Mindfulness Intervention to Study the Neurobiology of Depression
Phase: NA
Conditions: Depression
Sponsor: University of Illinois at Chicago

 
 
 
MINDFULNESS INTERVENTION TO STUDY THE NEUROBIOLOGY OF DEPRESSION: MIND 
RACHEL H. JACOBS 
 
UNIVERSITY OF ILLINOIS AT CHICAGO 
 
KLINGENSTEIN THIRD GENERATION FUND 
UNIVERSITY OF ILLINOIS AT CHICAGO CAMPUS RESEARCH BOARD 
NATIONAL CENTER FOR ADVANCING TRANSLATIONAL SCIENCES 
MIND AND LIFE INSTITUTE 
 
IRB PROTOCOL VERSION 7 
 
6/30/14 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
Specific Aims:   
Approximately 50% of adolescents with a history of depression experience recurrent 
symptoms within two years of recovery from a major depressive episode (Curry et al, 2011).  
Depression during adolescence is associated with functional impairment, suicide, and depression 
in adulthood (Gould et al., 1998; Lewinsohn et al., 1999).  No currently available treatment 
protects adolescents from these lifelong sequelae.  The objective of the proposed study is to 
examine how rumination, a maladaptive thought pattern, serves as a mechanism in the 
maintenance of depression, particularly in the relapse of depression among adolescents.  A novel 
intervention targeting this mechanism, Rumination-focused Cognitive Behavior Therapy (R-
CBT; Levin & Nolen-Hoeksema, 2011), adapted from Rumination-focused Cognitive Behavior 
Therapy for residual depression in adults (Watkins et al., in press) will be evaluated in 
preventing the relapse of depression among youth (ages 12 – 18) who have already experienced 
MDD. In addition, resting state network (RSN) connectivity analysis and functional MRI using 
an emotion regulation task will be used to investigate how rumination effects the functioning of 
the default mode network (DMN) as well as frontolimbic regions and whether R-CBT improves 
the functioning of this system in youth with a history of MDD.  
 
Aim 1: To pilot R-CBT as a prevention program for the recurrence of adolescent depression, 30 
adolescents with a previous diagnosis of MDD will be randomized to either eight weeks of R-
CBT or an assessment control. 
• Hypothesis 1a: R-CBT will result in stable or decreased ruminative tendencies; whereas youth 
in the control condition will demonstrate stable or increased ruminative tendencies. 
• Hypothesis 1b: R-CBT will result in a greater decrease in residual depression symptoms 
compared to controls. 
• Hypothesis 1c: Adolescents who receive R-CBT will be less likely than adolescents in the 
control condition to relapse to a full major depressive episode over the two year follow-up 
period. 
 
Aim 2: To use RSN connectivity and fMRI to investigate how rumination impedes emotion 
regulation among adolescents with a history of MDD. 
• Hypothesis 2a: Higher levels of rumination will be associated with hyperconnectivity of the 
DMN. 
• Hypothesis 2b: Higher levels of rumination will be associated with aberrant activity in 
frontolimbic regions (i.e., prefrontal cortex and amygdala), during performance of a rumination 
induction.  
• Hypothesis 2c: Adolescents who demonstrate reductions in rumination during R-CBT will also 
demonstrate normalized DMN connectivity and frontolimbic activity during a rumination 
induction.  
 
Aim 3: To examine whether adolescents with a history of MDD differ from their healthy peers in 
terms of brain connectivity or functioning.  

 
 
• Hypothesis 3a: Youth with a history of depression will demonstrate increased intrinsic 
functional connectivity within the DMN and between the DMN, SN, and EN relative to HC 
youth  
• Hypothesis 3b: Youth with a history of depression will report higher levels of rumination 
when compared to HCs. Increasing levels of rumination will be associated with increased 
functional connectivity between the DMN and frontolimbic regions. 
• Hypothesis 3c: When explicitly challenged with a rumination induction, youth with a history 
of MDD will demonstrate greater activation in DMN and frontolimbic regions in comparison 
to HC youth.  
• Hypothesis 3d: Self-report rumination will predict observed connectivity within the DMN 
and frontolimbic regions among both youth with a history of MDD and HCs.  
 
Background and Significance: 
Rumination is a response to distress involving a passive and perseverative thought 
pattern, rather than active problem solving.  A tendency to ruminate predicts the future onset, 
number, and duration of major depressive episodes (for a review see Nolen-Hoeksema, Wisco, & 
Lyubomirsky; 2008).  Moreover, research has demonstrated that MDD is one of the most 
prevalent disorders among adolescents (Costello et al., 2006), making the availability of 
interventions that effectively prevent relapse critically important in ameliorating the life-long 
consequences of recurrent depression.   
Currently, no published studies examine the impact of rumination on the neural systems 
implicated in emotion regulation among adolescents.  The proposed study will examine whether 
decreases in maladaptive ruminative tendencies are associated with a normalization of brain 
connectivity during the resting state in regions of the DMN as well as functional activity during 
task requiring emotion regulation in frontolimbic regions.  Disturbances in the ability to regulate 
emotion within frontolimbic circuits and the DMN likely contribute to the persistence of 
depression over the lifespan (Pizzagalli, 2011).  Thus, in addition to examining how rumination 
disrupts effective emotion regulation, thereby contributing to the maintenance and reoccurrence 
of adolescent depression; this study will examine whether a rumination intervention can 
normalize resting state and functional disturbances in these brain regions.   
Preliminary evidence suggests depression and rumination are correlated with DMN 
activity and connectivity.  For example, greater activations in DMN regions during the resting 
state are associated with higher levels of depressive rumination (Hamilton et al., in press).  
Internally focused thought is associated with increased DMN connectivity and interferes with the 
performance of cognitive tasks (Sheline et al., 2010).  Moreover, a ruminative self-focus is 
associated with enhanced recruitment of limbic, medial, and dorsolateral prefrontal regions 
(Cooney et al., 2010), as well as altered recruitment of mechanisms that potentiate negative 
affect (Ray et al., 2005).  In sum, the DMN has been implicated in depression and has been 
linked to rumination among adults; however, these associations have not yet been explored 
among adolescents.  
A recent review of neuroimaging studies among youth converge on hypo- and 
hyperactivation aberrations in brain activity in frontolimbic regions implicated in the processing 
and regulation of emotion (Hulvershorn et al., 2011).  The emotion regulation task used in this 
protocol is designed to probe this aberrant frontolimbic circuitry.  We hypothesize that 
adolescents who engage in more frequent rumination will demonstrate aberrant activations in 
frontolimbic regions, including increased activation in regions such as the ventrolateral 

