Developing a Culturally Appropriate Depression Prevention Program: Opportunities and Challenges

This paper describes the experiences of the first author and his colleagues in the development and implementation of a depression prevention program that specifically targets Latina mothers. Building on the earlier papers that highlight the underutilization of mental health services by Latinos in general, this paper will make the case that the situation is particularly concerning with regards to depression. In addition to the fact that depression is a highly prevalent disorder among Latino adults, the potential consequences for children of parents with depression are significant. Thus, the underutilization of formal mental health services by Latinos makes depression a critical public health problem that calls for creative solutions. One possible solution is the careful development and implementation of prevention programs. Depression prevention programs have some advantages over formal mental health treatment in that they can be offered at a relatively low cost, can be packaged in ways that make them less stigmatizing, and if effective, can reduce the incidence of cases that develop into clinical depression.This paper will describe the process of developing a novel depression prevention program, with a particular focus on the attention paid to cultural sensitivity. We describe the complexity inherent in defining cultural sensitivity and illustrate in concrete ways its implementation in the development and evaluation of the prevention program. In addition, we explore some of the challenges that emerge when attempting to balance the creation of a program that is culturally sensitive with the demands of rigorous quantitative evaluation.     

The Unified Protocols for Children and Adolescents in Partial Hospitalization: Using Implementation Science Frameworks to Guide Adaptation

Partial hospitalization programs (PHPs) and other acute mental health treatment programs, which are becoming increasingly common, may help divert children and adolescents from inpatient psychiatric care and provide a concentrated dose of intervention to individuals living in low-resource areas. However, there have been relatively few examinations of the effectiveness of PHPs in addressing emotional concerns (e.g., anxiety, depression, irritability) and functional impairment in youth. Further, evidence-based treatments originally designed for delivery in an outpatient weekly format may require significant adaptation to be appropriate for delivery in acute mental health settings, which differ significantly from weekly outpatient care in program structure, patient acuity, and staffing. In this intervention development and adaptation report, we present the rationale for adapting a transdiagnostic approach to treating emotional disorders—the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/A)—for a hospital-based, general psychiatric partial hospitalization program. We use implementation science frameworks to describe our iterative approach to treatment adaptation and testing and to describe in detail proactive, planned adaptations to the UP-C/A for partial hospitalization that occurred prior to initial implementation and pilot testing. Three case examples (child, preadolescent, adolescent) are presented to illustrate how a transdiagnostic approach to care such as the UP-C/A can be used intensively in an acute mental health setting to address emotional and behavioral concerns, including safety.     

Testing a Gender Additive Model: The Role of Body Image in Adolescent Depression

Despite consistent evidence that adolescent girls are at greater risk of developing depression than adolescent boys, risk factor models that account for this difference have been elusive. The objective of this research was to examine risk factors proposed by the gender additive model of depression that attempts to partially explain the increased prevalence of depression in adolescent girls. The theory suggests that body image and eating related variables predict depression for girls, but not for boys, above and beyond the variance accounted for by other well-known risk factors, some of which were examined in the current study. The sample was 247 adolescent girls and 181 adolescent boys studied over a 24-month duration. Results suggest that body dissatisfaction is a potent predictor of depression for girls, but not for boys, above and beyond the predictive effects of other established risk factors. Results provide insight into the etiology of adolescent depression and the disparate rate of depression among adolescent girls and provide direction for identifying high-risk individuals and developing effective prevention programs.     

Prevention of depression among Icelandic adolescents

Major depression and dysthymia are frequent, debilitating, and chronic disorders, whose highest rate of initial onset is during the late adolescent years. The effectiveness of a program designed to prevent an initial episode of major depression or dysthymia among adolescents was investigated. Participants were 171 fourteen-year-old “at risk” Icelandic adolescents who were randomly assigned to a prevention program or a treatment-as-usual assessment only control group. They were identified as “at risk” by reporting the presence of depressive symptoms or a negative attributional style. The program was based on a developmental psychosocial model of enhancement of resilience to factors associated with the occurrence of mood disorders. The results indicated that the prevention program resulted in a significantly lower rate of major depression and dysthymia than did the control group. The study demonstrated that school personnel in the school setting can implement such prevention programs.     

