Publications by authors named "Nick Midgley"

65 Publications

[Evaluation of Short-term Psychoanalytic Child Therapy (PaCT) for Young Children with Depressive Disorders: Results from a Pilot Study].

Prax Kinderpsychol Kinderpsychiatr 2021 Jun;70(5):445-464

Klinik und Poliklinik für Psychiatrie, Psychotherapie und Psychosomatik des Kindes- und Jugendalters Universität Leipzig Deutschland.

Depressive disorders in early childhood are associated with high psychosocial impairment and tend to remain stable over time without adequate treatment. Short-term psychoanalytic therapy is a common form of child psychotherapy, yet there is a lack of empirical evaluation of this approach for young children with depressive disorders. Therefore, this secondary evaluation of a study on the treatment of anxiety disorders used an uncontrolled pre-post design in a clinical setting to investigate whether children with depressive comorbidity would evidence significant diagnostic and symptomatic remission after treatment with manualized short-term Psychoanalytic Child Therapy (PaCT). Nineteen children who had an anxiety disorder and a (subclinical) depressive disorder (assessed with the Preschool Age Psychiatric Assessment using DSM-IV criteria) were treated with PaCT. After treatment, 15 of 19 children (78.94 %) were remitted and 15 of 17 children (88.24 %; 2 were lost to follow-up) were free of depressive disorders at the 6-month follow-up. Further analyses revealed significant effects for pre- to post and pre- to follow-up comparisons regarding internalizing symptoms and overall problems using parent- and (nursery-)teacher-ratings. These results suggest that short-term PaCT shows promise as a treatment for childhood depressive disorders.
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http://dx.doi.org/10.13109/prkk.2021.70.5.445DOI Listing
June 2021

'It's always difficult when it's family. . . whereas when you're talking to a therapist. . .': Parents' views of cognitive-behaviour therapy for depressed adolescents.

Clin Child Psychol Psychiatry 2021 May 19:13591045211013846. Epub 2021 May 19.

Research Department of Clinical, Educational and Health Psychology, University College London, UK.

Background: Parents are key to helping their adolescent child access psychological therapy for mental health problems such as depression. However, little is known about how parents experience their child's psychological therapy. We aimed to explore parents' experiences of their adolescent child's cognitive behaviour therapy for depression.

Method: We applied Thematic Analysis (TA) to qualitative data from in-depth interviews with parents ( = 16) whose adolescent child was randomly allocated to CBT in a large multisite RCT for adolescent depression (the IMPACT trial). Interviews were conducted at the end of treatment.

Results: We generated two main themes: parents' perceptions of the adolescent's journey through therapy, and parents' perceptions of the therapeutic setting and process. Each included four sub-themes. Parents talked about key factors that impacted on their child's progress through treatment, including the adolescent's readiness for therapy and the adolescent-therapist relationship.

Conclusion: Parents' insights confirm the foundations of what is considered good clinical practice of CBT for adolescent depression, including tailoring therapy to the adolescent, and establishing a strong adolescent-therapist relationship. Parents recognised that, for CBT to be helpful, their child had to be willing to engage in therapy and able to develop a trusting relationship with their therapist.
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http://dx.doi.org/10.1177/13591045211013846DOI Listing
May 2021

The Evidence-Base for Psychodynamic Psychotherapy With Children and Adolescents: A Narrative Synthesis.

Front Psychol 2021 27;12:662671. Epub 2021 Apr 27.

Research and Development Unit, Tavistock and Portman NHS Trust, London, United Kingdom.

Despite a rich theoretical and clinical history, psychodynamic child and adolescent psychotherapy has been slow to engage in the empirical assessment of its effectiveness. This systematic review aims to provide a narrative synthesis of the evidence base for psychodynamic therapy with children and adolescents. Building on two earlier systematic reviews, which covered the period up to 2017, the current study involved two stages: an updated literature search, covering the period between January 2017 and May 2020, and a narrative synthesis of these new studies with those identified in the earlier reviews. The updated search identified 37 papers (28 distinct studies). When combined with papers identified in the earlier systematic reviews, this resulted in a combined total of 123 papers (82 distinct studies). The narrative synthesis of findings indicates that there is evidence of effectiveness for psychodynamic therapy in treating a wide range of mental health difficulties in children and adolescents. The evidence suggests this approach may be especially effective for internalizing disorders such as depression and anxiety, as well as in the treatment of emerging personality disorders and in the treatment of children who have experience of adversity. Both the quality and quantity of empirical papers in this field has increased over time. However, much of the research demonstrates a range of methodological limitations (small sample sizes, lack of control groups etc.), and only 22 studies were Randomized Controlled Trials. Further high-quality research is needed in order to better understand the effectiveness of psychodynamic psychotherapy for children and young people.
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http://dx.doi.org/10.3389/fpsyg.2021.662671DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8110733PMC
April 2021

A systematic review of shared decision making interventions in child and youth mental health: synthesising the use of theory, intervention functions, and behaviour change techniques.

Eur Child Adolesc Psychiatry 2021 Apr 22. Epub 2021 Apr 22.

Child Attachment and Psychological Therapies Research Unit (ChAPTRe), University College London and Anna Freud National Centre for Children and Families, 4-8 Rodney Street, London, N1 9JH, England.

Reviews around interventions to improve shared decision making (SDM) for child and youth mental health have produced inconclusive findings on what approaches increase participation. Importantly, the previous reviews did not explore the use of theory, as well as mechanisms of change (intervention functions) and active units of change (behaviour change techniques). The aim of this review was to explore these factors and ascertain how, if at all, these contribute to SDM. Five databases were searched up until April 2020. Studies met inclusion criteria if they were: (a) an intervention to facilitate SDM; (b) aimed at children, adolescence, or young people aged up to 25, with a mental health difficulty, or their parents/guardians; and (c) included a control group. Data were extracted on patient characteristics, study design, intervention, theoretical background, intervention functions, behaviour change techniques, and SDM. Quality assessment of the studies was undertaken using the Effective Public Health Practice Project (EPHPP) quality assessment tool. Eight different interventions met inclusion criteria. The role of theory to increase SDM remains unclear. Specific intervention functions, such as 'education' on SDM and treatment options and 'environmental restructuring' using decision aids, are being used in SDM interventions, as well as 'training' for clinicians. Similarly, behaviour change techniques linked to these, such as 'adding objects to the environment', 'discussing pros/cons', and clinicians engaging in 'behavioural practice/rehearsal'. However, as most studies scored low on the quality assessment criteria, as well as a small number of studies included and a low number of behaviour change techniques utilised, links between behaviour change techniques, intervention functions and increased participation remain tentative. Intervention developers and clinicians may wish to consider specific intervention functions and behaviour change techniques to facilitate SDM.
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http://dx.doi.org/10.1007/s00787-021-01782-xDOI Listing
April 2021

The alliance-outcome association in the treatment of adolescent depression.

