Programs that Work
Coping with Stress Course
Healthy and Safe Children
Children not experiencing anxiety or mood disorders, such as depression
Age of Child
Type of Setting
Community-Based Service Provider
Health Care Provider
Type of Service
Type of Outcome Addressed
Evidence Level (What does this mean?)
The Coping with Stress Course (CWS) targets adolescents at risk for depression who are experiencing elevated depressive symptoms, or "demoralization." The program involves cognitive-restructuring techniques in which participants learn to identify and challenge negative or irrational thoughts that may contribute to the development of future mood disorders, such as depression. CWS is an adaptation of the Adolescent Coping with Depression Course (Clarke, Lewinsohn, and Hops, 1990), which targets adolescents already experiencing major depression or dysthymia.
Adolescents at risk for depression
The first randomized control trial (Clarke et al., 1995) included 222 ninth and tenth grade students from three suburban high schools in Oregon. The Center for Epidemiological Studies Depression Scale (CES-D) was administered to 1,652 students, and 471 adolescents with elevated CES-D scores were asked to participate in an interview during which their diagnostic outcomes were assessed on the interviewer-rated Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Epidemiological Version (K-SADS-E). Interviews were held with 222 students (those who obtained informed consent from parents); 46 were diagnosed with current affective (mood) disorders and were excluded from the study, while 172 met inclusion criteria for elevated depressive symptoms, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria. Of these students, 150 agreed to be randomized to either CWS (76 students) or a "usual care" control condition (74 students). Adolescents were 70 percent female, and the majority was non-Hispanic white (93 percent). Subjects were assessed immediately after the intervention and at 6-month and 12-month follow-up points. The dropout rate at posttest was 17 percent, at 6 months it was 20 percent, and at 12 months it was 27 percent. No significant differences were found between study dropouts and completers on initial depression severity or on demographic variables. Adolescent outcomes were measured on three diagnostic interview tests, the Global Assessment of Functioning Scale (GAF, an assessment of severity of impairment), the K-SADS-E, and the Longitudinal Interval Follow-up Evaluation (LIFE). Items from the K-SADS-E were also extracted to form the Hamilton Depression Rating Scale (HAM-D). Adolescent self-reports of depression were assessed on the CES-D.
Clarke et al. (2001) undertook a second randomized control trial of CWS on a sample of 45 experimental and 49 control group youths aged 13-18 from Portland, Oregon. All participants were offspring of adults treated for depression in a health maintenance organization (HMO). Potential adult cases were found by reviewing the HMO pharmacy records for dispensation of antidepressant medication and the mental health appointment system during a two-year period (5,954 adult patients). Medical charts were reviewed for a depression diagnosis, determining that 3,935 of these adults (66 percent) had been diagnosed with depression. Recruitment letters signed by treating physicians were mailed to adults they judged appropriate for the study (2,995 patients), and 458 adults (15 percent) refused. The adolescent offspring of 2,083 of the contacted adults were asked to participate in the study. Interviews were scheduled with 744 families (966 youth) and completed with 481 parents (65 percent) and 551 adolescents (57 percent). Eligible offspring were required to have depressive symptoms insufficient to meet clinical criteria for affective disorder and no history of a past mood disorder, such as depression or bipolar disorder. Of the 551 interviewed youth/parent dyads, 79 did not meet study criteria, and the remaining 472 were classified into one of three mutually exclusive depression severity groups. Those classified as having "medium-severity depression" (123 youth or 26 percent) were the focus of this study. "Medium severity" was defined as the youth having a CES-D score of greater than 24 and/or reporting some level of depressive symptoms on the clinical interview, but at a level that was insufficient to meet full criteria for a DSM-III-R diagnosis. These adolescents were randomized to usual HMO care (49 youth) or usual care plus CWS (45 youth), and 29 youth declined to participate. Follow up assessments were conducted immediately posttreatment, and at 12 and 24 months. Outcomes were assessed on the interviewer-rated K-SADS-E, the HAM-D, and the GAF. Parent reports of child behavior and depression were assessed on the Child Behavior Checklist (CBCL), and adolescent self-reports of depression were measured on the CES-D.
Key Evaluation Findings
The study by Clarke et al. (1995) reported:
- On the K-SADS-E and LIFE interviews, a significant advantage was found for the CWS group at 12 months, with incidence rates for affective disorder of 15 percent compared with 26 percent for the control group. No significant differences were detected on the HAM-D, or for disruptive behavior, anxiety, or substance abuse.
- Analyses of the GAF score found a significant effect favoring the treatment group from pretest to initial posttest, but no significant effects when the entire study period was examined (pretest to 12-month follow-up).
- Outcomes on the self-reported CES-D showed significantly fewer cases of either major depression and/or dysthymia (a more minor form of depression) for the treatment group compared with the control group from pretest to initial posttest. No significant differences were detected when outcomes were measured from pretest to 12-month follow-up.