A Meta-Analysis of Universal School-Based Prevention Programs for Anxiety and Depression in Children

Anxiety and depression are among the most common mental health issues experienced in childhood. Implementing school-based prevention programs during childhood, rather than adolescence, is thought to provide better mental health outcomes. The present meta-analysis aimed to investigate the efficacy of universal school-based prevention programs that target both anxiety and depression in children (aged 13 years or below), and examine three moderators (i.e., program type, primary target of program, and number of sessions) on prevention effects. PsycINFO, PubMED, and Google Scholar were systematically searched for relevant articles published up to and including January 2018. Fourteen randomised controlled trials, consisting of 5970 children, met eligibility criteria. Prevention programs led to significantly fewer depressive symptoms at post-program (g?=?0.172) and at long-term follow-up periods (g?=?0.180), but not at short-term follow-up. Programs were not found to prevent anxiety symptoms across any time point. Considerable heterogeneity was observed for all effects. Program type and length were found to moderate the relationship between prevention program and outcomes. Prevention programs were effective in preventing depressive symptoms at post-program and long-term follow-up, while no significant preventative effect on anxiety symptoms was observed. The FRIENDS Program and programs which contained a greater number of sessions showed beneficial effects on anxiety and depressive symptoms. Universal programs aimed at preventing both anxiety and depression in children are limited. Future research should investigate the long-term evaluation of school-based prevention programs for anxiety and depression in children.     

Implementing a Comprehensive Program for the Prevention of Conduct Problems in Rural Communities: The Fast Track Experience

Childhood conduct problems are predictive of a number of serious long-term difficulties (e.g., school failure, delinquent behavior, and mental health problems), making the design of effective prevention programs a priority. The Fast Track Program is a demonstration project currently underway in four demographically diverse areas of the United States, testing the feasibility and effectiveness of a comprehensive, multicomponent prevention program targeting children at risk for conduct disorders. This paper describes some lessons learned about the implementation of this program in a rural area. Although there are many areas of commonality in terms of program needs, program design, and implementation issues in rural and urban sites, rural areas differ from urban areas along the dimensions of geographical dispersion and regionalism, and community stability and insularity. Rural programs must cover a broad geographical area and must be sensitive to the multiple, small and regional communities that constitute their service area. Small schools, homogeneous populations, traditional values, limited recreational, educational and mental health services, and politically conservative climates are all more likely to emerge as characteristics of rural rather than urban sites (Sherman, 1992). These characteristics may both pose particular challenges to the implementation of prevention programs in rural areas, as well as offer particular benefits. Three aspects of program implementation are described in detail: (a) community entry and program initiation in rural areas, (b) the adaptation of program components and service delivery to meet the needs of rural families and schools, and (c) issues in administrative organization of a broadly dispersed tricounty rural prevention program.     

Developing a culturally appropriate depression prevention program: the family coping skills program

Depression is a disorder that can have particularly deleterious effects on individuals from racial/ethnic minority and low-income backgrounds. Culturally appropriate prevention programs offer a way to provide accessible and effective mental health services to these underserved populations. The authors introduce the Family Coping Skills Program (FCSP), a novel depression prevention program developed specifically for low-income Latina mothers. The authors present the theoretical underpinnings of the FCSP and describe their efforts to make the program culturally appropriate and to enhance recruitment and retention of participants. Initial outcome data from an uncontrolled trial were promising and support continued development and evaluation of the FCSP and other similar programs.     

Randomized Controlled Trial Testing the Effectiveness of a Depression Prevention Program (‘Op Volle Kracht’) Among Adolescent Girls with Elevated Depressive Symptoms

Depression rates rise dramatically from the early to late adolescence. Especially young adolescent girls with elevated depressive symptoms are at high risk for developing a depression during adolescence or adulthood. Therefore, the prevention of depression is important especially in this high-risk group. The aim of the present study was to examine the effectiveness of the Cognitive Behavioral Therapy (CBT) component of the depression prevention program ‘Op Volle Kracht’ (OVK) among Dutch adolescent girls with elevated depressive symptoms. In total, 102 adolescent girls (11–15 years) in the first and second year of secondary school participated in this study. The girls in the experimental group (n?=?50) followed the eight CBT-lessons of OVK and reported depressive symptoms 1 week prior to the start of the lessons, after every lesson, at one-month and 6-months follow-up. The girls in the control group (n?=?52) exclusively reported depressive symptoms at the same time points. Latent Growth Curve Modeling showed that the decrease in depressive symptoms was significantly larger for girls in the experimental group compared to the girls in the control group. Furthermore, it was found that at 6-months follow-up, the girls in the experimental group had significantly lower levels of depressive symptoms compared to the girls in the control group. These findings indicate that the CBT-component of OVK effectively reduces depressive symptoms in short term and possibly prevents the development of a clinical depression.     