Psychotherapy (Chic) 2021 03;58(1):95-108

Department of Applied Health Research.

A growing body of research has consistently demonstrated a relationship between alliance and treatment outcomes in youth psychotherapy. However, previous research often suffered methodological issues that prevented detailed investigation of temporal relationships between alliance and symptomatology. The current study explored the directions of effect between alliance and outcome by examining the associations between early alliance and subsequent outcome while controlling for patients' baseline severity and prior symptom change. It also examined potential moderators of this association. Data were drawn from the IMPACT study, a randomized controlled trial comparing cognitive-behavioral therapy and short-term psychoanalytic psychotherapy versus a brief psychosocial intervention in the treatment of adolescent depression. Adolescents (N = 224) and therapist (n = 139) rated the alliance 6 weeks after randomization. Depression severity and overall psychopathology were assessed at baseline, 6, 12, 36, 52, and 86 weeks after randomization. Patients' age, gender, baseline depression severity, conduct disorder symptoms, and treatment type were examined as potential moderators of the alliance-outcome association. Data were analyzed using multilevel models. Findings suggested that higher early alliance ratings were associated with subsequent symptom reduction, even after controlling for prior symptom change and baseline severity. There was some evidence that the strength of this association was strongest in cognitive-behavioral therapy, weaker in short-term psychoanalytic psychotherapy, and statistically indistinguishable from zero in brief psychosocial intervention. These findings suggest that early therapeutic alliance with adolescents may influence subsequent outcome independent of prior symptom change and initial severity but that the effect of the alliance on outcome might vary across treatment types. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/pst0000366DOI Listing
March 2021

The experience of sleep problems for adolescents with depression in short-term psychological therapy.

Clin Child Psychol Psychiatry 2021 Apr 7:13591045211006157. Epub 2021 Apr 7.

Psychology and Language Sciences, University College London, UK.

A growing body of literature demonstrates a strong relationship between sleep disturbances and depression in adolescence. In spite of this, few studies have explored how adolescents with depression experience sleep problems. The present study aimed to qualitatively explore the experience of sleep problems in adolescents with depression, including their understanding of how a psychological therapy impacted on these sleep difficulties. The sample included 12 adolescents with sleep disturbances who had been offered treatment for depression through a large, multi-centre, randomised controlled trial. Semi-structured interviews conducted after treatment and 1-year post treatment were analysed using thematic analysis. Two main themes were identified. Both themes demonstrated how an overarching desire to escape impacted the adolescents' sleep in distinct ways; 'thinking about the 'bad stuff'' was characterised by ruminative thinking, which prevented sleep, whereas 'sleep as an escape' indicated a desire to sleep excessively due to feelings of helplessness. Overall, the findings demonstrate a nuanced relationship between sleep and depression in adolescence, and imply that the underlying meaning of the sleep difficulties for each young person should be considered in the delivery of therapy for adolescent depression.
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http://dx.doi.org/10.1177/13591045211006157DOI Listing
April 2021

Associations between baseline cortisol and trajectory of symptom improvement in depressed adolescents receiving psychological therapy.

J Affect Disord 2021 05 23;287:191-195. Epub 2021 Mar 23.

University of Cambridge, Cambridgeshire and Peterborough NHS Foundation Trust. Electronic address:

Background: Cortisol hypersecretion in depressed adolescents and adults is associated with more persistent illness and may signal a lower response to psychological therapies. A meta-analysis of small and heterogenous studies demonstrated that higher pre-treatment basal cortisol levels were associated with poorer response specifically to psychological therapy for depression. The objective of this study was to investigate the relationship between both morning and evening salivary cortisol levels and response to psychological therapy in depressed adolescents participating in one large randomised controlled trial.

Methods: We tested the association between morning and evening salivary cortisol levels at baseline and improvement in depressive symptoms in response to psychological therapies in depressed adolescents at 6 time points: baseline, 6, 12, 36, 52- and 86-weeks post-randomisation, using the self-reported Mood and Feelings Questionnaire (MFQ).

Results: High evening cortisol was associated with a slower initial decline in depressive symptoms (cortisol x quadratic time p = .022); however it was not associated with total change in depressive symtoms over the whole course of the study. Morning cortisol was not associated with change in depressive symptoms. These effects were not significantly different across the three psychological therapies.

Limitations: Results may not generalize to adolescents receiving other treatments (medication) or no treatment, and may not generalize to adults. Only a minority of eligible participants collected valid cortisol samples.

Conclusions: Higher pretreatment evening cortisol may impair a depressed adolescent's ability to use psychological therapy.
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http://dx.doi.org/10.1016/j.jad.2021.03.046DOI Listing
May 2021

The first experimental study of transference work-in teenagers (FEST-IT): a multicentre, observer- and patient-blind, randomised controlled component study.

BMC Psychiatry 2021 02 17;21(1):106. Epub 2021 Feb 17.

Division of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo, P.O. box 1171, 0318, Blindern, Oslo, Norway.

Background: Little is known about the influence on outcome of exploration of the patient-therapist relationship (that is, transference work) in psychoanalytic psychotherapy. We hypothesized that depressed adolescents would have better long-term effects from psychoanalytic psychotherapy with than without transference work.

Methods: Depressed adolescent (16 to 18 years) were recruited in health authority funded out-patient clinics in Oslo and Vestfold County, Norway. They were randomized to 28 weeks of treatment with psychoanalytic psychotherapy with or without transference work. Change was assessed using linear-mixed models. The primary outcome measure was the Psychodynamic Functioning Scale (pre- post-, and 1-year post-treatment). Level of depression was measured at the same time points and during therapy (week 12, and 20).

Results: 69 adolescents were treated with (N = 39) or without (N = 31) transference work. The mean number of sessions was 18.6 (SD = 8,6) in the transference work group and 18.0 (SD = 10.9) in the non-transference work group. Both groups showed large and significant improvement on Psychodynamic Functioning Scale during the whole study period. The difference between the two groups was not significant during the treatment period (95% CI -.79 to 1.2, p = .674, F = .18), or from post-treatment to one-year follow-up (95% CI -.13 to .96; p = .134; F = 2.3). For the secondary outcome measures the transference work group had significantly better outcomes from 12 weeks in treatment to one-year follow-up (Beck Depression Inventory, 95% CI - 1.7 to -.14, p = .022; Montgomery and Åsberg Depression Rating Scale, 95% CI - 1.6 to -.23, p = .009).