 
 
prefrontal cortex (VLPFC) and dorsolateral prefrontal cortex (DLPFC) relative to adolescents 
who engage in less rumination.  Increased connectivity between DMN regions will also be 
associated with rumination in adolescents with a history of MDD.  We further hypothesize that 
R-CBT will normalize these aberrant patterns.  In contrast, adolescents who do not receive R-
CBT will continue to demonstrate exaggerated DMN connectivity and aberrant frontolimbic 
activations during emotion regulation task compared to the first scan and the R-CBT comparison 
group.   
The proposed project is innovative in testing a novel intervention that targets a known 
mechanism, rumination, in the relapse of depression.  This contribution will be significant in that 
it may curtail the high relapse rates of depression observed among adolescents.  This 
investigation will also be the first to examine whether modulating the neural circuits involved in 
rumination can increase emotion regulation among adolescents, thereby preventing depression 
relapse.  
 
Research Plan:   
Participants and Protocol This study will dovetail on ongoing recruitment for the study of mood 
disorders among youth in the Colbeth Clinic. The clinic is located within the Institute for 
Juvenile Research (IJR), together with several other child psychiatry clinics and research labs, 
and is the home to the Pediatric Mood Disorders Program. The Psychiatry Department at UIC 
has the largest pediatric psychiatry academic program in Chicago for the evaluation and 
treatment of mood and anxiety disorders, ADHD, and autism. Chicago has a population of 11 
million in the greater metro area and surrounding communities. The patient population is socio-
demographically diverse, with strong representation from various racial groups, including 
Caucasian, African-American, and Hispanic individuals. There are few other academic programs 
in the city or surrounding states that are actively competing for the recruitment of affectively 
disordered youth.  As such, the proposed project will capitalize on existing resources and 
infrastructure.  Thirty adolescents with past MDD who are currently in partial or full remission 
and who agree to participate will be randomized to receive eight weeks of R-CBT in a one-on-
one individual format or to an assessment only control condition.   
Recruitment We will not use clinic records to identify patients.  Our main source of recruitment 
will be flyers in the clinic and community with potential participants initiating the first contact.  
Examples of community sources include community centers, public libraries, health centers, and 
school guidance counselors. Potential participants will still be responsible for contacting study 
staff to initiate potential participation.  Individuals will not be approached in person about the 
study in these community locations.  Similarly, guidance counselors and school staff will only 
display and distribute approved study materials.  They will not provide study staff with potential 
participant contact information. The phone screen is likely to occur over the phone, but may 
occur in person if the participant/participant’s family prefers.  Clinicians in PMDC/Pediatrics 
will also give out our contact information if they identify potential participants.  If a participant 
gives the clinician verbal consent for us to initiate contact with them, we will do so.  We will 
also post on a variety of online recruitment sites. Examples include craigslist, clinicaltrials.gov, a 
listserv called the neighborhood parents network, and place an ad in the NAMI Chicago 
newsletter (please see attached script). Periodically, we will run advertisements on Chicago 
public transit (please see attached draft ad).  

 
 
Randomization The randomization procedure will be generated by computer and given in a 
sealed envelope to the staff member meeting with the adolescent at the MRI visit.  We will 
stratify based on gender and age (breaking at 15). 
R-CBT This intervention targets rumination and other maladaptive forms of emotion regulation 
such as suppression and avoidance and provides skills training in effective coping strategies.  
Mindfulness is a key component of this intervention as a strategy for disengaging from one’s 
thoughts.  Strategies from Dialectical Behavior Therapy (DBT), such as the use of effective 
interpersonal skills, are also included as methods for regulating strong emotion.  R-CBT is a 
structured, manual based program designed to be delivered weekly over eight weeks.  Sessions 
are 60-90 minutes in length.  Twenty-five adolescents will receive eight weeks of R-CBT. 
Session 1: Introduction – psychoeducation, BIG and ASK skills 
Session 2: Becoming more aware – an introduction to mindfulness 
Session 3: Changing the channel and behavioral activation 
Session 4: Body scan, opposite action, awareness of emotion 
Session 5: Psychoeducation about rumination and problem solving 
Session 6: Mindfulness of breath and promoting positive emotions 
Session 7: Rumination about anger and assertiveness, the context of relationships 
Session 8: Mindfulness of emotions, increasing positive emotions 
Assessment-only control Fifteen adolescents will complete ongoing clinical assessments as well 
as a pre- and post- MRI.  As these adolescents will be in remission at the time of the wait-list and 
will receive close monitoring, this design is feasible and ethically sound.  Any adolescent who 
experiences a relapse during the course of the study will receive a treatment referral if they do 
not already have a clinician. 
Healthy Control Twenty-five age-, sex-, and IQ- matched healthy participants (no current or past 
psychiatric history) will complete clinical assessments and an fMRI scan at baseline. Healthy 
control participants will not receive treatment or long-term clinical monitoring.  
Medication management:  Participants may remain on any maintenance medication (ADHD or 
antidepressant SSRI/SNRI) through the course of the study.  Medication will not be altered in 
any way because of participation in this study although psychiatrists treating participants may 
ask the study therapist for information regarding the participant’s symptoms for the purposes of 
providing the best quality of continuing care.  Medication treatment is not a focus of this study, 
but will be closely monitored as reported by the child and parent and documented on the 
treatment log.   
Eligibility: 
Human Subjects Involvement and Characteristics 
This study will involve 40 youth (25 R-CBT, 15 Assessment Only) ages 12-18 with a history of 
unipolar depression and their parent/s,and 25 matched healthy controls. 
Inclusion Criteria  
1. Previous diagnosis of Major Depressive Disorder according to DSM-IV criteria confirmed 
by the KSADs that is currently in partial or full remission.  Partial remission is defined as 
not meeting full DSM-IV criteria for MDD; whereas full remission requires 8 weeks with 
an absence of clinically significant symptoms.  
2. Stabilized on medication. All study subjects will be stabilized on medication meaning they 
have been on an antidepressant (SSRI or SNRI) for a minimum of 6 weeks, with no dose 
changes within the 2 weeks prior to entering the study.  Medication changes over the 
course of the study will be closely documented.Participants not taking any psychiatric 

 
 
medication are also eligible, provided they are in remission and meet other 
inclusion/exclusion criteria. 
3. 12-18 years of age must have one parent available who speaks English 
4. Youth assent, parent consent including agreement for sessions and assessments to be 
recorded (digital audio recording).  
5.  IQ > 70, determined by a WASI scale.  
 
