Laura Pass then spoke on "Brief behavioural activation for adolescent depression (BATD-A)".  She pointed out that in children & young people, "irritability" may be a more obvious symptom than "low mood", and that kids are often made to continue activities by parents/school although they have lost enjoyment.  Apparently up to 20% of adolescents will experience an episode of depression by the time they reach 18 years old (and 50% of all depressed adults were first depressed before age 18).  About 1 in 40 adolescents are currently depressed. Sadly being depressed in one's teens has worrying implications for adulthood, with increased likelihood of adult depression, substance abuse, underachievement in education and employment, and increased chance of becoming a parent before age 21.  Laura went on to introduce the behavioural theory of depression maintenance which involves reinforcement for depressed behaviour, and/or lack of reinforcement for non-depressed behaviour.

She talked about three levels of behavioural activation (BA) approach - Activity Scheduling, an ultra brief simple approach, often used as the initial stage of CBT with depression, and a key technique in adult IAPT settings (e.g. PWP intervention involving 3 to 8 half hour sessions over the phone or face to face); Lejuez et al's method, a brief treatment not involving functional analysis which focuses on values, typically delivered across 5 to 10 sessions; and Martell et al's approach, incorporating detailed functional analysis, as well as consideration of avoidance and approach behaviours, delivered usually over 20 to 24 sessions.  It's worth pointing out however that there is little evidence to suggest that making BA more complex adds to its effectiveness, so Eker's et al's 2014 meta-analysis - "Behavioural activation for depression: an update of meta-analysis of effectiveness and sub-group analysis- reported that "We found no association between effect size and the level of complexity of the BA used in studies where functional analysis and other 'complex' elements were added ... In addition to complexity we explored the number of sessions via meta-regression.  The median number of sessions in included studies was eight, there was no evidence that the number of sessions was associated with effect size."  

As had been already pointed out, many depressed adolescents continue to be fairly active ... partly because of parental & school pressure.  They do often however report irritability & loss of enjoyment.  Laura Pass's intervention used Lejuez's behavioural activation approach to encourage activities that adolescents valued and to decrease reinforcement for depressive behaviours.  She highlighted four "key concepts" - 1.) Consideration of key life areas.  2.) Identification of values in each life area.  3.) Selection and daily engagement in valued activities.  4.) Structure & support available to live a valued life.  I have explored these issues of increasing focus on enjoyment & values in the past in a couple of blog posts - see "Targeting behavioural activation better both for decreasing depression and increasing wellbeing".

Laura's treatment - Brief Behavioural Activation for Adolescents (BATD-A) - consists of 8 one-hour sessions, weekly (offer 2x weekly for first fortnight if possible) with a 9th review session a month after session 8.  Parents were invited to sessions 1, 6, 8 and review.  Weekly questionnaires were used including a depression measure and, interestingly, my old friends the ORS & SRS - see, for example, the post "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent & potentially dangerous".  Session content apparently looks like - Session 1 (+P): BA rationale, activity log.  Session 2: Review activity log, balance of activities.  Session 3: Life Areas and Values, do 1 target activity.  Session 4: Introduce Valued Activities, do 3 target activities.  Session 5: Review valued activities, schedule them.  Session 6 (+P): Progress review, contracts, problem-solving.  Session 7: New activity cycle, areas left to work on.  Session 8 (+P): Relapse prevention. Review (+P): Review progress, review care plan.

Interesting stuff, and we then moved onto the heavyweight presentation of the symposium, or at least the heavyweight-in-training presentation as the described IMPACT research trial's results won't be reported until next year.  IMPACT is an acronym for Improving Mood with Psychodynamic and Cognitive Therapies.  Shirley Reynolds, the presenter, has presumably been eating & sleeping this trial for a good while now ... 475 young people randomised to one of 3 manualised conditions - short term psychodynamic psychotherapy (28 sessions + 5 parent), CBT (20 sessions), and brief psychosocial intervention (12 weeks).  Primary outcome is relapse at 86 weeks.  IMPACT MR is a piggyback MRI study and IMPACT ME an additional qualitative one.  Big, expensive stuff.  I was interested to hear Shirley comments that she'd found (in this multi-centre study) that delivery of psychological therapy in routine CAMHS is highly variable and unpredictable, and that engagement of depressed adolescents in any therapy is a pretty big challenge (no face-to-face treatment is going to work if the client is absent!).  I chatted to her a bit afterwards about this study.  It's exciting ... not least because of the impressive involvement of the psychodynamic psychotherapists.  There's a big question around whether their more extensive input will result in more prolonged treatment gains.  Breath-holding stuff!

And then on to a choice of a final keynote.  I went to Michelle Moulds presenting on "Rumination and memory in depression".  She gave Nolen-Hoeksema's 1991 definition of depressive rumination - "responding to sad mood with thoughts that focus attention on depressive symptoms and their possible causes, meanings and implications".  She affirmed that there's a substantial amount of evidence that rumination predicts the onset and maintenance of depression.  My sense was that Michelle is deeply immersed in her areas of research - rumination, abstract & concrete thinking, observer perspective, effects of pleasant & unpleasant mood, and so on.  She gave quite an extensive, thoughtful review of where she is in some of her research explorations.  For other researchers and would-be researchers in these fields, I'm sure there was much that Michelle said to look at and chew over.  The problem for a "jobbing clinician" like me was that there was little of immediate practical value to take away.  I was left with a mixed sense of respect and frustration.  Partly I wanted to say something like "Go away and keep following these fascinating questions with the admirable understanding & rigour you obviously bring to these subjects.  When you have developed some new clinically useful insights, please come back and talk again at a general conference like this ... but not until then!"

For the next post on the second full day of the conference see "Warwick BABCP conference: 2nd day - behavioural activation, Kyrios OCD, 'mind the gap', & DeRubeis on personalization (4th post)".


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