Conclusion: The findings suggest that exploration of the adolescents' relations to the therapist amplify the effects of short-term psychoanalytic psychotherapy on their depressive symptoms for adolescents with a Major Depressive Disorder.

Trial Registration: ClinicalTrials.gov . Id: NCT01531101 . Registered 8 February 2012.
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http://dx.doi.org/10.1186/s12888-021-03055-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888176PMC
February 2021

The therapeutic relationship in child psychotherapy: integrating the perspectives of children, parents and therapists.

Psychother Res 2021 Jan 28:1-13. Epub 2021 Jan 28.

Psychology Department, Pontifical Catholic University of Chile, Santiago, Chile.

Objectives: To describe and analyse the therapeutic relationship integrating the views of children, parents and therapists.

Methods: This study employs a qualitative methodology, assuming a discovery-oriented approach which draws from grounded theory. Twelve psychotherapy triads participated, composed of children aged 6-10, their parents and psychotherapists. Semi-structured follow-up interviews were conducted (N=36), including a drawing in the case of the children.

Results: A positive therapeutic relationship with children and parents was viewed as a gradually constructed process, based on a positive emotional encounter between participants. It was facilitated primarily by the therapist's commitment and playful stance, the child and therapist mutual involvement, and the parent's collaboration. These aspects entailed a trustful, validating and caring relationship, that shaped children and parents' motivations towards therapy and facilitated change.

Conclusions: From a multiple-perspective approach, therapy was conceived as a relational experience. The development of positive relationships required different and evolving dispositions from therapy main actors. Therapists' genuine feelings and engagement in therapeutic activity seem central, underlining the importance of addressing relational aspects in child therapy research and training.
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http://dx.doi.org/10.1080/10503307.2021.1876946DOI Listing
January 2021

Treatment of depression in children and adolescents.

Lancet Psychiatry 2021 02;8(2):97

Research Department of Clinical, Educational, and Health Psychology, University College London, London, UK; Child Attachment and Psychological Therapies Research Unit (ChAPTRe), Anna Freud Centre, London, UK.

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http://dx.doi.org/10.1016/S2215-0366(20)30518-6DOI Listing
February 2021

Cross-sectional and longitudinal associations between psychotic and depressive symptoms in depressed adolescents.

Eur Child Adolesc Psychiatry 2021 Jan 11. Epub 2021 Jan 11.

Department of Psychiatry, University of Cambridge, Douglas House, 18b Trumpington Road, Cambridge, CB2 8AH, UK.

Adults with major depressive disorder (MDD) with psychotic features (delusions and/or hallucinations) have more severe symptoms and a worse prognosis. Subclinical psychotic symptoms are more common in adolescents than adults. However, the effects of psychotic symptoms on outcome of depressive symptoms have not been well studied in adolescents. Depressed adolescents aged 11-17 with and without psychotic symptoms were compared on depression severity scores at baseline and at 28- or 42-week follow-up in two large UK cohorts. Psychotic symptoms were weakly associated with more severe depression at baseline in both cohorts. At follow-up, baseline psychotic symptoms were only associated with depressive symptoms in one sample; in the other, the effect size was close to zero. This supports the DSM5 system of psychotic symptoms being a separate code to severity rather than the ICD10 system which only allows the diagnosis of psychotic depression with severe depression. There was no clear support for psychotic symptoms being a baseline marker of treatment response.
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http://dx.doi.org/10.1007/s00787-020-01704-3DOI Listing
January 2021

Psychological Mediators of the Association Between Childhood Emotional Abuse and Depression: A Systematic Review.

Front Psychiatry 2020 4;11:559213. Epub 2020 Dec 4.

Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.

A number of existing meta-analyses and narrative reviews have already addressed the relation between childhood adversity and depression, yet none of them has examined the specific link between emotional abuse and depression highlighted by previous research. It is no longer appropriate to regard childhood maltreatment as a unitary concept when considering its effects on subsequent depression; instead, subtypes of childhood maltreatment need to be scrutinized separately. This review addresses this significant gap by critically evaluating empirical studies examining psychological mediators of the relationship between childhood emotional abuse and subsequent depression. A systematic search of nine electronic databases was conducted to identify eligible studies published in English between January 1980 and January 2020. Given the heterogeneous outcomes of eligible studies and the inconsistent reporting of indirect effects, a narrative synthesis, rather than a quantitative meta-analysis, was conducted. An appraisal of methodological quality was also included. We identified 34 papers, comprising 18,529 adults and 3,434 adolescents, including 888 clinical participants. Our synthesis suggests that studies on mediators in the emotional abuse-depression link have focused on five clusters of intervening variables: early maladaptive schemas, cognitive-personality variables, emotion dysregulation, interpersonal styles, and stressful negative events. Only 11 studies identified the unique contribution of emotional abuse to depression by controlling for other forms of childhood maltreatment. Our findings support several routes with relative consistency (e.g., early maladaptive schemas, hopelessness, negative cognitive styles, brooding rumination, overall emotion dysregulation). Because psychological mediators function as a complex interrelated system, controlling for the interrelation between them is important. The evidence for the purported mediating role of the factors identified in this review should be considered with caution given the relative dearth of large-scale, adequately powered longitudinal studies. This review proposes a comprehensive multilevel theoretical framework as a basis for future research.
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http://dx.doi.org/10.3389/fpsyt.2020.559213DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7746653PMC
December 2020

Parents' understanding and motivation to take part in a randomized controlled trial in the field of adolescent mental health: a qualitative study.

Trials 2020 Nov 23;21(1):952. Epub 2020 Nov 23.

Child Attachment and Psychological Therapies Research Unit (ChAPTRe), Anna Freud National Centre for Children and Families, 4-8 Rodney Street, London, N1 9JH, UK.

Background: Little is known about why parents agree to take part in randomized controlled trials for adolescent mental health. This study aimed to investigate parents' perspectives on participating in a trial for psychological treatment of depression. The study explored parents' motivations, understanding of the trial and perspectives on the acceptability of the trial.