Exclusion Criteria  
1. IQ < 70 
2.  Currently meeting full criteria for MDD (or endorsement of current suicidality with plan or 
intent (assessed via KSADS and CDRS clinical interviews).  Adolescents who have a CDRS 
score > 65 or more than 3 symptoms of MDD rated as clinically significant (scores of 3 on the 
KSADS) must have an outside clinician in order to participate in the study. Suicidality must be 
absent for a minimum of 2 weeks before entry into the study can be reconsidered. 
3. Concurrent psychiatric diagnoses will not be exclusionary if secondary to MDD, with the 
exception of lifetime history of autism, any psychotic disorder, bipolar disorder, an eating 
disorder, or alcohol/substance abuse within the previous 6 months.   
4. Metal braces or retainers - these subjects may enroll in the study at a later date if/when 
orthodontics are removed.  If these potential subjects are in need of psychiatric services, they 
will be given referrals. 
5. Claustrophobia 
6. Recent (within two weeks) change in antidepressant (SSRI/SNRI) medication. 
7. Severe neurological disorder or mental illness that would interfere with participation in the 
study. 
8. Current pregnancy – Parents will be asked this information at the phone screen.  At the clinic 
eligibility visit, female participants will be asked about sexual activity in a private room separate 
from their parents using the pregnancy script/screen that we have created. This script details that 
if a female is ineligible due to pregnancy or inadequate birth control, this information will not be 
disclosed to her parent(s).  Participants who are sexually active will be asked about birth control 
method. Abstinence will be considered an approved form of contraception.  
9. Psychotropic medication other than antidepressant (SSRI/SNRI) or ADHD medication. 
 
*The same inclusion/exclusion criteria apply for healthy-control participants, with 2 exceptions:  
(1) healthy participants may not meet criteria for any current or past psychiatric history; (2) 
healthy participants may not be taking any psychiatric medication. Depressed or suicidal 
participants cannot be screened into the healthy cohort. All participants recruited as potential 
healthy controls will undergo the same clinical evaluation as participants with a history of 
depression. This evaluation screens for both current and past depression and suicidality, as well 
as for anxiety disorders, disruptive behavior disorders, psychosis, mania, and trauma. It is 
possible that participants who are being screened as healthy controls could meet criteria for any 
of these psychological disorders. If this is the case, they will be informed that they are not 
eligible for the study. If they meet criteria for a past history of depression, they will be informed 
that they could possibly participate in the randomized arm of the study; if they are interested in 
this option they will be consented and screened as such. 
 
Schedule of Assessments: Participants with a History of MDD 

 
 
 
Adolescent Self-Report Assessment Schedule 
Measure 
Time point 
RADS 
Baseline, every 2 weeks over 
intervention, every 3 months over 
follow-up 
MASC 
Baseline, every 2 weeks over 
intervention, every 3 months over 
follow-up 
RRS 
Baseline, every 2 weeks over 
intervention, every 3 months over 
follow-up 
PESQ 
Baseline, week 8, 6 months, 12m, 
18m, 24m 
 
PANAS 
Baseline, every 2 weeks over 
intervention, every 3 months over 
follow-up 
CAMM 
Baseline, week 8, 6 months, 12m, 
18m, 24m  
BADS 
Baseline, week 8, 6 months, 12m, 
18m, 24m 
Metal Screen 
Prior to both MRIs 
Petersen Puberty Scale 
Baseline, Year 1, Year 2 
Satisfaction Questionnaire 
Week 8, Year 1, Year 2 
 
Parent Self-Report Assessment Schedule 
Measure 
Time point 
BDI 
Baseline, week 8, every 3 months 
over follow-up 
BADS 
Baseline, week 8, 6 months, 12m, 
18m, 24m  
RRS 
Baseline, week 8, every 3 months 
over follow-up 
Satisfaction Questionnaire 
Week 8, Year 1, Year 2 
Demographics/History 
Baseline 
 
 
Independent Evaluator Assessment Schedule 
Measure 
Time point 
K-SADS 
Baseline, 8 week, 6 month, 12m, 
18m, 24m 
CDRS-R 
Baseline, 8 week, 6 month, 12m, 
18m, 24m 
CGAS 
Baseline, 8 week, 6 month, 12m, 
18m, 24m 

 
 
IE Blindness 
Baseline, 8 week, 6 month, 12m, 
18m, 24m 
*IE follow-up schedule may vary as an adolescent RADS self-report total score > 60 over 
follow-up period will trigger a full IE assessment.   
*IE follow-up visits may be conducted over the phone if participants are not available to come 
into the clinic during the specified time period (e.g. away at college). Please see the attached 
instructions to the Independent Evaluator, which will be placed as a cover sheet to the interview 
packet when a phone assessment is necessary. In these instances, every effort will be made to 
schedule assessment visits during college breaks when the participant is home for holidays, but 
phone assessments will be used in the event this is impossible. 
 
 
Schedule of Assessments: Healthy Control Participants 
 
Adolescent Self-Report Assessment Schedule 
Measure 
Time point 
RADS 
Baseline 
MASC 
Baseline 
RRS 
Baseline 
PESQ 
Baseline 
 
PANAS 
Baseline 
CAMM 
Baseline 
BADS 
Baseline 
Metal Screen 
Prior to MRI 
Petersen Puberty Scale 
Baseline 
 
Parent Self-Report Assessment Schedule 
Measure 
Time point 
BDI 
Baseline 
BADS 
Baseline 
RRS 
Baseline 
Demographics/History 
Baseline 
 
 
Independent Evaluator Assessment Schedule 
Measure 
Time point 
K-SADS 
Baseline 
CDRS-R 
Baseline 
CGAS 
Baseline 
IE Blindness 
Baseline 
 
 
 
Description of Measures 

 
 
Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-
PL; Kaufman et al., 1997).  The K-SADS-PL will be administered to parents and adolescents to 
obtain youth diagnoses. It will also be used as a follow-up measure, by the IE, at 8-weeks, 6-
month, 12-month, 18-month and 24-month visits. 
Global Assessment Scale for Children (CGAS; Shaffer et al., 1983) provides a measure of global 
impairment and functioning over the previous month. The scale ranges from 1 (lowest) to 100 
(highest) functioning.  Green et al. (1994) provide evidence for the psychometric soundness of 
the CGAS and suggest that ratings obtained in clinical contexts may reflect evaluations of 
functional competence rather than symptom severity.  CGAS scores will be assigned by the IE at 
each assessment period (baseline, 8-week, 6 month, 12-month, 18-month and 24-month).   
Children’s Depression Rating Scale – Revised (CDRS-R, Poznanski & Mokros, 1996).  The 
CDRS-R is a 17-item clinician-rated depression severity measure.  Scores on the CDRS-R are 
based on interviews with the adolescent and parent and can range from 17 to 113, with higher 
scores representing more severe depression.  The scale has good internal consistency (α = .85), 
inter-rater reliability (r = .92), test-retest reliability (r = .78) and is correlated with a range of 
validity indicators including global ratings and diagnoses of depression (Poznanski & Mokros, 
1996). The CDRS will be administered by the IE at baseline, 8-week, 6-month, 12-month, 18-
month and 24-month.   
WASI The WASI is a screening instrument that estimates IQ scores rapidly and efficiently. It is 
a standardized, normed, and validated short form of both the WISC-III and the WAIS-III and 
provides a reliable and valid estimate of verbal, performance, and general intellectual 
functioning. The WASI is designed for use with individuals aged 6-89 years old and is 
individually administered. The four subtests of the WASI (vocabulary, block design, similarities, 
and matrix reasoning) tap various facets of intelligence, such as verbal knowledge, visual 
information processing, spatial and nonverbal reasoning, and crystallized and fluid intelligence. 
The WASI will be administered at the baseline visit. 
Demographics/History. The parent will complete a demographics/history form at baseline. 
Metal Screening A metal screening is delivered as part of the pre-scan procedures. This 
screening asks specifically about metallic implants and past experiences with metal to further 
ascertain any possible risks the person may incur by entering the scanner. If any metallic 
implants are reported that are unsuitable for the scanner, the subject is excluded from the study. 
If the subject is unsure of the nature of certain implants and/or there is any appreciable risk of an 
unknown implant (e.g., the subject had surgery for a brain aneurysm but is unaware of whether a 
metallic clip was placed), the experimenter will err on the side of caution and exclude the subject 
from the study. 
Reynolds Adolescent Depression Scale – 2 (RADS; Reynolds 1986). The RADS is a 30-item 
self-report measure capturing constructs of depression including dysphoria, anhedonia, negative 
self-evaluation, and somatic complaints and has good psychometric properties (Reynolds & 
Mazz, 1996). The child will complete this form at baseline, every 2 weeks over intervention, and 
every 3 months over  follow-up period. 
Child and Adolescent Mindfulness Measure (CAMM; Grego, Dew, & Baer, 2005). The CAMM 
is a developmentally appropriate measure of mindful attention for youth with adequate internal 
consistency. The child will complete this form at baseline, 8 weeks, 6-month , 12-month, 18-
month and 24-month evaluations. 
Ruminative Responses Scale (RRS; Nolen-Hoeksema & Morrow, 1991). The RRS is a 22-item 
scale that captures a stable tendency to ruminate including rumination focused on symptoms as 

 
 
well as introspection/self-isolation and self-blame. The child will complete this form at baseline, 
every 2 weeks over the intervention, every 3 months over follow-up period. The parent will 
complete this form at baseline, week 8, and every 3 months over follow-up period. 
Behavioral Activation Depression Scale (Kanter et al., 2007).  This is a self-report measure 
designed to examine the targets of behavioral activation treatment: sleeping, activity, avoidance, 
rumination, social problems, work and school problems, coping skills, mood dependent 
behaviors, and awareness and identification of problems.  The parent and child will complete this 
form at baseline, week 8, 6-month, 12-month, 18-month and 24-month. 
Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & 
Conners, 1997).  The MASC is a is a 39 item 4-point Likert self-report rating scale which has 
shown robust psychometric properties in clinical, epidemiological and intervention studies, 
includes four factors, physical symptoms (tense/restless and somatic/autonomic subfactors), 
social anxiety (humiliation/ rejection and public performance subfactors), harm avoidance 
(anxious coping and perfectionism subfactors) and separation/panic anxiety. Three-week test-
retest reliability for the MASC is .79 in clinical (March et al., 1997) and .88 in school-based 
samples (March & Sullivan, 1999).  The child will complete this form at baseline, every 2 weeks 
over the intervention, and every 3 months over the follow-up period. 
Positive And Negative Affect Scales (PANAS; Watson, Clark, & Tellegan). (1988). The PANAS 
includes two 10-item scales, one assessing positive affect and the other negative affect. The child 
will complete this form at baseline, every 2 weeks over the intervention, and every 3 months 
over the follow-up period.   
Petersen Pubertal Developmental Scale (Petersen et al., 1988). The PDS is a widely used self-
report measure of pubertal status that asks about subjective perceptions of development including 
changes in skin, height, pubic hair growth, and breast growth.  The scale was designed for 
longitudinal studies and has adequate psychometric properties and good validity. The child will 
complete this form at baseline and Year 1. 
Personal Experience Screening Questionnaire (PESQ; Winters, 1991) The PESQ provides a 
quick, cost-effective way to screen 12- to 18-year-olds for substance abuse. The child will 
complete this form at baseline, 8-weeks, 6-month, 12-months, 18-months and 24-month visits.. 
Beck Depression Inventory (Beck, Steer, & Brown, 1996). The Beck Depression Inventory 
(BDI) consists of 21 items rated on a 4-point Likert-type scale, with higher scores indicating 
greater depression. The parent will complete this form at baseline, week 8 and every 3-months 
throughout the follow-up period. 
Satisfaction Questionnaire (SQ). After the 8 week intervention and at one year, parent and child 
rate items regarding satisfaction with the intervention.   
Optional Sleep Study Measure:  
Pittsburg Sleep Quality Index (Buysse, D.J., et. Al, 1989) a 19-item questionnaire that evaluates 
indices of sleep characteristics (e.g., sleep quality, latency, duration, efficiency) and is 
considered a standard measure of sleep quality (Buysse, D.J., 2004). If an adolescent and parent 
opts into this portion of the study, this form will be completed every night for 7 nights by the 
adolescent.  The sleep study must take place during the 8 week intervention phase of the study. 
IE Blindness: This checklist allows the independent evaluator to indicate what treatment 
condition they think the participant is enrolled in and how confident they are in that rating on a 
4-point Likert-type scale (not all to completely certain).  
MRI Protocol for Scan 1 and Scan 2 
 

