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BACKGROUND: Definitions of dichotomous outcome terms, such as "response," "remission," and "recovery" are central to the design, interpretation, and clinical application of randomized controlled trials of adolescent depression interventions. Accordingly, this scoping review was conducted to document how these terms have been defined and justified in clinical trials. METHOD: Bibliographic databases MEDLINE, Embase, APA PsycInfo, and CINAHL were searched from inception to February 2020 for randomized controlled trials evaluating treatments for adolescent depression. Ninety-eight trials were included for data extraction and analysis. RESULTS: Assessment of outcome measurement instruments, metric strategies, methods of aggregation, and measurement timing, yielded 53 unique outcome definitions of "response" across 45 trials that assessed response, 47 unique definitions of "remission" in 29 trials that assessed remission, and 19 unique definitions of "recovery" across 11 trials that assessed recovery. A minority of trials (N = 35) provided a rationale for dichotomous outcomes definitions, often by citing other studies that used a similar definition (N = 11). No rationale included input from youth or families with lived experience. CONCLUSION: Our review revealed that definitions of "response," "remission," "recovery," and related terms are highly variable, lack clear rationales, and are not informed by key stakeholder input. These limitations impair pooling of trial results and the incorporation of trial findings into pragmatic treatment decisions in clinical practice. Systematic approaches to establishing outcome definitions are needed to enhance the impact of trials examining adolescent depression treatment.

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Background: Fear of flying (FoF) is a phobia with 10-40% prevalence in the industrialized world. FoF is accompanied by severe economic, social, vocational, and emotional consequences. In recent years, virtual reality (VR)-based exposure therapy (VRET) for FoF has been introduced. Positive long-term efficacy of FoF-VRET has been reported by several studies, which, however, were limited by relatively small, non-representative samples and a lack of comparative pre/post functional efficacy outcome measures. Our objective was to evaluate the efficacy of a VRET treatment utilizing a large-scale VR system, experienced by a representative sample of self-referred individuals. Methods: We conducted a retrospective survey. Of 274 individuals who received the treatment (over a period of 3 years), 209 met inclusion/criteria, and 98 agreed to participate. We mainly collected information regarding flight activity before and after treatment relying on evidence such as boarding passes and flight tickets. The primary outcome measures were (1) number of flights per month (FpM) and (2) number of flight hours per month (FHpM). For each participant, these outcomes were computed for the post-treatment period (≥6 months after FoF-VRET) and the corresponding pre-treatment period. Results: FpM (mean ± SD) increased from 0.04 ± 0.06 to 0.16 ± 14 flights (p < 0.0001). FHpM rose from 0.19 ± 0.35 to 0.79 ± 0.87 h per month (p < 0.0001). Conclusion: These results are indicative of FoF-VRET treatment efficacy. Future studies should evaluate long-term maintenance of the treatment effect and thus identify the optimal frequency for delivery of periodic booster treatments.

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OBJECTIVE: In the past two decades, newer psychotherapy treatments have emerged for the treatment of major depression. This review aimed to comprehensively synthesize the evidence for mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), and positive psychotherapy (PPT) in treating a current episode of major depression. METHODS: A systematic search of the Ovid MEDLINE, Embase, PsycINFO, and Cochrane databases was conducted for randomized controlled trials of MBCT, ACT, and PPT for major depression. Standardized mean differences were calculated with Hedges' g to complete random-effects meta-analysis. Heterogeneity was assessed with the Cochran Q statistic and I2 statistic. Subgroup analysis was conducted to further investigate heterogeneity. RESULTS: A random-effects meta-analysis of 15 studies (MBCT, N=7; ACT, N=4; PPT, N=4) revealed that all three therapies showed efficacy in reducing symptoms of depression with a small favorable effect, compared with all control conditions (N=946; Hedges' g=0.34; 95% confidence interval=0.14, 0.54; p<0.001). Cochrane's Q statistic (Q=32, df=15, p=0.007) suggested significant heterogeneity (I2=53%). A mixed-effects model test for subgroup differences showed significant differences between active controls and treatment-as-usual controls (χ2=15.3, df=1, p<0.001). Overall quality of evidence and publication bias were low. CONCLUSIONS: Meta-analysis shows that MBCT and ACT may be superior to inactive or treatment-as-usual controls and that PPT may be comparable to active controls for reducing symptoms of major depression after an acute course of therapy. However, the quality of the evidence was low. High-quality studies are needed to confirm the efficacy of these interventions.