Methods: Sixty-five parents took part in this qualitative study. Their adolescent children had been randomly allocated to one of three active psychological treatments for depression as part of the IMPACT trial and were interviewed about their experiences of participating in the study. Semi-structured interviews were analysed using framework analysis.

Results: For seven of the sixty-five parents, their experience of taking part in the trial was not covered in their interview so they were excluded from the analysis. The analysis was therefore based on the data from the parents of 58 adolescents taking part in the trial. The most commonly cited motivation for taking part in the study reported by parents was a desire to help others going through similar difficulties. Parents generally reported finding trial participation acceptable, although there were aspects that some reported finding less acceptable, including randomization and the burden of research assessments. Others spoke positively about the experience of trial participation and found it enjoyable or even therapeutic. Importantly, some did not appear to have a good understanding of the trial design, including randomization and treatment allocation.

Conclusions: This study indicates that trial participation can be a positive experience for parents, yet it raises concerns about how trialists can ensure that consent is fully informed, given that some parents appeared to have a poor understanding of the trial. Future studies should seek to explore how communication with trial participants can be improved, to ensure that trial participation is fully informed. Patient and public involvement will be crucial in ensuring this communication is accessible to stakeholders.

Trial Registration: ISRCTN registry ISRCTN83033550 . Registered on 15 October 2009.
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http://dx.doi.org/10.1186/s13063-020-04857-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684724PMC
November 2020

Enhancing parental reflective functioning through early dyadic interventions: A systematic review and meta-analysis.

Infant Ment Health J 2021 01 18;42(1):21-34. Epub 2020 Nov 18.

Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.

Parental reflective functioning (PRF) is an important predictor of infant attachment, and interventions that target parent-infant/toddler dyads who are experiencing significant problems have the potential to improve PRF. A range of dyadic interventions have been developed over the past two decades, some of which explicitly target PRF as part of their theory of change, and some that do not explicitly target PRF, but that have measured it as an outcome. However, no meta-analytic review of the impact of these interventions has been carried out to date. The aim of this review was to evaluate the effectiveness of dyadic interventions targeting parents of infant and toddlers, in improving PRF and a number of secondary outcomes. A systematic review and meta-analysis was conducted in which key electronic databases were searched up to October 2018. Eligible studies were identified and data extracted. Data were synthesised using meta-analysis and expressed as both effect sizes and risk ratios. Six studies were identified providing a total of 521 participants. The results of six meta-analyses showed a nonsignificant moderate improvement in PRF in the intervention group (standardised mean difference [SMD]: -0.46; 95% confidence interval [CI] [-0.97, 0.04]) and a significant reduction in disorganised attachment (risk ratio: 0.50; 95% CI [0.27, 0.90]). There was no evidence for intervention effects on attachment security (odds ratio: 0.71; 95% CI [0.19, 2.64]), parent-infant interaction (SMD: -0.10; 95% CI [-0.46, 0.26]), parental depression (SMD: -1.55; 95% CI [-3.74, 0.64]) or parental global distress (SMD: -0.19, 95% CI [-3.04, 22.65]). There were insufficient data to conduct subgroup analysis (i.e. to compare the effectiveness of mentalisation-based treatment with non-mentalization-based treatment interventions). Relational early interventions may have important benefits in improving PRF and reducing the prevalence of attachment disorganisation. The implications for future research are discussed.
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http://dx.doi.org/10.1002/imhj.21896DOI Listing
January 2021

Internet-based psychodynamic versus cognitive behaviour therapy for adolescents with depression: study protocol for a non-inferiority randomized controlled trial (the ERiCA study).

Trials 2020 Jun 29;21(1):587. Epub 2020 Jun 29.

Department of Psychology, Stockholm University, Stockholm, Sweden.

Background: Adolescent depression is a common mental health problem and there is an urgent need for effective and accessible treatments. Internet-based interventions solve many obstacles for seeking and receiving treatment, thus increasing access to effective treatments. Internet-based cognitive behavioural therapy (ICBT) for adolescent depression has demonstrated efficacy in previous trials. In order to broaden the range of evidence-based treatments for young people, we evaluated a newly developed affect-focused Internet-based psychodynamic treatment (IPDT) in a previous study with promising results. The purpose of the planned study is to evaluate the efficacy of IPDT for adolescent depression in a non-inferiority trial, comparing it to ICBT.

Methods: The study will employ a parallel randomized non-inferiority design (ratio 1:1; n = 270). Eligible participants are adolescents 15-19 years suffering from depression. The primary hypothesis is that IPDT will be non-inferior to ICBT in reducing depressive symptoms from pre-treatment to end of treatment. Secondary research questions include comparing outcomes of IPDT and ICBT regarding anxiety symptoms, emotion regulation and self-compassion. Additional data will be collected to evaluate cost-effectiveness as well as investigating predictors, moderators and mediators of outcome. In addition, we will examine long-term outcome up to 1 year after end of treatment. Diagnostic interviews with MINI 7.0 will be used to establish primary diagnosis of depression as well as ruling out any exclusion criteria. Both treatments consist of eight modules over 10 weeks, complemented with therapist support through text messages and weekly chat sessions. Primary outcome measure is the Quick Inventory of Depressive Symptomatology in Adolescents Self-Rated (QIDS-A17-SR). Primary outcome will be analysed using data from all participants entering the study using a multilevel growth curve strategy based on the weekly measurements of QIDS-A17-SR. The non-inferiority margin is defined as d = 0.30.

Discussion: This trial will demonstrate whether IPDT is non-inferior to ICBT in the treatment of adolescent depression. The study might therefore broaden the range of evidence-based treatment alternatives for young people struggling with depression. Further analyses of data from this trial may increase our knowledge about "what works for whom" and the pathways of change for two distinct types of interventions.

Trial Registration: ISRCTN12552584 , Registered on 13 August 2019.
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http://dx.doi.org/10.1186/s13063-020-04491-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322832PMC
June 2020

The factor structure of the Working Alliance Inventory short-form in youth psychotherapy: an empirical investigation.

Psychother Res 2021 04 15;31(4):535-547. Epub 2020 May 15.

Child Attachment and Psychological Therapies Research Unit (ChAPTRe), Anna Freud National Centre for Children and Families, London, UK.

