• PPN Home
• Programs that Work
  • View by outcome area
  • View by indicator
  • View by topic
  • View by evidence level
  • View alphabetically
• Research in Brief
• Resources and Tools
• Expert Perspectives
• Partner Pages
• Search the Site

Programs that Work

Adolescent Coping with Depression Course

Program Info Program Overview Program Participants Evaluation Methods Key Evaluation Findings

Probable Implementers Funding Implementation Detail Issues to Consider Example Sites

Contact Information Available Resources Bibliography Last Reviewed

Program Info

Top  

Program Overview

The Adolescent Coping with Depression Course (CWD-A) is a skills-based small-group treatment program for actively depressed adolescents. The intervention consists of 16 two-hour sessions delivered over a period of eight weeks. Adolescents are taught several skills hypothesized to relieve depression, including assertiveness, relaxation skills, cognitive restructuring techniques, mood monitoring, increasing pleasant activities, and communication and conflict-resolution techniques. A parent component helps keep parents aware of what their teens are learning in the program, regarding general topics discussed, skills taught, and the rationale for their use..

Top  

Program Participants

Adolescents with high levels of depression symptoms

Top  

Evaluation Methods

Kahn et al. (1990) studied the effects of the CWD-A program in a sample of Utah middle school students in grades six to eight. The sample was drawn from the entire population of a large suburban middle school serving a middle-income level neighborhood (1,293 students). A school-wide self-report screening for depression was undertaken, using an adapted version of the Children's Depression Inventory (CDI) and the Reynolds Adolescent Depression Scale (RADS). One hundred eighty-six students (14.4 percent) scored above the predetermined cutoffs for having depression. To rule out situational or transitory mood disorders, assessment procedures were repeated one month after the initial screening. At the reassessment, 110 students (59 percent of the initial 186 students) met the criteria for depression. Seven students did not obtain consent to participate further and an additional nine students left the study school, leaving a total of 94 students. These students were assessed on a structured interview, the Bellevue Index of Depression (BID), and 79 students met BID cutoff scores for depression. Six of these students moved out of the study area, two were excluded for receiving concurrent outpatient psychological/psychiatric services, and three did not receive parental consent. The final sample was 68 students, who were randomly assigned to one of four groups: (a) CWD-A, (b) relaxation treatment (which involved progressive relaxation skills and basic relaxation training), (c) self-modeling treatment (which involved repeated observation of oneself on edited or rehearsed videotapes showing only desired target behaviors), or (d) a waitlist control group. There were 17 students in each of the four groups, and sampling strategies were used to equate for grade and gender. Posttesting on the RADS, CDI, and BID occurred immediately upon completion of the intervention and at a one-month follow-up.

Lewinsohn et al. (1990) studied CWD-A in a sample of 59 high school students, aged 14-18 years, from Eugene and Portland, Oregon. Potential study participants were recruited via letters and announcements to health professionals, school counselors, and the media. A total of 114 adolescents were interviewed, and 69 met the inclusion criteria for elevated levels of depression. Participants were drawn from four cohorts, including two in Eugene and two in Portland. Participants in each cohort were randomly assigned to one of three conditions: (1) Adolescent-Only (19 students); (2) Adolescent+Parent, an identical group for adolescents with their parents enrolled in a separate parent group (21 students); and (3) Wait-List Control (19 students). Ten students withdrew before or during treatment, leaving a total of 59 study participants (no significant differences were found between completers and noncompleters). When treatment and control groups were compared prior to the intervention, the only significant difference found between groups was that control subjects had a higher average number of siblings than did subjects in the treatment groups. Outcomes were assessed among treatment and control groups at immediate posttreatment and at a one-month and a six-month follow-up. Adolescent outcomes were assessed on the interviewer-rated Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Epidemiological Version (K-SADS-E). Youth self-reports were measured on the Beck Depression Inventory (BDI), the Center for Epidemiological Studies Depression Scale (CES-D), three scales assessing depressogenic cognitions or thoughts, the Pleasant Events Schedule, the Spielberger State Anxiety Questionnaire, and the Issues Checklist (a measure of conflict resolution). Parent reports of their child's behavior problems and depression were assessed on the Child Behavior Checklist (CBCL), and reports of disagreements between parent and teen assessments were measured on the Issues Checklist.

