Meeting Summary

Workshop on the Prevention of Depression in Children and Adolescents

June 21, 2004 – June 22, 2004
Rockville, Maryland

Sponsors:
National Institute of Mental Health (NIMH)
National Institute on Drug Abuse (NIDA)

Introduction

In June 2004, NIMH and NIDA sponsored a two-day meeting to consider the research on the prevention of depression in children and adolescents, and to consider new opportunities to develop further the empirical base for additional preventive approaches. The Institutes used the strategic plan described in the 2003 NIMH publication Breaking Ground, Breaking Through: The Strategic Plan for Mood Disorders Research as a backdrop to the meeting. The plan provides a review of research advances in understanding the etiology, treatment and prevention of major depression and bipolar disorder, identifying research gaps and providing recommendations for further research on mood disorders.

The following is a summary of the topics addressed at the meeting:

Epidemiology

Large-scale epidemiological studies of youth depression that cover childhood through adolescence do not exist. Yet, a substantial number of epidemiological and other studies of mental disorders in youth demonstrate that depression is a significant public health problem, with identified risk factors and periods, and is often comorbid with other mental disorders, and substance use disorders. Rates of depression vary by developmental period (childhood lower than adolescence) and gender (higher rates in adolescent girls than in boys), factors to account for when considering prevention approaches.

Assessment

Research on the current state of the art in assessment and diagnosis of depression in children and adolescents suggests that assessment tools are available to adequately screen individuals at high risk for depression and assess the presence of depressive disorders in children and adolescents. Use of multiple reports (parent and child) is important for accurate diagnosis of depression in children.
For prevention, screening tools have been used to identify individuals at risk for depression and for assessing outcomes of preventive interventions. As such, prevention researchers should be encouraged to also use diagnostic assessments of depression to help ensure that cases of depression are being excluded from trials and that interventions are actually preventing depressive episodes.

Risk and Protective Factors

Participants considered risk and protective factors for depression in youth broadly in terms of biological/environmental and interpersonal/intrapersonal factors.
Risk factors for depression may be dynamic, and research on when and why risk factors occur and how they influence each other may further elucidate overall risk for depression.
A better understanding of protective factors may help understand why some individuals at risk for depression do not develop the disorder. Protective factors may be biological, psychosocial, environmental and multiply determined.

Economic Burden of Depression

Participants reviewed available information on the economic burden of depression in youth, knowledge gaps, and future research opportunities.
The costs associated with youth depression are not well known, but estimates include costs to the youth, to family, to the health care system, and to other child service systems.

Current Approaches to Preventing Depression in Youth

Prevention researchers presented results of their interventions targeting the reduction of risk for depression and internalizing disorders with indicated, selective and universal preventive interventions. They discussed these interventions with a focus on the theoretical and conceptual models used, the level of risk targeted, and reviewed intervention content and effects on depression and related outcomes.
The group briefly reviewed the state of the art for prevention of depression in adults. This provided a framework for the consideration of the current state of the science for youth—for instance, in terms of where in the prevention research cycle these two approaches are situated.
Much of the evidence for reducing risk for depression supported indicated prevention approaches. These interventions target youth who are experiencing symptoms of depression, but do not meet current DSM criteria for disorder (subsyndromal). Primarily, these prevention approaches involve using cognitive behavioral approaches or interpersonal psychotherapy approaches that have been found to be effective for treating depression in adults and youth. Intervention targets include reducing negative cognitions, increasing involvement in positive activities, strategies to promote optimism, and managing interpersonal and psychosocial stressors.
Booster sessions or other maintenance interventions may be necessary to maintain the preventive effects of interventions.
Selective preventive interventions targeting youth at increased risk for depression due to individual and environmental risk factors may also prove useful for preventing depression. Issues that may be relevant to examining the impact of selective interventions for depression include examining moderating factors that could influence intervention results, such as level of risk at baseline.
Universal preventive interventions for depression, targeting all youth regardless of their level of risk, do not have the same evidence base as selective and indicated approaches; however, these prevention approaches may provide important opportunities for decreasing population levels of depression, because they would potentially impact a broader number of individuals across the risk spectrum.
Shifting rates of depression in the population may require a consensus around the scientific evidence for preventive interventions for depression. Shifting rates of depression in the population would also involve strategies for disseminating evidence-based prevention programs.
A cardiology researcher discussed the science on depression prevention in relation to efforts to shift population rates of death from cardiovascular disease (CVD) through preventive interventions, and considered whether the strength of the evidence for preventing depression in youth, was sufficient for taking intervention approaches to scale.
Much of the success in decreasing rates of death from CVD comes from broad education about risk factors, through the mass media, and early detection of heart disease and risk factors for heart disease. A challenge for depression prevention is that while individuals can perform CVD prevention approaches, most depression-prevention programs involve working with trained professionals individually or in a group format.