The Working Alliance Inventory short form (WAI-S) is one of the most commonly used alliance measures with adolescents. Yet, its factor structure has received minimal attention in the youth alliance literature. This study investigated the factor structure of the WAI-S in psychotherapy for adolescent depression and explored its measurement invariance across time, therapeutic approaches and patients' and therapists' perspectives. The existence of method effects associated with the negatively worded items of the scale was also assessed. The setting of this study is the IMPACT trial, a randomized controlled trial assessing the effects of three therapeutic interventions in the treatment of adolescent depression. The WAI-S was completed at 6, 12 and 36 weeks after randomization by 338 adolescents and 159 therapists. Data were analysed using confirmatory factor analysis. The hypothesized Bond-Task-Goal alliance structure was not supported and a general, one-factor model was found to be more psychometrically valid. The existence of a method effect and measurement invariance across time and treatment arms were also found. While the distinction between the specific alliance dimensions is conceptually and clinically interesting, at an empirical level the alliance features of the WAI-S in youth psychotherapy remain strongly intercorrelated.
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http://dx.doi.org/10.1080/10503307.2020.1765041DOI Listing
April 2021

Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression: Randomized Controlled Trial.

J Med Internet Res 2020 03 30;22(3):e18047. Epub 2020 Mar 30.

Department of Psychology, Stockholm University, Stockholm, Sweden.

Background: Adolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments.

Objective: This trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents.

Methods: The trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment.

Results: IPDT was significantly more effective than the control condition in reducing depression (d=0.82, P=.01), the result of which was corroborated by the second depression measure (d=0.80, P<.001). IPDT was also significantly more effective in reducing anxiety (d=0.78, P<.001) and increasing emotion regulation (d=0.97, P<.001) and self-compassion (d=0.65, P=.003). Significantly more patients in the IPDT group compared to the control group met criteria for response (56% vs 21%, respectively) and remission (35% vs 8%, respectively). Results on depression and anxiety symptoms were stable at 6 months follow-up. On average, participants completed 5.8 (SD 2.4) of the 8 modules.

Conclusions: IPDT may be an effective intervention to reduce adolescent depression. Further research is needed, including comparisons with other treatments.

Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 16206254; http://www.isrctn.com/ISRCTN16206254.
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http://dx.doi.org/10.2196/18047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7154938PMC
March 2020

Toward precision therapeutics: general and specific factors differentiate symptom change in depressed adolescents.

J Child Psychol Psychiatry 2020 09 12;61(9):998-1008. Epub 2020 Jan 12.

Department of Psychiatry, University of Cambridge, Cambridge, UK.

Background: The longitudinal course of multiple symptom domains in adolescents treated for major depression is not known. Revealing the temporal course of general and specific psychopathology factors, including potential differences between psychotherapies, may aid therapeutic decision-making.

Methods: Participants were adolescents with major depressive disorder (aged 11-17; 75% female; N = 465) who were part of the IMPACT trial, a randomized controlled trial comparing cognitive behavioral therapy, short-term psychoanalytic psychotherapy, and brief psychosocial intervention. Self-reported symptoms at baseline and 6, 12, 36, 52, and 86 weeks postrandomization were analyzed with bifactor modeling.

Results: General psychopathology factor scores decreased across treatment and one-year follow-up. Specific melancholic features and depressive cognitions factors decreased from baseline to 6 weeks. Conduct problems decreased across treatment and follow-up. Anxiety increased by 6 weeks and then reverted to baseline levels. Obsessions-compulsions did not change. Changes in general and specific factors were not significantly different between the three psychotherapies during treatment. During follow-up, however, conduct problems decreased more in brief psychosocial intervention versus cognitive behavioral therapy (1.02, 95% Bayes credible interval 0.25, 1.96), but not versus short-term psychoanalytic psychotherapy.

Conclusions: The clinical response signature in this trial is best revealed by rapid reductions in depression symptoms and general psychopathology. Protracted improvements in general psychopathology and conduct problems subsequently occur. Psychosocial treatments for adolescent depression have comparable effects on general and specific psychopathology, although a psychoeducational, goal-focused approach may be indicated for youth with comorbid conduct problems.
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http://dx.doi.org/10.1111/jcpp.13194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7496892PMC
September 2020

When adolescents stop psychological therapy: Rupture-repair in the therapeutic alliance and association with therapy ending.

Psychotherapy (Chic) 2020 12 13;57(4):471-490. Epub 2020 Jan 13.

Research Department of Clinical, Educational and Health Psychology.

The therapeutic alliance predicts dropout from psychological therapy, and ruptures in the therapeutic alliance may also predict dropout, yet there is a dearth of research with adolescents. This study investigated whether markers of rupture-repair in the alliance were indicative of different types of treatment ending in adolescents receiving psychological treatment for depression. Data were from the IMPACT study, a trial investigating the effectiveness of therapies for adolescent depression. Participants were randomly allocated to receive a brief psychosocial intervention, cognitive-behavioral therapy, or short-term psychoanalytic psychotherapy. The sample ( = 35) comprised adolescents who had either completed their treatment ( = 14) or dropped out ( = 21) according to their therapist. Dropout cases were further classified as dissatisfied ( = 14) or got-what-they-needed ( = 7) based on posttherapy interviews with the adolescent and therapist. Selected recordings of therapy sessions were rated using the Rupture Resolution Rating System and Working Alliance Inventory (observer version). Therapeutic alliance and rupture-repair during therapy were similar for completers and got-what-they-needed dropouts, whereas dissatisfied dropouts had poorer therapeutic alliance, more ruptures, ruptures that were frequently unresolved, and greater therapist contribution to ruptures. Qualitative analysis of sessions led to the construction of three categories of therapist contribution to ruptures: therapist minimal response, persisting with a therapeutic activity, and focus on risk. Results suggest that ruptures, especially when unresolved, could be warning signs of disengagement and dropout from therapy. Future research should investigate how ruptures may be effectively identified and resolved in treatment with adolescents. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/pst0000279DOI Listing
December 2020

Do sleep disturbances in depressed adolescents improve following psychological treatment for depression?

J Affect Disord 2020 02 21;262:205-210. Epub 2019 Oct 21.

Department of Psychiatry, University of Cambridge, Cambridge, UK.

Background: Persistent sleep disturbances are one of the most common symptoms of Major Depressive Disorder (MDD) in adolescence. These are not typically targeted in psychological treatments and it is not known if psychological treatment for depression improves sleep.

Methods: Secondary analyses were conducted using data from a large, multi-centre, randomised controlled trial (Goodyer et al., 2017b). Young people aged 12-18 years (N = 465; 75% female) met diagnostic criteria for Major Depressive Disorder, based on the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS). They were randomised to one of three psychological treatments. Sleep difficulties were assessed at baseline, post-treatment (36 weeks) and one year follow up (86 weeks) with the K-SADS, and the Mood and Feelings Questionnaire (MFQ).