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INTRODUCTION: Separation anxiety disorder (SAD) comprises one aspect of attachment dysregulation or insecurity. Although SAD aggravates posttraumatic stress disorder (PTSD) risk, no clinical research has tracked how many patients with PTSD have SAD, its clinical associations, or its response to PTSD treatment. Our open trial of interpersonal psychotherapy (IPT) for veterans with PTSD assessed these SAD domains. METHODS: Twenty-nine veterans diagnosed with chronic PTSD on the Clinician-Administered PTSD Scale were assessed for SAD using the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), and for Symptom-Specific Reflective Function (SSRF), another dysregulated-attachment marker capturing patients' emotional understanding of their symptoms. Patients received 14 IPT sessions for PTSD with assessments at baseline, Week 4 (SCI-SAS and SSRF), and termination for SAD, PTSD, and depression. RESULTS: At baseline, 69% of patients met SAD criteria. Separation anxiety did not correlate with baseline PTSD severity, depressive severity, or age when traumatized; patients with and without SAD had comparable PTSD and depression severity. Patients with baseline comorbid SAD who completed IPT (N = 17) reported significantly improved adult separation anxiety (p = .009). Adult SAD improvements predicted depressive improvement (p = .049). Patients with SAD showed a stronger relationship between early SSRF gains and subsequent adult SAD improvement (p = .021) compared with patients without SAD. DISCUSSION: This first exploration of dysregulated/insecure attachment features among patients with PTSD found high SAD comorbidity and adult SAD improvement among patients with SAD following IPT. Highly impaired attachment patients normalized attachment posttreatment: 14-session IPT improved attachment dysregulation. This small study requires replication but begins to broaden clinical understanding of separation anxiety, attachment dysregulation, and PTSD.

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OBJECTIVE: This study examined clinical and retention outcomes following variable length prolonged exposure (PE) for posttraumatic stress disorder (PTSD) delivered by one of three treatment modalities (i.e., home-based telehealth [HBT], office-based telehealth [OBT], or in-home-in-person [IHIP]). METHOD: A randomized clinical trial design was used to compare variable-length PE delivered through HBT, OBT, or IHIP. Treatment duration (i.e., number of sessions) was determined by either achievement of a criterion score on the PTSD Checklist for Diagnostic and Statistical Manual-5 (DSM-5; PTSD Checklist for DSM-5) for two consecutive sessions or completion of 15 sessions. Participants received PE via HBT (n = 58), OBT (n = 59) or IHIP (n = 58). Data were collected between 2012 and 2018, and PTSD was diagnosed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), administered at baseline, posttreatment, and 6 months following treatment completion. The primary clinical outcome was CAPS-5 PTSD severity. Secondary outcomes included self-reported PTSD and depression symptoms, as well as treatment dropout. RESULTS: The clinical effectiveness of PE did not differ by treatment modality across any time point; however, there was a significant difference in treatment dropout. Veterans in the HBT (odds ratio [OR] = 2.67; 95% confidence interval [CI] = 1.10, 6.52; p = .031) and OBT (OR = 5.08; 95% CI = 2.10; 12.26; p < .001) conditions were significantly more likely than veterans in IHIP to drop out of treatment. CONCLUSIONS: Providers can effectively deliver PE through telehealth and in-home, in-person modalities although the rate of treatment completion was higher in IHIP care.

