New Technologies for Cognitive Behavior Therapy (CBT) Treatment of Adolescent Depression
Condition: Depression
MeSH terms: Depression; Depressive Disorder
Study type: Interventional

Summary: 
      The goal of this study is to examine the use of new technologies in disseminating and
      improving CBT treatment for adolescent depression. An on-line therapist training tutorial
      will be followed by 12 weeks of CBT treatment according to the training protocol. CBT
      treatment will be augmented with the use of automated text messages for homework reminders
      and reinforcement of learning. In session patient education and review of CBT concepts will
      be augmented through teaching materials delivered via iPad. 16 therapists will be recruited,
      each treating 4 depressed adolescents. Half the therapists will be randomly assigned to TAU,
      followed by the training intervention. Automated patient outcomes measures will be examined.
    

Detailed description: 
      Point prevalence estimates for major depressive disorder in adolescents range from 4% to 8%,
      and the lifetime prevalence of experiencing a major depressive episode by age 18 is estimated
      at 20% to 25%. Depression afflicts the lives of adolescent girls at twice the rate of boys,
      and depressive episodes typically last for 7-9 months without treatment. Unfortunately, less
      than half of adolescents who report a major depressive episode in the past year also report
      having received treatment. Even with treatment, the risk of relapse in the subsequent 2 years
      ranges from 20%- 60%. Adolescent depression is associated with suicidal thoughts and
      behaviors in teens, the third leading cause of death in youths 15-19 years old. The incidence
      and time course of suicidal ideations and behaviors in depressed adolescents has been
      examined in the Treatment for Adolescents with Depression Study (TADS),Treatment of Selective
      Serotonin Reuptake Inhibitor (SSRI)-Resistant Depression in Adolescents (TORDIA) study,and
      the Treatment of Adolescent Suicide Attempters (TASA) study. These federally-funded clinical
      trials provide considerable evidence about the effectiveness of pharmacological,
      psychotherapeutic, and combined treatments for adolescent depression; they also underscore
      the critical need to improve training and resources for treatment providers and patients in
      the pursuit of better outcomes. Evidence-based practice (EBP) is 'treatment [or intervention]
      based on the best available science or research evidence'. In 2005, the American
      Psychological Association (APA) Presidential Task Force advocated EBPs "to promote effective
      psychological practice and enhance public health by applying empirically supported principles
      of psychological assessment, case formulation, therapeutic relationship, and intervention".
      It asks clinicians to adopt EBPs and encourages development of health care policies
      reflecting this view. Research supports the efficacy and effectiveness of both CBT and
      antidepressant treatments for adolescent depression. The demand for trained CBT providers
      exceeds the supply, reflecting a need for more efficient and effecting training platforms. In
      April 2007, the National Institute of Mental Health (NIMH) held the "Partnerships to
      Integrate Evidence-Based Mental Health Practices into Social Work Education and Research"
      meeting. They concluded that important initiatives in EBP existed in academic programs, but
      the need for social workers prepared to deliver them is not being met. The Surgeon General's
      Report on Mental Health reached a similar conclusion regarding EBP use in community settings.

      New technologies can increase access to specialized training and can improve training
      quality. Web-based training can be made available at any time, eliminates costs and
      difficulties associated with traveling, and enrollment is not constrained by class size or
      trainer availability. Trainees can work a their own pace and training quality is improved by
      use of consistent, standardized interactive exercises presented with multi-modal learning
      techniques that increase knowledge retention. Online CBT training is effective and
      well-received by clinicians; engaging and retaining adolescents in treatment has been
      challenging. Telephone contact between sessions can improve both outcomes and satisfaction in
      depression treatment. Between-session contact from a clinician via the internet has improved
      outcomes, as much as four-fold in one study.

      Depressed adolescents can be treated effectively with antidepressant medications, but
      medication noncompliance was over 50% in the TORDIA study. Estimates are that only a third of
      patients started on an antidepressant receive treatment of adequate dose and duration.
      Patient non-adherence was the most common reason for failure, with side effects being a major
      factor for discontinuing treatment in the initial weeks. Monitoring common side effects, such
      as altered sleeping patterns, nightmares, restlessness, and changes in appetite is
      particularly important in adolescents; 3%-8% of youths treated with antidepressants show
      increased "behavioral activation" which may increase the risk for suicidal ideation or
      behavior. Such concerns are the basis for the American Academy of Child and Adolescent
      Psychiatry's treatment recommendation "During All Treatment Phases, Clinicians Should Arrange
      Frequent Follow-up Contacts That Allow Sufficient Time to Monitor the Subject's Clinical
      Status, Environmental Conditions, and, If Appropriate, Medication Side Effects." Use of text
      messaging to assess side effects and provide messages of reassurance and support could help
      medication compliance.