CWD-A was evaluated by Rohde, Lewinsohn, and Seeley (1994) in a sample of 14 to 18-year-old students from Oregon. Potential subjects were recruited through newspaper ads and announcements to health professionals and school counselors. Students were screened and included if they were diagnosed with major depressive disorder, without concurrent bipolar disorder, panic disorder, generalized anxiety disorder, alcoholism, conduct disorder, or drug use disorder; without current involvement in other treatment for depression; and without a need for immediate treatment or hospitalization. Eighty-four students met the criteria for inclusion, with a subsequent attrition rate of 22 percent. The average participant age was 16.3 years, 74 percent of the students were female, 99 percent were white, and 49 percent had had a previous episode of major depressive disorder. Subjects were randomly assigned to one of three conditions: (1) CWD-A for adolescents only (31 students); (2) CWD-A for adolescents with a separate group for parents (29 students); or (3) a waiting list control group (24 students). Analyses were conducted separately for low-severity and high-severity groups with regard to past history of major depressive disorder. Outcomes were assessed at posttest on the Hamilton Depression Rating Scale (HAM-D) using a structured interview, and adolescent self-reports of depression on the BDI and the CES-D.

The longer-term effects of CWD-A were studied by Clarke et al. (1999) in a sample of 123 adolescents from Eugene and Portland, Oregon. Participants were recruited between 1988 and 1991 via announcements to health professionals and school counselors, television and newspaper stories, and advertisements. Three hundred thirty-one adolescents aged 14 to 18 years and at least one of their parents participated in a screening interview. Eligible adolescents were determined by the interview to have major depressive disorder or dysthymia (moderate depression); a total of 171 adolescents met these criteria. Twenty-seven adolescents were excluded because they exhibited current mania/hypomania, panic disorder, generalized anxiety disorder, conduct disorder, psychoactive substance abuse/dependence, lifetime organic brain syndrome, mental retardation, or schizophrenia, or because they were determined to need immediate, acute treatment. An additional 21 adolescents were excluded for concurrently receiving other treatment for depression. The final sample of 123 adolescents was randomly assigned to one of three 8-week acute conditions: (1) CWD-A (45 students), (2) CWD-A with a separate parent group (42 students), or (3) waitlist control (36 students). Seven treatment cohorts were conducted at each of the two sites. Of the initial 123 study participants, 27 did not complete the intervention, leaving a total of 96 (37 in the adolescent-only group, 32 in the adolescent + parent group, and 27 in the control group). Attrition was not significantly related to experimental group, demographic characteristics of adolescents, intake diagnosis of major depressive disorder versus dysthymia, intake BDI score, or intake HAM-D score. Of the 96 adolescents, 71 percent were female and had a mean age of 16.2 years. Four percent of the adolescents were not in school, 44 percent lived in two-parent families, and 28 percent had one or two parents with graduate or postgraduate education. The three experimental groups did not differ significantly on any of the demographic or baseline outcome variables. Immediately after posttest assessment, participants completing the CWD-A groups were randomly reassigned to one of three conditions for the two-year follow-up period: (1) booster sessions plus assessments every four months (24 students), (2) assessments only every four months (16 students), or (3) assessments only once per year (24 students). At posttest and follow-up, outcomes were measured on the K-SADS-E interview, the HAM-D interview, the interviewer-rated Global Assessment of Functioning Scale (GAF), the adolescent-reported BDI, and the parent-reported CBCL scales.