 
 
Pulse Sequence 
Approximate Scan Time 
3-Plane Localizer 
1 minute 
Anatomical Sequence 
5 minutes 
Resting State fMRI 
6 minutes 
Functional Imaging 
 
Rumination Task 
Self-monitoringPilot 1 
Self-Monitoring Pilot 2 
 
30 minutes 
 
MRI Scanning All adolescents with a history of MDD will be scanned twice: at baseline and then again 
at an 8 week follow-up time point corresponding to the end of the active intervention. All healthy 
control participants will be scanned once: at baseline. 
Rumination Task  
This event-related slow fMRI paradigm consists of rumination and distraction inductions and is 
based on principles of previous experimental psychology studies (i.e., Lyubomirsky & Nolen-
Hoeksema, 1993). To induce negative mood, participants are asked to generate four negative life 
events prior to entering the scanner (Failure event, Sad family event, Hurtful event, and 
Frustrating event). Prior to the scan, participants will be trained on stimuli using index cards 
providing rumination prompts for two of the generated events. At the beginning of the 
ruminative thought mini-block, participants are given mood induction instructions: ‘Remember 
the time when someone badly hurt your feelings; Remember the saddest event in your family; 
Remember the time you were so sad/frustrated that you felt there was no hope for you; 
Remember when you failed badly at something. Use your imagination to bring this fully into 
your mind and picture the event.’ The instruction ‘Focus on the idea on the screen and use your 
imagination to think in this way’ then appears for 5 seconds. The ruminative trial includes 30 
seconds of self-referential thought with prompts such as ‘what your feelings mean,’ followed 
immediately by 6 seconds of mood rating (‘How sad do you feel right now?’ and ‘How much are 
you focused on your feelings right now?’ on a 1-4 Likert scale for 3 seconds each). After every 
rumination event, there is a 10-15s jittered crosshair interval, followed by the distraction event. 
An example distraction prompt is ‘raindrops on a window.’ Prompts were modified from 
standard rumination protocols for a younger population (Hilt & Pollak, 2012). The entire task 
takes just under 10 minutes. This task has been adapted for adolescents based on fMRI research 
with adults (Johnson et al., 2009). After the scan is completed, a positive mood induction will be 
used to remedy low mood.  In addition, the PI will be available to meet with any participant who 
may be distressed and need clinical intervention. 
Self-monitoring Pilot 1 Participants will repeat the 6 minute resting state scan. At intermittent 
intervals of 15-45 seconds 4 brief questions will appear, probing the participant’s  thinking 
patterns using a likert scale of 1-4. The questions will be in line with the following: 1) How 
much did you think about your feelings? 2) How much did your mind wander to different topics? 
3) How much did you think about the past? 4) How much did you think about the future? 
Self-monitoring Pilot 2 In this instance, participants will repeat the 6 minute resting state scan 
and a quadrant will be displayed at varying intensities throughout the 6 minutes (see attached 
image).  The participant will be instructed to indicate the degree to which they are thinking about 
the past, present, or future and whether these thoughts have a negative, neutral, or positive 

 
 
valence. The purpose of manipulating the brightness of the quadrant over the course of the 6 
minutes is to control the salience of the probe, so that it is present for the participant to note the 
continuous changes in their thinking pattern moment-to-moment, but not always so salient that it 
primes a particular response. 
RSN and fMRI Data Acquisition A quadrature coil will be used to provide greater B1-field 
uniformity across the brain. Twenty-five axial slices will be acquired. Parameters for functional 
scans are: TE=25.4ms; flip angle = 82°; FOV = 20x20 cm; acquisition matrix = 64x64; TR= 1.2 
sec; 4mm slice thickness with 1mm gap. High resolution anatomic images will also be acquired 
for co-registration and normalization of the functional data. Three dimensional inversion 
recovery fast spoiled gradient recalled acquisition in the steady state or 3D IRfSPGR will be 
obtained (TR = 13.8 ms, TE = 1.9 ms, TI= 300ms, flip angle = 25°, acquisition matrix = 
512x192, FOV = 22x16.5 cm2, slices = 120, slice thickness/gap = 1.5/0 mm/mm, NEX = 1, 
bandwidth = ±22.7 kHz, acquisition= 4:18 min). Freesurfer will be used to reconstruct brain 
cortical surface from structural MRI data and co-registration. Resting state functional images 
will be preprocessed in SPM8 for slice timing correction, motion correction, image 
normalization, and 8mm Gaussian imaging smoothing. Artifact Detection Tools (ART, 
http://www.nitrc.org/projects/artifact_detect) software will be used for automatic detection of the 
global mean and motion outliers in the functional data (z-threshold = 6, and movement threshold 
= 2mm). A band-pass temporal filter with cutoff frequencies of .01- .10 Hz will be used on the 
normalized functional images to extract the low-frequency resting-state BOLD signal.  
Mock scanner training, videos and CDs will be used for scanner familiarization. A color high-
resolution LCD projector projects visual stimuli onto a rear projection screen, attached to the top 
of the magnet bore and viewed via an angled double mirror system mounted on the GE head coil.   
 
Optional Sleep Monitoring Task 
Procedures: All enrolled participants will have the option of completing a naturalistic sleep 
monitoring task. This task involves wearing a watch-like device on the wrist for eight days (7 
nights) between the baseline visit and 8 week scan. 
 
Subjects will wear actigraphs, a watch-like device, on their non-dominant wrist for eight 
days (7 nights) Ancoli-Israel, S. et al., 2003) The output of the Actiwatch will be digitally 
integrated using actigraphy principles. Actigraphy measures will be total sleep time in minutes, 
sleep onset latency in minutes (period between bed time and sleep onset), wake after sleep onset 
in minutes (time spent awake after initial onset of sleep), sleep efficiency (percentage of time in 
bed spent asleep), and sleep fragmentation (amount of interruption of sleep as manifested by 
physical movement).   
 
In addition to wearing the device, subjects will be asked to complete two subjective sleep 
quality measures. Subjects will complete the Pittsburgh Sleep Quality Index (PSQI; Buysse, D.J., 
et al., 1989), a standard measure used to assess sleep quality. They will also complete a simple 
daily sleep log requiring a yes/no response for items:1) “Do you often wake up at night and have 
a hard time falling back to sleep again?’’, 2) ‘‘Do you have difficulty staying asleep?’’, and 3) 
‘‘Do you think that you have a sleep problem?” 
 
