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Little treatments show big promise for youth psychiatric problems


 

EXPERT ANALYSIS FROM THE ANXIETY AND DEPRESSION CONFERENCE 2017

 

– Very brief, outside-the-box therapeutic interventions are racking up respectable efficacy scores in randomized, controlled trials addressing a variety of common psychiatric problems in youths, Jessica L. Schleider observed at the annual conference of the Anxiety and Depression Association of America.

The impetus for developing very brief interventions – or VBIs, as they are known in psychotherapy research parlance – is mounting recognition that conventional treatment approaches have by and large failed children and adolescents who have mental health problems, explained Ms. Schleider, a doctoral candidate in clinical psychology at Harvard University in Cambridge, Mass.

Jessica L. Schleider, a doctoral candidate in clinical psychology at Harvard University in Cambridge, Mass. Bruce Jancin/Frontline Medical News
Jessica L. Schleider


According to data from the Centers for Disease Control and Prevention and the Child Mind Institute, only 20% of American children and adolescents who have significant mental health problems access mental health services. And among those who do, only a minority complete their planned course of treatment.

Reimbursable treatment plans for youth mental health problems typically entail about 16 sessions. Yet national insurance reimbursement data indicate those youths who do access treatment attend on average fewer than four sessions.

“Given that the current model just doesn’t seem to be meeting the needs of kids and families across the country, novel approaches are going to be necessary to really reduce the burden of youth mental illness on a broad scale,” Ms. Schleider asserted.

She characterized VBIs as an example of what is often referred to in TED Talks as “disruptive innovation.” VBIs are intended to extend the reach of youth mental health services by offering interventions that are brief, affordable, accessible, and scalable. It’s a concept that has captured the imagination of officials at the National Institute of Mental Health, which is funding her VBI work and that of others under the institute’s experimental therapeutics initiative.

Ms. Schleider coauthored a recent meta-analysis of 50 randomized, controlled trials of single-session interventions (SSIs) for mental health problems in a collective 10,508 youths. The investigators found that the treatment effect size varied by the target problem. The largest effect size documented – 1.05, which is a strong benefit – was for SSIs targeting eating disorders. The weakest was for the 18 randomized trials addressing substance abuse, with an effect size of a mere 0.08 (J Am Acad Child Adolesc Psychiatry. 2017 Feb;56[2]:107-15).

“The mean effect size across all categories is 0.32, which is decent. It’s in the small-to-medium range,” she noted. “But if you zoom in on the most common types of youth mental health problems – anxiety, conduct, and depression – we see that the overall effect of those single-session programs compares surprisingly well to the full-length treatments that we have, further supporting a possible value as an element of our mental health system.”

For SSIs addressing anxiety, for example, the mean posttreatment effect size was 0.56, compared with 0.61 for conventional multisession programs. For conduct problems, SSIs produced a mean effect size of 0.54, versus 0.46 for full-length treatment programs. And while the effect size of SSIs for depression was small, at 0.18, the same might be said for the 0.28 mean effect size for standard depression therapy programs.

Mean SSI treatment effect sizes were larger for children than for adolescents, at 0.42, compared with 0.19.

Ms. Schleider also presented highlights of a published randomized, double-blind trial of a self-administered computer-guided SSI she and her coauthor have developed. That SSI is designed to briefly teach troubled adolescents a growth personality mindset: that is, the belief that personal traits such as shyness, sadness, and intelligence are malleable through effort and hard work, rather than static and unchangeable.

“Kids with fixed mindsets tend to fare worse than those with growth mindsets,” she said. “They give up prematurely in response to social and academic stress, and they engage in a lot more negative self talk.

The intervention borrows from the achievement motivation theory developed by Carol S. Dweck, Ph.D., professor of psychology at Stanford (Calif.) University and author of the book, “Mindset: the New Psychology of Success.”

The trial randomized 96 subjects aged 12-15 years to a half hour spent on a computer with the growth mindset intervention or a shared feelings control. These were teens with elevated levels of internalizing problems. Eighty-four percent of them met criteria for anxiety by the SCARED CHILD (Screen for Child Anxiety Related Disorders – Child Version) or for depression via the CDI (Children’s Depression Inventory). Subjects were followed up immediately post treatment and again at 3, 6, and 9 months, with 74% of the original group participating in the final follow-up.

The guided growth mindset group showed significant reductions from baseline in CDI and SCARED scores at every follow-up point, while the control group remained unchanged.

“What I see as the bottom line are the 9-month follow-up effects: All effect sizes for youth- and parent-reported outcomes of anxiety and depression are in the small-to-medium range,” Ms. Schleider said. “But this is quite promising, I think, for a 30-minute intervention that kids can complete on their own.”

Also, the mindset intervention strengthened postintervention measures of the adolescents’ perceived control. On a postintervention, laboratory-based, standardized social stress test, the mindset intervention group achieved physiologic recovery more than three times faster than did the controls, as assessed via electrodermal activity.

Ms. Schleider called the study results “promising and exciting.” She is now working with therapists at McLean Hospital, Belmont, Mass., to see whether administering the growth mindset intervention at the start of youth intensive cognitive-behavioral therapy for anxiety results in improved treatment outcomes.

“By teaching kids that change is possible, it might improve their engagement in CBT or reduce their dropout rates,” she noted.

Ms. Schleider is also pilot studying a parent-directed growth mindset intervention to learn whether it improves parents’ attitude toward psychotherapy and seeking services for a troubled child.

Her randomized trial was supported by the National Institute of Mental Health, the American Psychological Association, and the Harvard Center on the Developing Child. She reported having no financial conflicts.
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