Clarke and colleagues (2002) evaluated CWD-A in a sample of depressed youths with depressed parents in a health maintenance organization (HMO). The sampling frame consisted of approximately 410,000 members enrolled in a Kaiser Permanente Northwest HMO, around Portland, Oregon. Cases were identified in six separate cohorts over two years. Potential adult cases were found by reviewing antidepressant medication prescriptions, mental health appointments, and medical charts. Introductory study letters signed by each parent's treating physician were mailed to 2,995 adults. Of these families, 2,514 declined or were not reached before the baseline assessment. Four hundred sixty-three youth completed the baseline assessment but were not randomized to experimental group, for reasons such as the family was not eligible, the youth was categorized as "resilient," or the youth declined. In the final sample, 88 eligible adolescents aged 13 to 18 who met current Diagnostic and Statistical Manual of Mental Disorders DSM-III-R criteria for major depression and/or dysthymia were randomly assigned to either usual HMO behavioral health care (47 adolescents) or usual care plus CWD-A (41 adolescents). Assessments were conducted immediately posttreatment (86 youths), at 12-month follow-up (80 youths), and at 24-month follow-up (73 youths). The treatment and control groups did not differ with respect to rates of current and past psychiatric disorder, the amount of "usual care" mental health and general health care services consumed during any phase of the day, or on any other key demographic, depression severity, functioning, or psychological measures. Outcomes were assessed via the K-SADS interview, the HAM-D interview, and the interviewer-rated GAF scale; parent reports on the CBCL, and parent and youth reports on the CES-D scale.

Finally, Rohde et al. (2004) assessed the effects of CWD-A in a sample of 93 adolescents aged 13-17. The youth were referred to the study between 1998 and 2001 by staff from the Department of Youth Services of Lane County, Oregon. All adolescents were under the supervision of an intake, probation, or parole officer and were not incarcerated at the time of entry into the study. Referred adolescents were screened for depression, and 93 adolescents meeting DSM-IV criteria for major depressive disorder and conduct disorder were randomly assigned to either CWD-A (45 youth) or Life-Skills/Tutoring (48 youth). The Life-Skills/Tutoring intervention consisted of current events review, training in life skills such as filling out a job application and an application for renting an apartment, and academic tutoring. Nine cohorts of youth were treated, and randomization occurred within the cohorts (i.e., within each cohort youths were assigned to one of the two treatment groups). A comparison of baseline demographic and clinical characteristics (including current and past episodes of psychiatric disorders and treatment) found the only significant difference between groups was gender; the CWD-A group had significantly more female participants than the Life-Skills/Tutoring condition (60 percent versus 38 percent). Participants were assessed posttreatment and at 6- and 12-month follow up periods by interview. Outcomes were assessed on the Longitudinal Interval Follow-Up Evaluation interview, the K-SADS-E-5 interview, the HAM-D interview, the interviewer-rated Children's Global Adjustment Scale, the self-reported Social Adjustment Scale, the self-reported BDI, the parent-reported CBCL scales, and youth criminal records.

Top  

Key Evaluation Findings

The study of 68 Utah middle school students by Kahn et al. (1990) found:

• Outcomes supported the efficacy of all three treatment groups (CWD-A, relaxation, and self-modeling) compared to the control group. Posttest scores on the self-reported RADS and CDI measures, and on the BID interview showed that the majority of students in the CWD-A and relaxation groups moved from the dysfunctional to the functional range and remained there at the one-month follow-up. More specifically,
  
  
  
  • RADS: 88 percent of CWD-A, 65 percent of relaxation, and 70 percent of self-modeling students moved from the dysfunctional to the functional range at posttest. At one-month-follow-up, 88 percent of CWD-A, 65 percent of relaxation, and 50 percent of self-modeling students remained in the functional range.
  
  
  • CDI: 88 percent of CWD-A, 76 percent of relaxation, and 59 percent of self-modeling students were in the functional range at posttest. At one-month follow-up, 76 percent of CWD-A, 65 percent of relaxation, and 44 percent of self-modeling students remained in the functional range.
  
  
  • BID: 76 percent of CWD-A, 65 percent of relaxation, and 59 percent of self-modeling students had moved from the dysfunctional to the functional range at posttest. (No one-month follow-up interviews were conducted).


• Students in the control group showed much lower rates of gains from pretest to posttest, with 81 percent of control students continuing to show significant levels of depressive symptomatology on the RADS, 88 percent showing dysfunctional outcomes on the CDI, and 81 percent showing dysfunctional outcomes on the BID.

• Of the Adolescent+Parent teens, 52 percent and, of the Adolescent-Only teens, 57 percent still met diagnostic criteria for depression on the K-SADS-E; in contrast, there was little change in the control condition, with 95 percent of teens meeting diagnostic criteria. When the two treatment groups were pooled, they were found to have significantly lower rates of depression compared to the control group. Analyses showed no significant differences between the two treatment conditions on the K-SADS-E.