Opportunities for Further Development and Testing of Prevention Models

Basic research

Basic research presents opportunities for furthering what is known about the etiology of depression and comorbid disorders as well as opportunities for developing novel interventions, and improving the targeting and timing of preventive interventions. Animal models may provide useful information about the timing of disorders, and help identify individuals at greatest risk for depression. Research with high risk families, where depression occurs in multiple generations, can further understanding of the transmission of risk for depression, and may lead to new targets for interventions.
Basic research on early experiences (e.g., in utero and early parenting) as well as affect regulation and brain regulation during adolescence may advance the understanding of risk for depression at important developmental periods.
As the evidence-base for prevention programs increases, neuroimaging may be useful for examining whether interventions that reduce symptoms and disorder also lead to changes in the brain.

Comorbidity

Common risk factors may exist for depression and other co-occurring and comorbid disorders. Identification of common risk factors may lead to opportunities to examine underlying neurobiological processes effecting comorbidity, and may increase understanding of etiology and provide novel intervention targets.
Treatment or prevention of disorders often comorbid with depression, such as childhood anxiety, may also reduce risk for depression. However, current research on this issue is mixed, primarily due to methodological problems or lack of longitudinal data examining the long-term effects of prevention and treatment of other disorders through high risk periods for depression onset.

Alternative depression prevention models

Given the disparities in access to mental health services for ethnic and minority populations, cultural relevance is an important feature of interventions, as it may increase engagement and adherence to intervention programs. In addition, interventions informed by cultural models may help explain pathways to depression, and provide opportunities for intervention.
Interpersonal problems and lack of skills to handle them have been associated with increased risk for depression. Interpersonal psychotherapy (IPT) targets problems in the depressed person’s relationships with others and provides specific skills to manage relationships and solve interpersonal problems. A few studies are currently adapting IPT treatment approaches for the prevention of depression in adolescents at high risk for depression, to buffer or reduce interpersonal stressors that may trigger clinical depression.

Summary of Accomplishments, Challenges and Opportunities in the Prevention of Depression in Children and Adolescents

Several themes emerged during the meeting. Available evidence suggests that depression is a serious public health problem for youth, and psychosocial, biological and environmental risk factors for depression have been identified across childhood and adolescence. Furthermore, there is evidence that some prevention programs can reduce risk for depression youth, especially among high risk youth. Additional evidence for the effectiveness of these preventive interventions in real world settings is needed, including evidence of their cost effectiveness, and ultimate implementation and dissemination within a variety of settings. Finally, basic research presents opportunities for furthering what is known about the etiology of depression and comorbid disorders, and may yield new opportunities for developing novel interventions, and improving the targeting and timing of preventive interventions.

Following the meeting, some of the participants prepared articles for a special issue of the American Journal of Preventive Medicine that focuses on the prevention of depression in children and adolescents. The articles in the supplement (Prevention of Depression in Children and Adolescents, Volume 31, Issue 6, Supplement 1, pp. 99-188, December 2006) focus on risk and protective factors for child and adolescent depression—and implications for depression, economic burden of depression, methodological considerations for assessing the effects of preventive interventions on reducing risk for depression, and translational research opportunities.