Depression Moderates the Relationship between Body Image and Health-Related Quality of Life in Adolescent Girls

Body image can predict health-related quality of life (HRQoL) in adolescent girls through self-esteem and psychological well-being. Additionally, depression is a significant predictor of adolescents’ HRQoL and is associated with body image. Therefore, we investigated whether the relationship between body image and HRQoL in adolescent girls is moderated by depression. In this cross-sectional study, adolescent girls’ body image, depression, and HRQoL (n?=?385, age: 12–15 years) were measured through self-report questionnaires. Multiple regression and simple slope analyses were conducted to examine the moderating effect of depression. Body image was positively correlated with HRQoL, whereas depression was negatively correlated with body image and HRQoL. Body image, depression, and their interaction explained 44.9% of the variance in HRQoL. Simple slope analysis showed that a more positive body image was associated with higher HRQoL among adolescent girls without depressive symptoms, but was not significantly related to HRQoL for adolescents with depressive symptoms. The moderating effect of depression was confirmed. In conclusion, screening for depression is recommended for adolescent girls prior to implementing body image interventions in schools and the community that are aimed at improving HRQoL. Furthermore, health care providers in schools and the community should provide psychological support for depression along with body image interventions to improve the HRQoL of girls in schools and the community. In particular, for girls with depressive symptoms, depression management should be conducted beforehand.     

Mental health consultation in infant day care: A new frontier of prevention

This paper deals with the mental health aspects of infant day care emphasizing that mental health input into the design, implementation and ongoing supervision/evaluation of the majority of day care programs is minimal at the present time. The author proposes the following three criteria by which the adequacy of mental health input in a day care program could be judged: 1) ongoing mental health consultation to the caregiver staff on a weekly basis and by the same clinician(s), 2) assignment of primary caregivers to the infants, 3) periodic naturalistic observations of the infants to be recorded and discussed by the caregivers. The author postulates that consultation to the caregiver staff of infant day care programs represents the opportunity to establish a new frontier of prevention. Therefore, the mental health profession should consider it a goal that every infant day care setting would have a mental health clinician as a consultant. The methods, preventive functions and manpower aspects of such consultation work is discussed.     

LOOKING GOOD, SOUNDING GOOD: FEMININITY IDEOLOGY AND ADOLESCENT GIRLS' MENTAL HEALTH

This study used a feminist psychodynamic developmental framework to test the hypothesis that internalizing conventional femininity ideologies in two domains—inauthenticity in relationships and body objectification—is associated with early adolescent girls' mental health. One hundred forty-eight eighth-grade girls completed measures of femininity ideology, self-esteem, depression, and demographic characteristics. In the first part of this study, we refined the Adolescent Femininity Ideology Scale originally developed by Tolman and Porche (2000) . In the second part, we used structural equation modeling to test models linking femininity ideology to mental health. Results revealed that body objectification, and to a lesser extent, inauthenticity in relationships, accounted for half of the variance in depression and over two-thirds of the variance in self-esteem in a critical period of development for adolescent girls. The importance of a feminist psychodynamic developmental framework for identifying and understanding salient dimensions of female adolescence is discussed.     

Developing internality and perceived competence: the empowerment of adolescent girls

A small group workshop, developed for Big Sisters of Colorado, Inc. to complement their traditional program, was evaluated to determine its effectiveness for working-class and underclass adolescent girls. The "Life Choices" program was successful with working-class Ss, resulting in increased internality and perceived competence for school success, social relationships and general life events. These Ss also increased their knowledge of both traditional and non-traditional career alternatives. However, the program did not succeed with underclass adolescent girls, who showed no increase in internality or knowledge of career alternatives and reported a significant decrease in perceived competence after completing the same program. It is suggested that the goals and strategies presented in such programs must be designed specifically for adolescents of different backgrounds if they are to result in empowerment of the participants.     