• Adolescent depression scores were significantly lower for the pooled treatment group compared to the control group on both the BDI and the CES-D. No significant differences were found between groups for adolescent reports of conflict on the Issues Checklist.


• No significant differences were found between pooled treatment and control groups for parent-reported CBCL scales or parent reports on the Issues Checklist.


• When the two treatment groups were compared, parents in Adolescent+Parent condition reported significantly lower problem scores for their children on the CBCL scales than did parents in the Adolescent-Only condition. No differences were found between the groups on the parent-reported Issues Checklist, and no differences were found between groups on any of the adolescent measures.


• No significant differences were found among groups for anxiety, participation in pleasant activities, or depressogenic thoughts.


• Treatment effects were assessed for the Adolescent+Parent and Adolescent-Only groups at one- and six-month follow-up. Results indicated the following:
  
  
  
  • There were no significant differences between groups for any of the adolescent variables, including the CES-D, the BDI, and the Issues Checklist.
  
  
  • Following the initial posttest, the Adolescent-Only group continued to show improved parent ratings on the CBCL scales, eliminating any significant differences between the two treatment groups by the six-month follow-up.

• No significant program effects were evident for the low-severity group.


• The contrast between the high-severity treatment group and the control group was statistically significant for adolescent reports of depression on the BDI.


• Marginally significant differences between the treatment and control group were found for the adolescent-reported CES-D depression scale and the interviewer-rated HAM-D.


• No significant differences between the Adolescent-Only and the Adolescent+ Parent treatment groups were found for any measures.

• Recovery from depression was defined as no longer meeting DSM-III-R criteria for either major depression or dysthymia for the two weeks following the posttest. Results indicated the two active treatments groups had significantly better outcomes when compared with controls, and they did not differ significantly from one another. Recovery rates were 65 percent for the adolescent-only group, 69 percent for the adolescent + parent group, and 48 percent for the control group.


• Compared with the control group, at posttest the combined treatment group was associated with significantly greater reduction in adolescent-reported BDI scores and interviewer-rated GAF scores. Differences in scores between the two treatment groups were not significant.


• At posttest, no significant differences were found between treatment and control groups for the HAM-D interview and the three parent-reported CBCL scales (depression, internalizing behavior, and externalizing behavior).


• Recurrence to depression was examined among the 46 adolescents in the two active treatment groups who had recovered at posttest. By both 12- and 24-month follow-ups, no significant differences in recurrence rates were found among groups. At 12 months, recurrence rates were 14 percent in the annual assessment group, 0 percent in the four-month assessment group, and 27 percent in the four-month booster plus assessment group. At 24-months, recurrence rates were 23 percent in the annual assessment group, 0 percent in the four-month assessment group, and 36 percent in the four-month booster plus assessment group.


• In the longitudinal comparison of the booster condition versus the two assessment-only conditions, the only significant effect found was for CBCL externalizing scores, with parents in the booster condition reporting greater reductions in externalizing symptoms over time.


• When comparisons were made over time between the two assessment-only conditions, a significantly greater score decline was observed among the frequent assessment participants (every four months) for both CBCL depression and internalizing subscales.

• There were no significant differences between the treatment and control groups for depression diagnoses or depression measures, including the CES-D, HAM-D, CBCL internalizing and externalizing scales, or the GAF scale.

• Posttest recovery rates for major depressive disorder were significantly greater in the CWD-A group than in the Life-Skills/Tutoring group, (39 percent versus 19 percent, respectively). Recovery rates for conduct disorder did not differ significantly between the groups (9 percent versus 17 percent).


• Compared with the Life-Skills/Tutoring group, the CWD-A treatment was associated with significant improvements on the BDI, the HAM-D interview, and the youth-reported Social Adjustment Scale. No significant differences were found between groups for parent ratings on the CBC, interviewer ratings on the Children's Global Adjustment Scale, or arrest rates.