Results: At baseline, 92% of young people exhibited clinically significant sleep difficulties. Exploratory analyses suggest that sleep difficulties significantly decreased from baseline to end of treatment on self-report and interview-based measures, and this decrease was maintained at follow up. Reduction in sleep difficulties did not differ between the psychological treatments. Approximately, half of young people reported residual sleep difficulties at the end of treatment and at follow-up.

Limitations: This paper reports secondary data analyses and findings are exploratory.

Conclusions: Tentative results suggest that psychological treatments for depression reduced sleep problems for some participants. However, young people with treatment-resistant sleep problems may benefit from adjunctive sleep interventions. Future work with a range of sleep measures is needed to determine those who have residual sleep problems at the end of treatment and post-treatment follow-up.
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http://dx.doi.org/10.1016/j.jad.2019.10.029DOI Listing
February 2020

Trajectories of depression symptom change during and following treatment in adolescents with unipolar major depression.

J Child Psychol Psychiatry 2020 05 24;61(5):565-574. Epub 2019 Oct 24.

Department of Psychiatry, University of Cambridge, Cambridge, UK.

Objective: To classify a cohort of depressed adolescents recruited to the UK IMPACT trial, according to trajectories of symptom change. We examined for predictors and compared the data-driven categories of patients with a priori operational definitions of treatment response.

Method: Secondary data analysis using growth mixture modelling (GMM). Missing data were imputed. Trajectories of self-reported depressive symptoms were plotted using scores taken at six nominal time points over 86 weeks from randomisation in all 465 patients.

Results: A piecewise GMM categorised patients into two classes with initially similar and subsequently distinct trajectories. Both groups had a significant decline in depressive symptoms over the first 18 weeks. Eighty-four per cent (84.1%, n = 391) of patients were classed as 'continued-improvers' with symptoms reducing over the duration of the study. A further class of 15.9% (n = 74) of patients were termed 'halted-improvers' with higher baseline depression scores, faster early recovery but no further improvement after 18 weeks. Presence of baseline comorbidity somewhat increased membership to the halted-improvers class (OR = 1.40, CI: 1.00-1.96). By end of study, compared with classes, a clinical remission cut-off score (≤27) and a symptom reduction score (≥50%) indexing treatment response misclassified 15% and 31% of cases, respectively.

Conclusions: A fast reduction in depressive symptoms in the first few weeks of treatment may not indicate a good prognosis. Halted improvement is only seen after 18 weeks of treatment. Longitudinal modelling may improve the precision of revealing differential responses to treatment. Improvement in depressive symptoms may be somewhat better in the year after treatment than previously considered.
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http://dx.doi.org/10.1111/jcpp.13145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216986PMC
May 2020

The Herts and Minds study: feasibility of a randomised controlled trial of Mentalization-Based Treatment versus usual care to support the wellbeing of children in foster care.

BMC Psychiatry 2019 07 10;19(1):215. Epub 2019 Jul 10.

The Centre for Health Services and Clinical Research, The University of Hertfordshire, Hatfield, UK.

Background: There is a lack of well-designed randomized controlled trials (RCTs) to investigate the efficacy of psychological therapies for children in foster care with emotional and behavioural difficulties. Mentalization-based therapy (MBT) focuses on supporting the carer-child relationship by promoting reflective capacity. This study examined the feasibility and acceptability of an RCT of MBT, delivered in a family-format, for children who are in foster care in the UK.

Method: Herts and Minds was a phase II, blinded feasibility RCT with follow-up of at 12 and 24 weeks post-randomisation. Participants were children (age 5-16) in foster care referred to a targeted mental health service, who had some level of difficulty as identified by the Strengths and Difficulties Questionnaire (SDQ). Aims were to assess: the feasibility of recruitment processes and study uptake; capacity to train mental health practitioners to deliver MBT to an acceptable level of treatment integrity; establish acceptability and credibility of MBT as an intervention for children in foster care; establish feasibility and acceptability to participants of conducting an RCT; and estimate the likely treatment efficacy effect size. Participants were randomly allocated to either MBT (n = 15) or Usual Clinical Care (UCC) (n = 21) individually or in sibling groups. A range of qualitative and quantitative data was gathered to assess feasibility.

Results: Feasibility was established with regard to: capacity to recruit participants to a study; capacity to train mental health practitioners to deliver MBT to an acceptable level of treatment integrity; acceptability and credibility of MBT; and feasibility and acceptability to participants of conducting an RCT. A number of issues made it difficult to estimate a likely treatment efficacy effect size.

Conclusion: With modifications, it is feasible to run an RCT of MBT for children in foster care. Both the therapy and research design were acceptable to participants, but modifications may be needed regarding both the timing of assessments and the identification of appropriate primary outcome measures. Given the lack of evidenced based therapies for this population, such a trial would be a significant contribution to the field. Findings may be useful for other groups planning clinical trials of psychological therapies for children in foster care.

Trial Registration: ISRCTN 90349442 . The trial was retrospectively registered on 6 May 2016.
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http://dx.doi.org/10.1186/s12888-019-2196-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6617562PMC
July 2019

Adolescents' experiences of brief psychosocial intervention for depression: An interpretative phenomenological analysis of good-outcome cases.

Clin Child Psychol Psychiatry 2020 Jan 20;25(1):106-118. Epub 2019 Jun 20.

Research Department of Clinical, Educational and Health Psychology, University College London, UK.

Background: Brief psychosocial intervention (BPI) is a treatment for adolescent depression that has recently demonstrated clinical effectiveness in a controlled trial. The aim of this study is to explore experiences of adolescents with major depression receiving BPI treatment in the context of good treatment outcomes.

Method: A subsample of five interviews from a larger study of adolescents' experiences of BPI was purposively selected, focusing on good-outcome cases. Interviews were analysed using interpretative phenomenological analysis to provide a richer understanding of participants' experiences of overcoming depression in the BPI group.

Results: Four central themes were identified: 'Being heard and feeling safe', 'Collaborative working enhancing therapy', 'Gaining a different perspective on one's self and relationships' and 'A positive therapeutic relationship'.

Conclusion: BPI is a novel approach with promising clinical effectiveness. Utilising adolescents' experiences has revealed potential psychological mechanisms of good treatment response to BPI. Overall implications for clinical practice with depressed adolescents are discussed.
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http://dx.doi.org/10.1177/1359104519857222DOI Listing
January 2020

The therapeutic relationship in Cognitive Behaviour Therapy with depressed adolescents: A qualitative study of good-outcome cases.

Psychol Psychother 2020 06 22;93(2):276-291. Epub 2019 May 22.

Department of Psychology, University of Bath, UK.

Objectives: This paper aimed to explore client experiences of the therapeutic relationship among adolescents with good outcomes after receiving Cognitive Behaviour Therapy (CBT) for moderate to severe depression.

Design: This was a qualitative study employing Interpretative Phenomenological Analysis (IPA).

Methods: As part of a randomized clinical trial, 77 adolescents with moderate to severe depression were interviewed using a semi-structured interview, which was audio-recorded. Five of these interviews, with adolescents aged 14-18 years who completed CBT and had good outcomes, were purposively sampled and analysed using IPA.

Results: The findings indicated that a positive therapeutic relationship was fostered with therapists who respected the adolescents' autonomy and sense of individuality, while offering experiences of emotional closeness and connection. This was achieved by balancing the dual roles of being 'friendly' and affable, with being a 'professional expert' thereby embodying a collaborative and egalitarian approach.

Conclusions: The therapeutic relationship in CBT can help to motivate adolescents to engage with cognitively and emotionally challenging tasks. By providing an understanding of what helps and hinders the development of a positive therapeutic relationship, the current findings offer important insight into how therapists can foster positive relationships with depressed adolescents. This knowledge will make it more likely that adolescents will engage in the treatment process and in turn experience greater therapeutic gains.

Practitioner Points: Offers a detailed phenomenological analysis of what fostered a positive therapeutic relationship in good outcome CBT, and what was experienced as harmful from the adolescents' perspective. Provides support that the therapeutic relationship is crucial in CBT; a respectful and understanding relationship provides a platform for the adolescent to carry out CBT activities and tasks.
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http://dx.doi.org/10.1111/papt.12232DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216827PMC
June 2020

Prognostic Implications for Adolescents With Depression Who Drop Out of Psychological Treatment During a Randomized Controlled Trial.

J Am Acad Child Adolesc Psychiatry 2019 10 1;58(10):983-992. Epub 2019 Apr 1.

University College London, UK.

Objective: High therapy dropout rates among adolescents have been reported, but little is known about whether dropout is associated with poor outcomes. This study aimed to examine clinical outcomes in adolescents with depression who dropped out of psychological therapy and to determine whether this varied by treatment type.

Method: Data were drawn from the Improving Mood with Psychoanalytic and Cognitive Therapies (IMPACT) study, a randomized controlled trial, comparing a brief psychosocial intervention, cognitive-behavioral therapy, and short-term psychoanalytic psychotherapy in the treatment of adolescent major depression. The sample comprised 406 adolescents with a diagnosis of major depression, 169 of whom dropped out of treatment before the planned end of therapy. Primary outcome was self-report Mood and Feelings Questionnaire (MFQ); secondary outcomes were Health of the Nation Outcome Scale for Children and Adolescents, Revised Children's Manifest Anxiety Scale, Modified Leyton Obsessional Inventory, and clinical diagnosis.

Results: During follow-up, there was a nonsignificant trend for dropouts to report higher depressive symptoms than completers. However, modeling showed insufficient evidence for an association between dropout and outcomes.

Conclusion: In contrast to studies of adult therapy, there was no strong evidence that adolescent patients who dropped out had poorer clinical outcomes compared with those who completed therapy, when dropout was defined as ending treatment without agreement of the therapist. This challenges us to understand why adolescents stop going to therapy, how dropout should be defined, and whether what is prescribed is what is always needed.

Clinical Trial Registration Information: Improving Mood and Preventing Relapse With Psychoanalytic Psychotherapy and Cognitive Behavior Therapy; http://www.isrctn.com/; 83033550.
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http://dx.doi.org/10.1016/j.jaac.2018.11.019DOI Listing
October 2019

'I Just Stopped Going': A Mixed Methods Investigation Into Types of Therapy Dropout in Adolescents With Depression.

Front Psychol 2019 5;10:75. Epub 2019 Feb 5.

Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.

What does it mean to 'drop out' of therapy? Many definitions of 'dropout' have been proposed, but the most widely accepted is the client ending treatment without agreement of their therapist. However, this is in some ways an external criterion that does not take into account the client's experience of therapy, or reasons for ending it prematurely. This study aimed to identify whether there were more meaningful categories of dropout than the existing dropout definition, and to test whether this refined categorization of dropout was associated with clinical outcomes. This mixed-methods study used a subset of data from the IMPACT trial, which investigated psychological therapies for adolescent depression. Adolescents were randomly allocated to a treatment arm (Brief Psychosocial Intervention; Cognitive-Behavioral Therapy; Short-Term Psychoanalytic Psychotherapy). The sample for this study comprised 99 adolescents, aged 11-17 years. Thirty-two were classified as having dropped out of treatment and participated in post-therapy qualitative interviews about their experiences of therapy. For 26 dropout cases, the therapist was also interviewed. Sixty-seven cases classified as having completed treatment were included to compare their outcomes to dropout cases. Interview data for dropout cases were analyzed using ideal type analysis. Three types of dropout were constructed: 'dissatisfied' dropout, 'got-what-they-needed' dropout, and 'troubled' dropout. 'Dissatisfied' dropouts reported stopping therapy because they did not find it helpful. 'Got-what-they-needed' dropouts reported stopping therapy because they felt they had benefitted from therapy. 'Troubled' dropouts reported stopping therapy because of a lack of stability in their lives. The findings indicate the importance of including the perspective of clients in definitions of drop out, as otherwise there is a risk that the heterogeneity of 'dropout' cases may mask more meaningful distinctions. Clinicians should be aware of the range of issues experienced by adolescents in treatment that lead to disengagement. Our typology of dropout may provide a framework for clinical decision-making in managing different types of disengagement from treatment.
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http://dx.doi.org/10.3389/fpsyg.2019.00075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370696PMC
February 2019

Therapists' techniques in the treatment of adolescent depression.

J Psychother Integr 2018 Dec;28(4):413-428

Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.