A Multi‐Family Group Intervention for Adolescent Depression: The BEST MOOD Program

Depression is the most common mental disorder for young people, and it is associated with educational underachievement, self‐harm, and suicidality. Current psychological therapies for adolescent depression are usually focused only on individual‐level change and often neglect family or contextual influences. The efficacy of interventions may be enhanced with a broader therapeutic focus on family factors such as communication, conflict, support, and cohesion. This article describes a structured multi‐family group approach to the treatment of adolescent depression: Behaviour Exchange Systems Therapy for adolescent depression (BEST MOOD). BEST MOOD is a manualized intervention that is designed to address both individual and family factors in the treatment of adolescent depression. BEST MOOD adopts a family systems approach that also incorporates psychoeducation and elements of attachment theories. The program consists of eight multifamily group therapy sessions delivered over 2 hours per week, where parents attend the first four sessions and young people and siblings join from week 5. The program design is specifically aimed to engage youth who are initially resistant to treatment and to optimize youth and family mental health outcomes. This article presents an overview of the theoretical model, session content, and evaluations to date, and provides a case study to illustrate the approach.     

Have Mental Health Education Programs Influenced the Mental Health Literacy of Those with Major Depression and Suicidal Ideation? A Comparison between 1998 and 2008 in South Australia

Mental health literacy is the knowledge and beliefs about mental disorders that aid their recognition, management, or prevention and is considered to be an important determinant of help‐seeking. This has relevance in suicide prevention, as depression, the clinical condition most frequently associated with suicidality, has been the target of community and professional education programs designed to enhance mental health literacy. In this study, whether such programs have influenced help‐seeking attitudes and behavior in those who are depressed and suicidal was considered. The results indicate that despite intensive community education programs over the last two decades, there has been little change in those who are depressed and suicidal in terms of their attitudes toward treatment seeking and, more importantly, their treatment‐seeking behavior. These results draw into question the value of current community education programs for those most vulnerable to suicidal behavior.     

The impact of mental health problems and religiosity on African-American girls' HIV-risk

We investigated the relationship between religiosity, mental health problems, and two sexual risk behaviors-condom use and number of partners. Participants were 80 sexually active African American girls in psychiatric care and their caregivers. Results indicated differential relationships, depending on parent versus youth report. Mother's religiosity was positively related to girls' condom use and not to girls' number of partners. Controlling for other predictors in the models, mother's religiosity explained as much as 15% of the variance in girls' condom use. Whereas parent and adolescent reports of girls' depression/anxiety and rule-breaking were positively associated with number of partners, reports of aggression were associated with having fewer partners. Neither parent nor youth reports of girls' mental health problems were associated with condom use. Controlling for other predictors in the models, girls' mental health problems accounted for as much as 31% of the variance in number of partners. Findings underscore the importance of adopting an ecological framework to understand both the risk and promotive factors for sexual risk taking among troubled girls. The roles of specific aspects of psychopathology and religiosity in relation to sexual risk behavior among African American girls in psychiatric care are discussed.     

Lessons Learned About Barriers to Implementing School-Based Interventions for Adolescents: Ideas for Enhancing Future Research and Clinical Projects

The majority of youth with mental health problems do not receive treatment, highlighting the critical need to transport evidence-based interventions into community settings, such as schools. Despite being able to reach a large number of adolescents and minority youth, the process of implementing evidence-based interventions to schools is challenging. This paper discusses some expected and unexpected challenges experienced during the implementation of an open trial and a pilot randomized controlled trial examining the acceptability and effectiveness of a school-based preventive intervention for adolescents at risk for internalizing disorders. First, we highlight key programs and findings on preventive interventions for adolescents at risk for depression and anxiety. Next, we provide a brief overview of the preventive intervention we implemented in schools. This provides a context for the section that describes implementation issues and highlights specific challenges and potential solutions for intervention implementation. Finally, the paper offers recommendations for researchers and clinicians interested in implementing school-based mental health services for adolescents.     