• At 6- and 12-month follow-ups, group differences in major depressive disorder and conduct disorder recovery rates were not significant. Similarly, no significant differences were found between groups for the BDI, the HAM-D, the Social Adjustment Scale, the CBCL, the Children's Global Adjustment Scale, or arrest rates. The convergence of scores by the 6-month follow-up was not due to CWD-A participants failing to maintain their gains, but instead was due to the Life-Skills/Tutoring participants achieving similar levels of improvement.

Top  

Probable Implementers

Public and private middle and high schools, community-based organizations, hospitals, clinics, after-school programs, and departments of correction.

Top  

Funding

Funding for the majority of the evaluations of CWD-A have been supported by grants from the National Institute of Mental Health.

Top  

Implementation Detail

Program Design

The CWD-A course combines cognitive and behavioral strategies that address the types of problems that commonly characterize depressed individuals (e.g., pessimism, low self-esteem, infrequent engagement in pleasant activities, social withdrawal, anxiety and tension, low social support, and increased conflict). CWD-A is based on the premise that teaching adolescents a variety of coping skills and strategies allows them to counteract the various factors that contribute to their depressive episodes and helps them deal more effectively with the problems they encounter (Rohde et al., 2005).

Curriculum

CWD-A is a group intervention that includes structured intervention sessions, repeated practice of skills, use of rewards and contracts, and homework assignments. The intervention consists of 16 two-hour sessions delivered over eight weeks to groups of six to ten adolescents, led by one or two therapists trained in the approach. Each participant receives a workbook that provides structured learning tasks, short quizzes, and homework assignments.

Components of the CWD-A course include

• increasing social skills (training in basic conversational techniques, planning of social activities, and strategies for making friends)


• increasing pleasant activities (teaching of basic self-change skills, including self-monitoring to establish a baseline, setting realistic goals, developing a plan for behavior change, and self-reinforcement for achieving the goals of their plan)


• decreasing anxiety (progressive muscle relaxation and deep breathing)


• reducing depressive cognitions (cartoon strips illustrate depressive thoughts and alternative positive thoughts that may be used to counter them)


• communication (acquisition of positive behaviors such as active listening and the inhibition of nonproductive behaviors such as accusations)


• four steps for problem solving: (a) defining the problem without criticism; (b) brainstorming alternative solutions; (c) evaluating and agreeing on a solution; and (d) specifying the agreement, including positive and negative consequences for compliance and noncompliance


• planning for the future (integration of skills, anticipation of future problems, and development of a life plan and goals).

Top  

Issues to Consider

This program received a "promising" rating. All six studies of the Adolescent Coping with Depression Course employed rigorous evaluation methodology, including randomized assignment, and found significant reductions in interviewer-rated, parent-rated, and self-reported depression symptoms for treatment children when compared with those in a control group or alternative treatment group. While evaluation findings were strong, most of the studies used small sample sizes that did not meet Promising Practices Network minimum requirements (30 per group) for classification as a "proven" program.

Studies by Rohde, Lewinsohn, and Seeley (1994) and Clarke et al. (1999) found no significant benefit of the inclusion of parent sessions to the intervention. These findings were not entirely consistent, as Lewinsohn et al. (1990) reported that at immediate posttest the parent condition reported significantly lower problem scores for CBCL scales than did the adolescent-only condition. However, these differences disappeared by the six-month follow-up.

In addition, the study by Rohde, Lewinsohn, and Seeley (1994) suggests that the effectiveness of CWD-A may be apparent only for seriously depressed adolescents, as no program effects were found for adolescents with a low severity of depression symptoms at baseline. No strong conclusions can be drawn at this point, as this was the only study that compared program effectiveness for adolescents with a low versus high severity of depression symptoms.

The effects of the addition of booster sessions were assessed by Clarke et al. (1999), who found that parents in the booster condition reported greater reductions in CBCL externalizing symptoms than did parents in assessment-only conditions. Again, since only one study to date has assessed the effect of the booster sessions, and no statistically significant differences were found among groups, no strong conclusions regarding booster-session effectiveness can be made.