      The popularity of Short Messaging Service (SMS) text messaging among adolescents is apparent
      to any parent with a teenage son or daughter. A Pew Research Center study found that text
      messaging has become the preferred channel for basic communication among teens. Teens
      interact with friends via text messaging more frequently than any other form of interaction;
      75% of 12-17 year-olds have their own cell phones, and 72% of all teens (88% of teenage cell
      phone users) use text messaging. Two-thirds of texting teens are more likely to use their
      cell phones to text with friends than to talk with them. Half of all teens send 50 or more
      texts per day. Girls use text messaging to a greater extent than boys, and three-quarters of
      teen cell phone users have unlimited texting.

      The popularity of SMS technology has only recently begun to be leveraged for scientific and
      public health applications, but use in research and health promotion is expanding. Cell phone
      text messaging has been used to collect daily data regarding asthma and diabetes symptoms.
      SMS reminders to use oral contraceptive may reduce unintended pregnancies,and medical test
      results provided by text messaging can encourage patients to seek treatment, which may be
      particularly useful for school-based health centers. A review of text messaging programs
      designed to influence health behavior found positive outcomes in 93% of the published
      studies72 including interventions addressing obesity, smoking, and bulimia nervosa. In a
      review of studies using cell phone and SMS programs to improve health outcomes and processes
      of care, a total of 101 process and outcomes were evaluated across 25 studies. Sixty percent
      of the cell phone/text messaging interventions resulted in positive outcomes (p.<.05)
      compared to control groups.

      Benefits of interactive voice response (IVR) methods to address personally sensitive topics
      have been published and extend to SMS applications. Text messaging has some advantages over
      IVR technology, which may account for its popularity among teens: Temporally, SMS is less
      disruptive since asynchronous interactions allow message receivers to postpone dialog
      engagement. Environmentally, text messaging may be more private, since they do not require
      verbal responses that might overheard in public. Use of key presses to silently respond to
      automated queries is possible via IVR, but additional equipment such as ear buds are needed
      and may not always be available. The efficiency and effectiveness of SMS applications in
      healthcare setting has been referred to as "the elephant knocking at the door." One reason
      treatments using EBPs are less effective than desired may be a lack of easily accessible
      training materials and supportive tools for implementation. CBT training manuals, alone and
      in combination with antidepressant management, have been created in academe and are publicly
      available. Unfortunately they are not being widely adopted by clinicians in community-based
      treatment programs. Manualized CBT developed specifically for depressed adolescents,
      including suicide prevention modules that contain safety plans, mood monitoring, goal
      setting, reducing negative emotions, and increasing positive reinforcements are publicly
      available. Interacting with adolescents on a daily basis to encourage homework compliance,
      evaluate treatment progress, monitor side effects, etc., would be prohibitive if clinicians
      needed to personally send and receive each tailored message. Fortunately, that is not
      necessary. Phase I results demonstrated the feasibility of computer-automated,
      dynamically-branching SMS protocols for interacting with depressed adolescents (see Progress
      Report below). Feedback from the adolescents in the Phase I study indicated willingness to
      embrace the use of this technology into treatment programs. They explicitly expressed
      interest in automated interactions permitting more open-ended and personally expressive
      content.

      The product to be developed in Phase II is responsive to this desire and will incorporate
      multimedia training materials for clinicians through a secure, password-protected website
      that will assist them in selecting, scheduling, and incorporating automated, personalized
      interactive SMS interactions into manualized CBT treatment. Automated interactions will
      facilitate homework assignments, monitor medication side effects, assess symptom severities,
      and encourage patients. Patient responses to the automated interactions will be reviewable by
      the clinicians through the same website, and reports of particularly worrisome behaviors,
      such as suicidal intent, will trigger immediate notifications to on-call clinical staff for
      immediate follow-up and intervention. The system and processes to be developed in Phase II
      are designed to improve the efficacy of adolescent depression treatment by improving
      clinician training and increasing the depth and breadth of patient engagement in their
      treatment regimen. We believe it will also hasten the onset of symptomatic improvement and
      will do so in a manner that improves patient satisfaction and increases safety monitoring.
    

Intervention name(s): Intervention
Intervention type(s): Behavioral
Intervention description(s): On line tutorial followed by text messaging during treatment and iPad for patient education
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment