Principal Investigator: Gregory N. Clarke and Peter M. Lewinsohn
Level of Intervention: Selected
Target Population: Adolescents with elevated self-reported depressive symptomatology
References: Clarke, Hawkins, Murphy, Sheeber, Lewinsohn, & Seeley (1995)
Theory (Risk & Protective Factors Targeted):
Based on multifactorial model of affective disorder proposed by Lewinsohn et al. (1985). In this model, depression is considered the result of multiple etiological elements acting in combination. These include negative cognitive processes, stressful events, vulnerabilities/risk factors (e.g. female gender, history of depression, family history) and immunities to depression (e.g. high self-esteem, coping skills, high frequency of positive activities).
Description of Intervention:
The "Coping with Stress Course" was an adaptation of the Adolescent Coping with Depression Course (Clarke, Lewinsohn, & Hopps, 1990) and consisted of 15 group sessions (45 minutes long) that took place after-school. It was a developmentally oriented cognitive intervention to promote adaptive coping. Adolescents were taught techniques, including cognitive-restructuring skills, to identify and challenge negative or irrational thoughts. The program utilized cartoons, role plays, and group discussions.
Initially, all students in 3 suburban high schools (N=1,652) were screened for elevated self-reported depressive symptomatology on the Center for Epidemiologic Studies-Depression Scale (CES-D; Roberts et al., 1991). The cutoff score designated by Roberts (score > or = to 24) was used as a way to identify adolescents at risk for future disorder (N=471). The screening process did not allow for comparisons between those who participated in the first screen and those who declined. In a second screen, subjects (N=222) with parental consent were administered the K-SADS(Schedule for Affective Disorders and Schizophrenia for School-Age Children) diagnostic interview (Orvaschel & Puig-Antich, 1986) to rule out a diagnosable disorder.
The sample consisted of 9th & 10th grade adolescents, 70% female, 92.5% Non-Hispanic White, with a median age of 15.3 years. The median parent education level was 1-2 years of college. The mean score of the intervention participants on the CES-D was 22.6. This was significantly higher than the mean score for the sample of subjects who declined to participate.
Subjects with elevated depressive symptoms but with no current major depression and/or dysthymia were randomized to the intervention (N=76) or a "usual care" control condition (N=74).
There were no group differences in terms of study-wide attrition that were related to depression severity or any demographic variables. There were significant differences between intake and post-intervention assessments with more subjects lost from the intervention condition. A significant main effect was found for CES-D scores indicating that the scores for the subjects that dropped out were significantly lower than the scores of those who remained in the program. The treatment and control groups differed by gender (Females more likely to be in the experimental condition than the control condition) so analyses were conducted with gender controlled. Although the study findings were similar when gender was not included, the more conservative findings were reported.
Follow-up (12 month)
Data across all assessment points (i.e. post-intervention, 6 months, 12 months) were included in a set of survival analyses. One-tailed tests were used because a priori hypotheses favored the intervention group. Results indicated that there were significantly fewer cases of MDD or Dysthymia in the experimental condition across the follow-up period compared to the control group (p<.05). Total incidence rate for the experimental group was 14.5%. For the control group the total incidence rate was 25.7%.
Repeated-measures ANOVA were used to examine CES-D scores. Results supported a significant reduction in depressive symptomatology in the experimental group compared to controls (p<.05) from intake to post-intervention. This result was not maintained when scores from the intake and the 12-month follow-up were compared. There were no significant group differences on a modified version of the Hamilton Depression rating Scale (Hamilton, 1960) used in this study.
Strengths & Limitations:
The Coping with Stress Course targeted the negative cognitive processes that often accompany depressive disorders by providing skills training on an individual level with at-risk youth. The results are extremely promising, particularly given the design of the study (randomized trial) and the use of diagnostic classifications as outcome measures. Diagnostic interviews were audiotaped as an ongoing check on reliability and a senior interviewer independently re-rated a random sample. The authors reported good inter-rater reliability on the interviews. It is important to note that the generalizability of the findings is somewhat limited given that the sample was predominantly middle class, Caucasian, and female.
Group leaders were specially trained school psychologists and counselors, each of whom had a minimum of a Masters degree. The leaders were provided with 40 hours of training. All sessions were audiotaped and a random set were selected and rated for protocol compliance (average protocol adherence was 93.9%). The authors did not provide any data on fidelity of the program once it was implemented.