Another study suggests that psychiatric comorbidity (i.e., the presence of other mental health problems in addition to depression) is generally not a reason to avoid the use of CWD-A for depressed adolescents (Rohde et al., 2001). The authors found that participants who also had anxiety disorders had higher depression measure scores at intake but a greater decrease in scores by posttest. Overall lifetime comorbidity was unrelated to diagnostic recovery from depression, but lifetime substance abuse/dependence was associated with a slower time to recovery. Study participants with attention-deficit and disruptive behavior disorders were more likely to experience depression recurrence post CWD-A treatment.

Finally, it should be noted that the program developers served as authors on all but one of the evaluations of CWD-A.

Top  

Example Sites

Eugene, Portland, and Lane County, Oregon
Salt Lake City, Utah

Top  

Contact Information

Gregory N. Clarke, Ph.D.
Kaiser Permanente Center for Health Research
3800 N. Kaiser Center Dr.
Portland, OR 97227
phone: (503) 335-6673
greg.clarke@kpchr.org

Top  

Available Resources

The Kaiser Permanente Center for Health Research provides free downloads of the CWD-A therapist manual, the CWD-A teen workbook, the CWD-A parent manual, and the CWD-A parent workbook at http://www.kpchr.org/public/acwd/acwd.html.

Top  

Bibliography

Clarke, Gregory N., Mark Hornbrook, Frances Lynch, Michael Polen, John Gale, Elizabeth O'Connor, John R. Seeley, and Lynn DeBar,      "Group Cognitive-Behavioral Treatment for Depressed Adolescent Offspring of Depressed Parents in a Health Maintenance Organization," Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 41, No. 3, 2002, pp. 305-313.  

Clarke, Gregory N., Paul Rohde, Peter M. Lewinsohn, Hyman Hops, and John R. Seeley, "Cognitive-Behavioral Treatment of Adolescent Depression: Efficacy of Acute Group Treatment and Booster Sessions,"   Journal of the American Academy of Child and Adolescent Psychiatry,   Vol. 38, No. 3, 1999, pp. 272-279.  

Kahn, James S., Thomas J. Kehle, William R. Jenson, and Elaine Clark, "Comparison of Cognitive-Behavioral, Relaxation, and Self-Modeling Interventions for Depression Among Middle-School Students,"   School Psychology Review,   Vol. 19, No. 2, 1990, pp. 196-211.  

Lewinsohn, Peter M., Gregory N. Clarke, Hyman Hops, and Judy Andrews, "Cognitive-Behavioral Treatment for Depressed Adolescents,"   Behavior Therapy,   Vol. 21, 1990, pp. 385-401.  

Rohde, Paul, Gregory N. Clarke, David E. Mace, Jenel S. Jorgensen, and John R. Seeley, "An Efficacy/Effectiveness Study of Cognitive-Behavioral Treatment for Adolescents with Comorbid Major Depression and Conduct Disorder,"   Journal of the American Academy of Child and Adolescent Psychiatry,   Vol. 43, No. 6, 2004, pp. 660-668.  

Rohde, Paul, Gregory N. Clarke, Peter M. Lewinsohn, John R. Seeley, and Noah K. Kaufman, "Impact of Comorbidity on a Cognitive-Behavioral Group Treatment for Adolescent Depression,"   Journal of the American Academy of Child and Adolescent Psychiatry,   Vol. 40, No. 7, 2001, pp. 795-802.  

Rohde, Paul, Peter M. Lewinsohn, and John R. Seeley, "Response of Depressed Adolescents to Cognitive-Behavioral Treatment: Do Differences in Initial Severity Clarify the Comparison of Treatments?"   Journal of Consulting and Clinical Psychology,   Vol. 62, No. 4, 1994, pp. 851-854.  

Rohde, Paul, Peter M. Lewinsohn, Gregory N. Clarke, Hyman Hops, and John R. Seeley, "The Adolescent Coping with Depression Course: A Cognitive-Behavioral Approach to the Treatment of Adolescent Depression," in Euthymia D. Hibbs, and Peter S. Jensen, eds.,   Psychosocial Treatments for Child and Adolescent Disorders: Empirically Based Strategies for Clinical Practice,   2nd ed., Washington, D.C.: American Psychological Association, 2005, pp. 219-237.  

Top  

Last Reviewed

September 2006

Top