Participants will return the monitoring device either in person at their next study visit or 
by mail. Participants that fail to return the monitoring equipment, by mail or in person, will be 
contacted via telephone by study staff and asked to return the device. They will be informed that 
the device contains personal data that is unlikely to be traceable to them, but we would like to 
remove. If participants do not respond to these requests and they have signed a release of 

 
 
information to communicate with their treating clinician, we will contact their clinician so that 
study staff can discuss returning the monitoring device at the participants’ next appointment.   
Compensation: Participants will receive an additional $15 dollars for completing the optional 
sleep study.  
Actigraphy Data Collection & Analyses: Data will be downloaded to a secure computer and 
processed subject by subject with the Actiwatch software (Actiware 5.59). Data will be carefully 
reviewed and checked for missing values and outliers. Sleep parameters will automatically be 
scored using the manufacturer’s software, with an epoch length of 15 seconds and a medium 
wake threshold value of 40 seconds. A sleep analysis will be conducted with the sensitivity of 
the algorithm set to “medium” to estimate actigraphic sleep parameters. Resulting data will be 
further analyzed with SPSS for Windows (version 18.0; SPSS Inc., Chicago, Illinois). To 
examine associations between actigraphy and subjective measures of sleep difficulties and mood 
in patient samples, we will conduct a series of Pearson Correlations. We will also conduct a 
series of multivariable regression models to examine the relative contributor of 
sociodemographic, behavioral, and clinical predictors (including measures of sleep) to 
participant outcomes. The significance level in SPSS will be set at 0.05. 
Clinical Risk: There is little foreseeable risk to participating in objective and subjective sleep 
assessment measures. Actigraph, commonly worn on the wrist like a watch, uses an 
accelerometer to measure movement during activity and rest. It is an objective, non-invasive 
measure endorsed by the American Academy of Sleep Medicine for assessing sleep patterns in 
community studies.  Self-report assessments comprise “yes/no” responses on a 3-item daily sleep 
log, and the Pittsburg Sleep Quality Index is a 19-item questionnaire that evaluates sleep 
characteristics (e.g., sleep quality, latency, duration, efficiency). These two measures are 
considered standard measures of sleep quality, brief to complete, and are unlikely to cause any 
undue burden to participants.  
Human Subjects:  
Clinical Trials Risks The primary clinical risk is that adolescents will experience an increase of 
MDD or suicidality during the study.  This risk is addressed through the close monitoring of 
symptoms every two weeks via self report. Clinically significant scores on self-report measures 
of depression or endorsement of critical suicidality items (see Appedndix I Suicidality 
Guidelines)will trigger a full assessment by the study team.  Participants in the assessment only 
control condition will complete the same assessment schedule and an in-person or phone 
assessment will be triggered by clinically significant self-report or any report of suicidality. Note 
that we will request and highly encourage participants who endorse suicidal ideation to complete 
an in-person assessment. Only if the participant refuses or if there is no other option, will the 
suicidality assessment be completed over the phone.   Participants will have 24-hour access to 
the research team and will receive clinical referrals if the adolescent experiences an onset of a 
full major depressive episode.  The team will facilitate the process of depressed adolescents 
receiving treatment in a prompt fashion and will stay in close contact with the adolescent and 
family during this transition time (minimum contact once per week).   
The primary risk during this study is that participants will experience an increase in 
depressive symptoms.  This is a risk of their disease course and not a risk of the study per se.  
We estimate that 50% of those in the assessment only group will relapse (Curry et al., 2011), 
whereas approximately 10% will relapse in the R-CBT condition, consistent with a recent trial in 
adults (Watkins et al., 2011).  The frequency of monitoring will provide clinical safety within the 
context of the current protocol.  Families will be given feedback and treatment 

 
 
recommendations. If a participant develops criteria for MDD (five symptoms that are clinically 
significant) the participant will be given referrals for active, acute treatment outside of the study 
protocol if they don’t already have an (out of research) clinician. A RADS score >77 at any 
assessment point will trigger an interview with study staff to assess depression symptomatology.  
The cut-off score of 77 on the RADS to trigger safety follow-up was selected based on 
guidelines in the RADS professional manual which identify 77 as the threshold for clinically 
significant depression (Reynolds, 1987, p. 6). In addition, youth who have a CDRS-R score > 65 
and more than 3 clinically significant symptoms of MDD must have an out of study primary 
clinician and be receiving treatment. Frequency of visits to outside providers will be documented 
on the outside treatment log and recorded at every in-clinic visit. 
Youth will report symptoms of depression and anxiety every 2 weeks during the 8 week 
intervention.  The RADS will serve as a trigger for a full assessment with study staff if the 
adolescent reports increasing or significant levels of depression (which will be monitored by 
comparing scores over time and a significant level of depression is defined as > 77 on the 
RADS). Community referrals will be provided in the event a family does not have a primary 
clinician.  
To offset the increased risk of including adolescents who are in partial, as opposed to full 
remission, it is required that adolescents who have a CDRS score > 65 or more than 3 symptoms 
of MDD rated as clinically significant on the K-SADS (score of 3), have a non-study clinician 
with whom they meet regularly in order to participate in the study. The American Academy of 
Child and Adolescent Psychiatry practice parameters for preventing relapse and recurrence in 
adolescent depression recommend meeting with a clinician approximately once/month (AACAP, 
2007). Thus, should participants meet this criterion for depressive symptom severity, study staff 
will strongly recommend treatment at this frequency. Whether the participant undergoes 
treatment at this rate will be at the discretion of the participant and their treating clinician. In this 
sense, adolescents in partial remission will be receiving treatment as usual with their non-study 
providers and through the research study may be randomized to receive additional intervention 
specifically targeting residual depression symptoms.  Study staff will document on the treatment 
log how often participants are seeing their provider.   
If intervention sessions are doubled up (2 intervention session in 1 visit), this does not 
represent an increased risk, as adolescents will continue to complete questionnaires regarding 
mood every two weeks online similar to the assessment only control. Study personnel and the 
Principal Investigator will continue to be available 24/7 to subjects who may need assistance 
with increasing depressive symptoms or emergent suicidality. The same procedures will be 
followed with healthy control participants should they develop depression or suicidality between 
the screening and baseline visits.  
Consent Procedures On the first day of the study, a member of the study team will review the 
consent forms for participation with participant and legal guardian. The nature of the research 
protocol, including its potential risks and benefits, will be explained verbally to all potential 
subjects and their parents. To ensure that they have understood the risks and benefits, both the 
subject and, if under 18, the parent will be asked independently to restate in their own words the 
known risks and benefits of the procedure. Parents will be asked to read and sign a consent form, 
and their children will be asked to read and sign an assent form that has been approved by the 
University of Illinois at Chicago Investigational Review Boards.  
Confidentiality All information obtained from the subjects is coded by number and kept in 
locked files. The information is not accessible to anyone but the study investigators. The research 