Effectiveness of inpatient treatment programs for mentally ill adults in public psychiatric facilities

This article updates the current state of knowledge and research on the effectiveness of inpatient treatment programs for mentally ill adults in the public sector to provide guidance for improving both research and services. National figures show inpatient facilities to still be predominant in the U.S. public mental health system; the populations and programs in these facilities are in serious need of science-based assistance. We summarize the major conceptual factors that influence the conduct and interpretation of inpatient outcome studies, clinical trials, or program evaluations (relevant domains and classes of variables, unit of analysis and effectiveness criteria, empirical findings on moderator variables). The major inpatient treatment approaches are described, and the empirical literature on effectiveness is reviewed. We conclude with a summary of the substantial accumulated evidence and recommendations for use of new assessment technology to assist with implementation of effective approaches and for advancing promising lines of research. The time seems ripe for exciting science-based advances in research and services.     

Exploring the Effectiveness of a Mixed-Diagnosis Group Cognitive Behavioral Therapy Intervention Across Diverse Populations

Depression and anxiety are the most common mental health disorders seen in clinical practice and they are highly comorbid. Cognitive behavioral therapy (CBT) has been demonstrated as an effective treatment for both depression and anxiety but is often not available to all individuals who could benefit from it. This paper investigates the effectiveness of a mixed-diagnosis group CBT intervention that incorporates mindfulness meditation for individuals presenting with depression and/or anxiety: CBT Basics II. This intervention was evaluated across two distinct mental health programs to determine both if it can demonstrate positive results and if it is feasible to implement in these types of programs. Sample 1 (n = 42 completers) consisted of higher-functioning individuals in a general mental health program. Sample 2 (n = 53 completers) consisted of individuals with more chronic and severe mental health diagnoses. Overall, intent-to-treat analyses revealed improvements in psychiatric symptoms, and increases in CBT knowledge and mindfulness skill across both programs. This indicates that CBT Basics II is effective across diverse mental health populations and shows promise for improving access to CBT.     

Have Broad‐Based Community and Professional Education Programs Influenced Mental Health Literacy and Treatment Seeking of those with Major Depression and Suicidal Ideation?

Mental health literacy is the knowledge and beliefs about mental disorders that aid in their recognition, management, or prevention; it is also a determinant of help seeking. As such, it is presumed to be important in community suicide prevention programs. In Australia there have been a number of government, professional, and charitable organizations as well as pharmaceutical company suicide prevention initiatives which have been designed to enhance public and professional knowledge about mental disorders, particularly depression. This naturalistic study conducted between 1998 and 2004 in a random and representative population sample examined the changes in mental health literacy and treatment seeking of those with major depression, both with and without suicidal ideation, and those who were neither depressed nor suicidal. Results indicated that there was marked improvement in mental health literacy for all three groups, although there was less change for those most in need of intervention (i.e., those with major depression and suicidal ideation). Furthermore, there were fewer changes in appropriate treatment seeking in those with major depression and suicidal ideation. These findings are consistent with literature reporting limited problem solving and decision making in those who are suicidal, and indicate that there are limits to broadbased community education programs. More focused suicide prevention initiatives are required, specifically for those who are depressed and suicidal.     

Positive Youth Development Program for Mental Health Promotion in College Campuses: Stakeholder Perspectives

The present study aimed at exploring stakeholder perspectives on felt need, potential content, receptivity and feasibility of a positive youth development program for mental health promotion in college campuses. Study objectives were attained through semi-structured interviews with 20 college faculty/administrators and five focus group discussions with 64 students across 16 colleges in a metropolitan city in South India. The need and relevance of a program for mental health promotion were endorsed by all the participants, and it was considered feasible with prior planning. Suggestions for potential content of such a program included mental health awareness, dealing with depression and anxiety, managing negative emotions, managing pressures and temptations, improving self-confidence, reflection and clarity about life goals, cultivating sense of gratitude, broadening other orientation, and time management skills. The content of intervention perceived as important by the two groups of stakeholders highlighted the broad convergences between the potential themes being considered by the researchers and the stakeholder views. Potential receptivity to the program was considered to be good though it was perceived to be influenced by the awareness about the importance of such a program. Suboptimal interest of college authority and/or students and competing academics and other programs were identified as potential challenges to program implementation. The findings are discussed with respect to implications for program development as well as for further research.