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BACKGROUND: Depressive and anxiety disorders are highly prevalent and detrimental in primary care settings. However, there are gaps in the literature concerning effectiveness and generalizability of empirically supported interventions and treatment of both depression and anxiety in primary care settings. The aim of this review is to systematically assess and meta-analyze the effectiveness of brief empirically-supported psychotherapies for treating depression and/or anxiety in primary care. METHODS: Seven electronic databases, five professional websites and manual search of reference lists were searched through April 2017 for randomized controlled trials (RCTs) of four psychotherapies treating primary care depression and anxiety: cognitive-behavior therapy (CBT), problem-solving therapy (PST), motivational interviewing (MI), and solution-focused brief therapy (SFBT). RESULTS: From an initial pool of 1140 articles, 179 articles were eligible for full-text review and 65 articles were included for final analysis. Sixty-five articles containing 198 effect sizes reported an overall treatment effect size of d = 0.462, p < 0.001. Single-predictor meta-regression indicated that marital status, treatment modality (individual versus group), and treatment composition were significant moderators. Multiple-predictor meta-regression discovered treatment setting (inside versus outside primary care) significantly moderated treatment effect, b = -0.863, p = 0.039 after controlling for other intervention characteristics. CONCLUSION: Treatment effects were found for CBT and PST, both for depressive and anxiety disorders. Interventions delivered outside primary care settings were more effective than those within, individual treatment had greater treatment effects compared to group treatment, and both technology-assisted and in-person treatments were found to be effective.

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BACKGROUND: Major depressive disorder (MDD) has a highly recurrent nature. After successful treatment, it is important to identify individuals who are at risk of an unfavorable long-term course. Despite extensive research, there is no consensus yet on the clinically relevant predictors of long-term outcome in MDD, and no prediction models are implemented in clinical practice. The aim of this study was to create a prognostic index (PI) to estimate long-term depression severity after successful and high quality acute treatment for MDD. METHODS: Data come from responders to cognitive therapy (CT) and interpersonal psychotherapy (IPT) in a randomized clinical trial (n = 85; CT = 45, IPT = 40). Primary outcome was depression severity, assessed with the Beck Depression Inventory II, measured throughout a 17-month follow-up phase. We examined 29 variables as potential predictors, using a model-based recursive partitioning method and bootstrap resampling in conjunction with backwards elimination. The selected predictors were combined into a PI. Individual PI scores were estimated using a cross-validation approach. RESULTS: A total of three post-treatment predictors were identified: depression severity, hopelessness, and self-esteem. Cross-validated PI scores evidenced a strong correlation (r = 0.60) with follow-up depression severity. CONCLUSION: Long-term predictions of MDD are multifactorial, involving a combination of variables that each has a small prognostic effect. If replicated and validated, the PI can be implemented to predict follow-up depression severity for each individual after acute treatment response, and to personalize long-term treatment strategies.

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BACKGROUND: Dropout rates for effective therapies for posttraumatic stress disorder (PTSD) can be high, especially in practice settings. Although clinicians have intuitions regarding what treatment patients may complete, there are few systematic data to drive those judgments. METHODS: A multivariable model of dropout risk was constructed with randomized clinical trial data (n = 160) comparing prolonged exposure (PE) and cognitive processing therapy (CPT) for rape-induced PTSD. A two-step bootstrapped variable selection algorithm was applied to identify moderators of dropout as a function of treatment condition. Employing identified moderators in a model, fivefold cross-validation yielded estimates of dropout probability for each patient in each condition. Dropout rates between patients who did and did not receive their model-indicated treatment were compared. RESULTS: Despite equivalent dropout rates across treatments, patients assigned to their model-indicated treatment were significantly less likely to drop out relative to patients who did not (relative risk = 0.49 [95% CI: 0.29-0.82]). Moderators included in the model were: childhood physical abuse, current relationship conflict, anger, and being a racial minority, all of which were associated with higher likelihood of dropout in PE than CPT. CONCLUSIONS: Individual differences among patients affect the likelihood they will complete a particular treatment, and clinicians can consider these moderators in treatment planning. In the future, treatment selection models could be used to increase the percentage of patients who will receive a full course of treatment, but replication and extension of such models, and consideration of how best to integrate them into routine practice, are needed.