Clarke et al. (2001) found:
- The CWS group scored significantly better than the control group on the CES-D, the HAM-D, the K-SADS-E suicide symptom total, and the GAF.
- Analyses of major depressive episodes during a 14-month follow-up (on average) found a significant advantage for the treatment group (9 percent incidence) compared with the control group (29 percent incidence).
- No significant effects were found for parent reports of child depression, or behavior problems on the CBCL externalizing or internalizing scales.
Public and private elementary, middle, and high schools; community-based organizations; hospitals; clinics; and after-school programs.
No funding suggestions at this time.
A cost-benefit analysis of CWS (Lynch et al., 2005) found that the average cost of the program per participant was $1,632 (in 2005 dollars), with identification and recruitment of participants for the study accounting for 65 percent of the costs. The authors found that although total and indirect costs were $610 higher in the CWS group than in the usual care group, the difference was not statistically significant. This finding suggests that the cost-effectiveness of CWS is comparable to that of other accepted depression treatments.
The theoretical background of the Coping with Stress Course is that teaching adolescents new coping strategies and strengthening their current coping skills provide them with some measure of "immunity" or resistance against the development of mood disorders later in life. The aim of CWS is to enhance at-risk adolescents' resilience in order to counteract their vulnerability to depression and other mood disorders.
Group size for the adolescent sessions is from six to ten adolescents, and the program consists of fifteen 45- to 60-minute group sessions. CWS uses cartoons, role-plays, and group discussions oriented to the developmental level of the participants.
Separate parent information meetings at the beginning, middle, and end of each adolescent course are optional. During these sessions, parents are informed about the general topics discussed, the skills taught in the adolescent groups, and the rationale for the use of the selected techniques.
CWS groups are led by specially trained school psychologists and counselors who have a minimum of a master's degree in clinical, counseling, or educational psychology, and who have previous experience in conducting psychoeducational groups with adolescents. Before beginning the group sessions, therapists are provided with 40 hours of training, including mock intervention sessions, role-playing adolescent responses to exercises, homework, and videotaped feedback.
Issues to Consider
This program received a "proven" rating. Both studies of the Coping with Stress Course employed rigorous evaluation methodology involving randomized assignment of study participants and found significant reductions in interviewer-rated and self-reported depression symptoms for treatment children when compared with those in a control group.
CWS was not found to be effective in reducing parent-reported psychosocial dysfunction and behavior problems among participating children. In addition, some of the positive results on self-reported and interviewer-rated depression were not maintained in one- and two-year follow-up assessments.
Studies of CWS suggest that the program can be successfully implemented in a wide range of settings. Clarke and colleagues have conducted CWS program evaluations in both an after-school setting as well as a clinical hospital setting, and the program was found to be effective in both.
A four-site replication study of CWS is currently under way, enrolling 320 youth total. Sites include Nashville, Tenn; Pittsburgh, Penn; Cambridge, Mass.; and Portland, Oreg. Results will be available in early 2007.
It should be noted that the program developers served as authors on both evaluations of the CWS.
Gregory N. Clarke, Ph.D.
Kaiser Permanente Center for Health Research
3800 N. Kaiser Center Dr.
Portland, OR 97227
phone: (503) 335-6673
The Kaiser Permanente Center for Health Research provides free downloads of the CWS therapist manual and the CWS teen workbook at http://www.kpchr.org/public/acwd/acwd.html.
Clarke, Gregory N., Mark Hornbrook, Frances Lynch, Michael Polen, John Gale, William Beardslee, Elizabeth O'Connor, and John Seeley,
"A Randomized Trial of a Group Cognitive Intervention for Preventing Depression in Adolescent Offspring of Depressed Parents," Archives of General Psychiatry, Vol. 58, 2001, pp. 1127-1134.
Clarke, Gregory N., Peter M. Lewinsohn, and Hyman Hops, Adolescent Coping with Depression Course, Eugene, Oreg.: Castalia Press, 1990.
Clarke, Gregory N., Wesley Hawkins, Mary Murphy, Lisa B. Sheeber, Peter M. Lewinsohn, and John R. Seeley, "Targeted Prevention of Unipolar Depressive Disorder in an At-Risk Sample of High School Adolescents: A Randomized Trial of a Group Cognitive Intervention," Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 34, No. 3, 1995, pp. 312-321.
Lynch, Frances L., Mark Hornbrook, Gregory N. Clarke, Nancy Perrin, Michael R. Polen, Elizabeth O'Connor, and John Dickerson, "Cost-Effectiveness of an Intervention to Prevent Depression in At-Risk Teens," Archives of General Psychiatry, Vol. 62, No. 11, 2005, pp. 1241-1248.