 
 
chart will be kept separate from any clinical chart that the participant may have at the IJR clinics.  
Some of the forms will be filled out using an online survey website, Qualtrics or REDCap. 
Subjects are not required to fill out the forms online, we are simply offering this for convenience. 
If they choose to do so, they will be given secure links to an ID-specific questionnaire – names 
will not be used anywhere. All results will be stored on the Qualtrics or REDCap website, but 
people will need a username and password to access these results. Only investigators who need 
to access this information for research purposes will be given this username and password.  
Parents and child will have separate links and will not be able to access one another’s data. In 
addition, given the integrated nature of the clinic and research activities, we will inform 
participants that if they have a clinician at IJR, the clinician will be told they are participating in 
the study.  However, further information (other than the instance of safety concerns) will not be 
given to the clinician unless the participant/family authorizes this contact with a release of 
information form.  If an adolescent reports clinically significant suicidality, both their clinician 
and their parent(s) will be notified immediately, but no later than 24 hours later.  Furthermore, 
we will inform participant’s family members that if child abuse or neglect is suspected we are 
required to make an anonymous call to the Department of Child and Family Services (DCFS) 
and describe the situation as fully as possible. If the DCFS suggests that the situation requires 
formal reporting, then a report will be made, and DCFS will provide intervention from that point. 
If a report is not warranted, a further assessment of child safety and wellbeing will be made. If 
any risk to the child is suspected and DCFS dictates that they need not be involved, the PI will 
consult with the adolescent and  parent to negotiate a safety plan, which will require the 
involvement of significant others as deemed safe and appropriate. Any needed additional support 
and services will be provided to the participant. 
Contact with Clinician Given the integrated nature of the IJR/UIC clinic, clinicians are likely to 
be able to deduce if their patients are participating in research.  It is explicit in 
consent/assent/HIPAA forms that the family must give authorization for clinical data to be 
shared with their clinician.  However, we do not require authorization to notify the participant’s 
physician of safety issues such as suicidality. We will ask the participant and their family to 
inform us if their clinician changes over the course of the study.  In this instance, they will need 
to complete a new authorization form.   
HIPAA In addition, an authorization form to Access PHI under the Health Insurance Portability 
and Accountability Act (HIPAA) will be presented to parents or caregivers (the legal guardian) 
of adolescents under the age of 18, and to individuals directly who are 18, to access PHI.  
MRI Scanning Risks Acoustic Noise The acoustic noise levels perceived by human subjects 
when undergoing MRI examination in our 3.0 Tesla magnet will be operated to ensure that 
human subjects no more noise than is recommended by the FDA.  In addition, all participants 
will use disposable earplugs. Time-Varying Magnetic Fields The concern about the time-varying 
magnetic fields used in MRI is that these can, in some instances, induce stimulation of peripheral 
nerves, thereby producing sensations such as “twitching” or “tingling”. Gradients used in our 3.0 
Tesla MRI system will typically be operated at levels below those considered to be negligible 
according to FDA guidelines. MR technologists receive special training to prevent peripheral 
nerve stimulation. Specific Absorption Rate (SAR) MRI scanning induces some heating of body 
tissues. Specific absorption rate (SAR), which determines heating, is the amount of 
radiofrequency (RF) energy deposited per unit volume of tissue per unit time. Our scanner 
console calculates SAR based on the subject’s body weight before running any pulse sequence 
and prohibits running of the sequence if that SAR exceeds the FDA-approved limit. Security is 

 
 
also provided by a restricted access area. Static Magnetic Fields The FDA has deemed that 
systems operating at 8.0 Tesla or less do not pose a significant risk. Possible Incidental Risks 
The physical confinement and isolation produced by the scanner could cause mild to moderate 
emotional distress, although in our extensive past experience, subjects generally tolerated the 
procedures remarkably well. All subjects will be able to communicate directly with technologists 
and study staff to inform them of any emotional or physical distress during the scanning 
procedure. If they wish, the scan will be terminated immediately and the subject will be removed 
from the scanner. Risk Associated with Repeat Scanning The effects of exposure are non-
cumulative (i.e., exposure on multiple occasions is no greater than exposure on a single 
occasion). Clinical MRI Issues If evidence of clinical abnormalities arises during image 
processing, this information will be communicated to the PI who will consult with Dr. Phan 
(who has many years of expertise with both clinical and research neuroimaging data).  If there is 
reason for concern, the participant and/or parents will be notified if any clinically significant 
lesions are detected. Risk of Low Mood: It is possible that subjects will experience residual low 
mood following the rumination induction task or in response to the overall emotional nature of 
the tasks.  To offset this risk, a positive mood induction will be conducted outside of the scanner 
and the PI will be on call to deal with any emergent clinical issues. 
Risk/Benefit Ratio Participants in the clinical trial may benefit from the increased monitoring of 
their depressive symptoms or from the R-CBT intervention. The findings of the MRI are unlikely 
to be of direct benefit to any of the subjects. Subjects will be informed of any clinically 
significant findings from the MRI or clinical assessment procedures. The subjects will receive 
monetary remuneration over the course of the study in the amount of $495. It is believed that the 
risks of participating in this study are outweighed by the protection offered by repeated 
assessment and clinical oversight as well as the potential benefit of improved understanding of 
the prevention of depression relapse.  
All participants will be closely monitored through assessments throughout the course of 
the intervention phase as well as the follow-up.  It is expected that a portion of the sample will 
develop increasing depressive symptoms over the course of the study.  These symptoms will be 
closely monitored and families will be given feedback and treatment recommendations. If a 
participant develops criteria for full MDD (five symptoms that are clinically significant) the 
participant will be given referrals for active, acute treatment outside of the study protocol if they 
do not already have an outside clinician.  We will seek to have participants continue in their 
assigned arm (R-CBT or assessment only), and will document outside treatment. If families 
wish, they may withdraw from the study all together. Any change in eligibility will be 
documented in the research chart using the eligibility checklist.  
Referral Process The project director, Rachel Jacobs, will maintain a referral database.  When 
notified by a P.I. or project staff that an adolescent is depressed or suicidal; Dr. Jacobs will 
contact the family immediately to connect them with a resource.  This referral database will 
include low fee and sliding scale options.  If an adolescent is actively suicidal, the family will be 
directed to a local Emergency Room.  Dr. Jacobs or the Study Coordinator will check in on the 
family at least once a week to determine if they have established contact with a provider. There 
are two situations which will trigger IE or study therapist evaluation with a CDRS, as well as 
parent and outside clinician contact. These two situations are if a participant scores >77 on the 
RADS or endorses ‘sometimes’ or ‘most of the time’ on the suicidality question (#14) on the 
RADS. Project staff will contact families a minimum of once a week until they have linked with 
the appropriate services to ensure that they are not left on a waitlist.  Frequency of visits to 