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The Penn State Worry Questionnaire - Past Week (PSWQ-PW) is an adaptation of the widely used Penn State Worry Questionnaire, measuring pathological worry weekly. However, it contains problematic negatively worded items and has not been validated in a large sample yet. To meet the needs of measurement-based care (MBC), we developed a shortened version (PSWQ-10) based on the PSWQ-PW, retaining only positively worded items, and examined its psychometric properties and clinical utility. Patients with Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), and other anxiety disorders completed the PSWQ-10 and other instruments during routine evaluation in an academic anxiety clinic. A second cohort from a perinatal clinic was evaluated similarly. The PSWQ-10 displayed excellent internal consistency, convergent and discriminant validity, and criterion group validity. Patients with GAD scored significantly higher than those with other anxiety disorders but did not differ from those with MDD. The PSWQ-10 showed sensitivity to change over time and demonstrated excellent psychometric properties in the perinatal population. The PSWQ-10 is a reliable, valid, efficient, and straightforward worry-focused instrument that can be readily used in MBC and help clinicians objectively measure worry as a treatment outcome in broad clinical populations.

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OBJECTIVE: Suicide is one of the leading causes of death among youth today. Schools are a cost-effective way to reach youth, yet there is no conclusive evidence regarding the most effective prevention strategy. We conducted a systematic review of the empirical literature on school-based suicide prevention programs. METHOD: Studies were identified through MEDLINE and Scopus searches, using keywords such as "suicide, education, prevention and program evaluation." Additional studies were identified with a manual search of relevant reference lists. Individual studies were rated for level of evidence, and the programs were given a grade of recommendation. Five reviewers rated all studies independently and disagreements were resolved through discussion. RESULTS: Sixteen programs were identified. Few programs have been evaluated for their effectiveness in reducing suicide attempts. Most studies evaluated the programs' abilities to improve students' and school staffs' knowledge and attitudes toward suicide. Signs of Suicide and the Good Behavior Game were the only programs found to reduce suicide attempts. Several other programs were found to reduce suicidal ideation, improve general life skills, and change gatekeeper behaviors. CONCLUSIONS: There are few evidence-based, school-based suicide prevention programs, a combination of which may be effective. It would be useful to evaluate the effectiveness of general mental health promotion programs on the outcome of suicide. The grades assigned in this review are reflective of the available literature, demonstrating a lack of randomized controlled trials. Further evaluation of programs examining suicidal behavior outcomes in randomized controlled trials is warranted.

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BACKGROUND: To investigate the effects of booster sessions in cognitive behavioral therapy (CBT) for children and adolescents with mood or anxiety disorders, whereas controlling for youth demographics (e.g., gender, age), primary diagnosis, and intervention characteristics (e.g., treatment modality, number of sessions). METHODS: Electronic databases were searched for CBT interventions for youth with mood and anxiety disorders. Fifty-three (k = 53) studies investigating 1,937 youth met criteria for inclusion. Booster sessions were examined using two case-controlled effect sizes: pre-post and pre-follow-up (6 months) effect sizes and employing weighted least squares (WLSs) regressions. RESULTS: Meta-analyses found pre-post studies with booster sessions had a larger effect size r = .58 (k = 15; 95% CI = 0.52-0.65; P < .01) than those without booster sessions r = .45 (k = 38; 95% CI = 0.41-0.49; P < .001). In the WLS regression analyses, controlling for demographic factors, primary diagnosis, and intervention characteristics, studies with booster sessions showed larger pre-post effect sizes than those without booster sessions (B = 0.13, P < .10). Similarly, pre-follow-up studies with booster sessions showed a larger effect size r = .64 (k = 10; 95% CI = 0.57-0.70; P < .10) than those without booster sessions r = .48 (k = 20; 95% CI = 0.42-0.53; P < .01). Also, in the WLS regression analyses, pre-follow-up studies showed larger effect sizes than those without booster sessions (B = 0.08, P < .01) after accounting for all control variables. CONCLUSIONS: Result suggests that CBT interventions with booster sessions are more effective and the effect is more sustainable for youth managing mood or anxiety disorders than CBT interventions without booster sessions.

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