When comparing the relative effectiveness of different psychological treatment approaches using clinical trials, it is essential to establish fidelity to each manualized therapy, and differentiation between the treatment arms. Yet few psychological therapy trials include details about the assessment of treatment integrity and little is known about the specific techniques used by therapists, or to what degree these techniques are shared or distinct across different therapeutic approaches. The aims of this study were: to establish the fidelity of two established psychological therapies - cognitive-behaviour therapy (CBT) and short-term psychoanalytic psychotherapy (STPP) - in the treatment of adolescent depression; and to examine whether they were delivered with adherence to their respective treatment modalities, and if they could be differentiated from each other and from a reference treatment (a brief psychosocial intervention; BPI). The study also aimed to identify shared and distinct techniques used within and across the three treatments. Audio-tapes (N=230) of therapy sessions, collected as part of a trial, were blind double-rated using the Comparative Psychotherapy Process Scale (CPPS), which includes subscales for cognitive-behavioural and psychodynamic-interpersonal techniques. The treatments were delivered with reasonable fidelity and there was clear differentiation in the use of cognitive-behavioural and psychodynamic-interpersonal techniques between CBT and STPP, and between these two established psychological therapies and BPI. An item-level analysis identified techniques used across all three treatments, techniques that were shared between BPI and CBT, and techniques that were unique to CBT and STPP.
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http://dx.doi.org/10.1037/int0000119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6276999PMC
December 2018

Facing Shadows: working with young people to coproduce a short film about depression.

Res Involv Engagem 2018 27;4:46. Epub 2018 Nov 27.

2Research Department of Clinical, Educational and Health Psychology, University College London, Cambridge, UK.

Background: IMPACT (Improving Mood with Psychoanalytic and Cognitive Therapies) is a multi-centre randomised controlled trial of three therapeutic interventions for the treatment of depression in young people. IMPACT- My Experience (IMPACT-ME), a qualitative research study, followed up a sub-sample of families involved in IMPACT to explore young people's experiences of therapy and depression. Members of the IMPACT-ME steering group, who brought their own experiences of depression and engaging with mental health services, were keen to find ways to provide information about depression and help-seeking beyond traditional academic audiences, specifically to other young people experiencing depression and wondering where to turn: their chosen medium was film. Here we describe and reflect on the four-day coproduction workshops in which researchers, young people and film-makers coproduced 'Facing Shadows', a short animation about depression and therapy (https://www.youtube.com/watch?v=LdmRPKUhNEY).

Main Body: We outline the process, focusing on the four-day creative, collaborative workshop in which young people shared their experiences, decided on the tone, tenor and message of the film, identified their primary audience and produced the bulk of the audio and visual material. The adults acted as facilitators: developing a creative, collaborative learning environment in which trusting relationships could flourish, as well as offering guidance, instruction, advice and support. To date the film has been viewed around 12,000 times on YouTube. The young people learned new skills, felt listened to and enjoyed the process. They produced a film which sends a hopeful message to other young people, '…

Conclusion: We reflect on the creative participatory workshop approach which transformed the project from dissemination to an insightful learning experience for young people and researchers alike.
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http://dx.doi.org/10.1186/s40900-018-0126-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6258258PMC
November 2018

Meaning and medication: a thematic analysis of depressed adolescents' views and experiences of SSRI antidepressants alongside psychological therapies.

BMC Psychiatry 2018 11 28;18(1):374. Epub 2018 Nov 28.

The Child Attachment and Psychological Therapies Research Unit (ChAPTRe), University College London and Anna Freud National Centre for Children and Families, London, UK.

Background: Adolescence is a key period of risk for the emergence of Major Depressive Disorder (MDD). The prescription of selective serotonin re-uptake inhibitors (SSRIs) for the treatment of depression in adolescents is an issue of worldwide controversy, and evidence regarding their safety and efficacy is inconclusive. In the UK, NICE guidelines have recently recommended offering SSRIs to adolescents alongside psychological therapy or on their own if therapy is refused. Thus, SSRIs are increasingly becoming a major component of treatment for adolescents. This study qualitatively explored adolescents' views and experiences of SSRIs within their accounts of engaging in a psychological therapy for depression, particularly focusing on meanings they attached to medication-use.

Methods: The qualitative study reports data from semi-structured interviews conducted 12-months post-treatment with 12 adolescents who were clinically referred and treated for depression as part of the IMPACT trial. The interviews were analysed using Thematic Analysis.

Results: Four themes were identified: 'a perceived threat to autonomy', 'a sign of severity', 'a support, not a solution', and 'an ongoing process of trial and error'.

Conclusions: This study highlights the value of bringing adolescents' voices into the broader debate on the use of antidepressants in their age group and in the development of future guidelines. Future implications for research and clinical practice are discussed.
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http://dx.doi.org/10.1186/s12888-018-1961-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6263068PMC
November 2018

TIGA-CUB-manualised psychoanalytic child psychotherapy versus treatment as usual for children aged 5-11 with treatment-resistant conduct disorders and their primary carers: results from a randomised controlled feasibility trial.

J Child Adolesc Ment Health 2018 Nov 14;30(3):167-182. Epub 2018 Nov 14.

c Institute of Health Sciences, University of Leeds , Leeds , UK.

Background: Parenting programmes are recommended for conduct disorders in 5-11 year olds, but ineffective for 25-33%. A feasibility trial was needed to determine whether a confirmatory trial of second-line, manualised short-term psychoanalytic child psychotherapy (mPCP) versus treatment as usual (TaU) is practicable.

Method: This was a two-arm, pragmatic, parallel-group, multi-centre, individually-randomised controlled feasibility trial with blinded outcome assessment. Child-primary carer dyads were recruited from National Health Service Child and Adolescent Mental Health Services and mPCP delivered by routine child psychotherapists.

Results: Thirty-two dyads (50% of eligible, 95% CI 37 to 63%) were recruited, with 16 randomised to each arm. Eleven (69%) completed ≥50% of 12 week mPCP and 13 (81%) . Follow-up was obtained for 24 (75%) at 4 months and 14/16 (88%) at 8 months. Teacher follow-up was 16 (50%) ≥1 session. Manual adherence was good. Baseline candidate primary outcomes were 37.4 (SD 11.4) and 18.1 (SD 15.7) on the Child Behaviour Checklist/Teacher Report Form externalising scale and 102.8 (SD 28.4) and 58.8 (SD 38.9) on the total score. Health economics data collection was feasible and the trial acceptable to participants.

Conclusion: Recruitment, teacher follow-up and the manual need some refinement. A confirmatory trial is feasible, subject to funding of research child psychotherapists.
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http://dx.doi.org/10.2989/17280583.2018.1532433DOI Listing
November 2018
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