 
 
outside providers will be documented on the outside treatment log and recorded at every in-clinic 
visit. 
End of intervention procedures Ethical principles require that all participants be given 
recommendations for any indicated further intervention and appropriate referrals at the point they 
exit intervention if necessary, (i.e., a premature termination, onset of MDD).  In the last 
intervention session, the therapist will a) provide the family a chance to state any concerns or 
questions they have; b) provide a summary of progress and outcomes; c) discuss follow-up 
interventions; and d) make recommendations about any necessary intervention.   
All end-of-intervention recommendations will be coded for data entry.  Families will be given a 
list of possible providers for the recommended intervention and will be told that a clinical report 
could be sent with the youth and/or parents' authorization to any new intervention provider(s). 
Similar procedures will be used for premature termination at any point in the study.  
Premature Termination At any time during the study, subjects may experience increased 
symptoms or develop clinical crises that lead to a recommendation to terminate from the 
assigned intervention (but almost never the assessment) portion of the protocol.  For example, a 
subject who became depressed, suicidal, or manic and required hospitalization would almost by 
definition require open clinical intervention.  Such subjects will be considered "premature 
terminators." Others will continue in study interventions, but will also require intervention 
outside the study as determined by the Principal Investigator.  "Drop Outs":  Subjects who 
terminate prematurely are to be distinguished from "drop outs" who are defined as subjects who 
refuse to furnish further data.  Subjects who drop out are not eligible for further study 
intervention. 
Any changes in eligibility status will be documented in the participant's research chart. 
Recording Procedures All intervention sessions and study assessments will be recorded 
throughout the course of the trial. Parent and child will be required to agree to the taping of 
sessions and assessments to be allowed into the trial.  Parents and youth who do not agree to 
taping procedures at the time of consent/assent will be provided with referrals outside the study.  
Recordings will be labeled by ID number and full names will not be used during the sessions or 
assessments.  All session recordings will be kept in password protected digital files and access on 
site will be limited to study personnel.  Originals of a randomly selected percentage 
(approximately 25%) of intervention sessions will be reviewed. These recordings will not be 
transcribed and they will be destroyed within one year of study completion.   
Compensation Remitted MDD Adolescents [articipants will receive $50 for their diagnostic 
interview to confirm eligibility.  For those in the R-CBT group, the participant will be 
reimbursed at a rate of $5 per session to offset travel expenses (5x8 = 40) and will receive 
parking permits as needed.  Those in the assessment only group will receive $10 for completing 
questionnaires every 2 weeks (10x4 = 40). This $40 will be received as cash when the 8 week 
diagnostic interview is completed.  Adolescents will receive $50 for the first MRI scan, and $75 
for the second MRI scan and follow-up diagnostic interview.  If all portions of the 8-week study 
are completed, this is a total of $215 compensation. The adolescent will directly receive cash 
payments in person (excluding R-CBT travel reimbursement, which will go to parents) after 
completing the appropriate study payment forms. The rest of the payments will arrive by check 
and will be addressed to the parent. 
 
For the follow-up, the adolescent will be reimbursed $50 for the 6, 12, 18, and 24 month 
clinical interviews for a total of $200 over the course of 2 years.  The adolescent will receive $10 
for completing the 3 month self-report measures and $20 for 9 month self-report measures.  

 
 
Participants will receive $25 each for both the 15- and 21-month self-report measures. The total 
compensation for the follow-up is $280. The optional sleep study will be compensated with an 
additional $15. Please see the payment schedule sheet for further details. 
 
Healthy control participants will receive $50 for the clinical screening visit and $50 for 
the fMRI scan. 
The compensation for clinical interviews will be received via cash and for the 
questionnaires, participants will receive a check.  
Data Plan A completely deidentified database will be created within one year of study 
completion, at which point all private identifiers, including contact information, will be 
destroyed.  Audio recordings will also be destroyed one year after study completion.   
Optional Sleep Study:  
An optional sleep study as a multiple-PI effort has been funded by the UIC Campus Research 
Board.  The purpose of this study is to collect feasibility data on collecting sleep data from 
participants across the lifespan. Participants do not need to complete the sleep study to 
participate in the rest of the MIND study.  This is an optional add-on. 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Appendix A: Study Procedures Flow Chart 
 
 

 
 
 
 
 
Appendix B. Study Eligibility Flow for Psychiatric History  
 

 
 
 
 
*Note: Depression and suicidality are assessed according to gold standard assessment parameters 
for evaluation and diagnosis of depression (AACAP, 2007).  Screening interviews are conducted 
using the K-SADS-PL diagnostic interview with both the parent and child, separately. Both the 
parent and child are asked the same questions, and the independent evaluator makes a combined 
summary rating based on both sources of information. In the case of discrepancies in the report 
of depression or suicidality, the most frequent disagreements occur in the items dealing with 
subjective phenomena where the parent does not know, but the child is very definite about the 
presence or absence of certain symptoms. This is particularly true for items like guilt, 
hopelessness, interrupted sleep, hallucinations, and suicidal ideation. In these instances, 
consistent with practice recommendations (AACAP, 2007), the child’s report is weighed more 
heavily in determining summary ratings. If the disagreements relate to observable behavior (e.g. 
appetite, psychomotor agitation/slowing), the examiner queries the parent(s) and child about the 
discrepant information. The evaluator’s combined ratings are used to ultimately yield a diagnosis 
of depression. In the case of safety monitoring for continued eligibility, monitoring is triggered 
by the child’s report on questionnaires, but the follow up evaluation is conducted with both the 
parent(s) and child in the same manner described above (using a similarly formatted rating scale 
for current symptoms, the Children’s Depression Rating Scale).