Compare and contrast assessment Depression
Effectiveness and moderators of individual cognitive behavioral therapy versus treatment as usual in clinically depressed adolescents- a randomized controlled trial
Stikkelbroek, Y., Vink, G., Nauta, M. H., Bottelier, M. A., Vet, L. J., Lont, C. M., ... & Bodden, D. H. (2020). Effectiveness and moderators of individual cognitive behavioral therapy versus treatment as usual in clinically depressed adolescents: a randomized controlled trial. Scientific Reports, 10(1), 1-13.
Clinical case study: CBT for depression in a Puerto Rican adolescent: Challenges and variability in treatment response Jimenez Chafey, M. I., Bernal, G., & Rosselló, J. (2009). Clinical case study: CBT for depression in a Puerto Rican adolescent: Challenges and variability in treatment response. Depression and Anxiety, 26(1), 98-103.
Compare
Contrast
[CBT is considered a level one intervention for use with adolescents with depression aged 12 to 18]. Australian Psychological Society (2018). Evidence-based psychological interventions in the treatment of mental disorders: A review of the literature (4th ed.), 17. https://psychology.org.au/getmedia/23c6a11b-2600-4e19-9a1d-6ff9c2f26fae/evidence-based-psych-interventions.pdf
Things to consider when writing the assessment
Include both "study-level" and
"methodological approach-level" critique
Methodological approach-level critique:
• Commentary on aspects inherent to the methodological approach e.g., "In randomised
controlled designs, the random allocation improves internal validity by controlling for
demographic and extraneous variables at baseline. Therefore, the findings from this RCT
provide more convincing evidence that xyz….than [your other study]”
Study-level critique:
• Commentary on specific methodological decisions within the studies. e.g., "Although
qualitative methods can provide rich insights into clients' experiences of therapy, this
qualitative study did not include quotes in their results section, which has compromised the
credibility of their findings."
RCT, you might critique
what they used for their control group or what statistical analyses they used (study specific
criticism). You might also comment on the problems with external validity - a limitation inherent
to all RCTs (criticism of the methodology more broadly)
Common feedback on the essays
• This essay could be improved by more sophisticated/accurate use of
research terminology and more persuasive writing.
• The introductory paragraph could be bolstered by providing a rationale for
performing a comparative analysis and providing a synopsis of the essay
structure
• Identify recommendations re: how future studies could address this
limitation
• More direct comparisons of the two methodological approaches were
required
• ----
• Good use of topic sentences and clear conclusion.
• Good clear argument/thesis statement
• Clear links between limitations, implications, and recommendations
• Good understanding of implications for validity and our confidence in the
findings
Things to avoid Using the words
• Fail or failed (instead say did not)
• Proof or proved (instead say support or supported)
• Avoid starting a sentence with a number
• Comply with APA
Questions to consider when reading articles to critically evaluate
Do the authors describe HOW participants were
randomised?
• How many participants were there? How much attrition
was there between baseline and follow-up? What could
this mean for the findings?
• Were there any baseline differences between the
intervention and control groups?
• What type of control was used? What does this mean for
what conclusions can be drawn about the treatment
effect?
• Are there any factors that could have led to the causal
effect of the intervention to be underestimated or
overestimated?
Ask yourself questions like:
o What are the strengths/limitations of each methodological approach and how do they differ?
o How confident can we be in their conclusions, given the strengths and
limitations of their study design?
o What is the nature of the conclusions that can be drawn? Were the
study conclusions warranted based on their findings/the methods
they used to come to those findings? Or were they overstated?
Resources
Resource regarding single source designs https://knowledgesociety.usal.es/sites/default/files/Single%20Subject%20and%20Time%20Series%20Designs.pdf
Participant 15 coexsisting metal health conditions on meds for depression no mention if on ADHD meds
Method used manualised CBT but went beyond the 12 sessions- 4 more were added [is this still CBT could this have been a confound?]
Small n design
Single-case designs (also referred to as N = 1 designs) are characterized by repeated measures on a single case. They usually involve an experimental manipulation of a treatment, although there are quasiexperimental versions, such as time series designs.
RTC
limitations
strengths
client heterogeneity may obscure important effects
questions is this tudy a narrtive case study? no uses standardised mesures Is this a systematic case study does it use systematic quanttiative data, multiple assessments of change over time; multiple cases; change in previously chronic or stable problems; and immediate or marked effects following the intervention.
limitation
when and what measures were taken?
What target variable are we assessing here?
what type of design -currently feels like an a b design
strength
AB design has absence of other in formation that could be making difference in this case change of school, family therapy was used given the cultural aspects the introduction of this may be a confounding factor that is not measured (outcome not purely a cbt thing) difficult to tease apart what made a difference here given lack of methodological rigour.
Causal influences throughout may have impacted outcomes
What are the graphs actually saying could they be misleading?
Hermeneutic Single-Case Efficacy Designs, Elliott (2002) has advocated expanded single-case designs that take an interpretive approach to examining client change and its causes. These designs aim to: (1) demonstrate that change occurred; (2) examine the evidence for concluding that therapy was responsible for the change; (3) examine alternative explanations for the change; and (4) examine which processes in therapy might have been responsible for change. They emphasize the use of a rich case record of comprehensive information on therapy outcome and process (e.g., using multiple perspectives, sources, and types of data), and critical reflection by the researcher, who systematically evaluates the evidence.
page 198 of textbook goes through a good example of a case study does this match up?
click to edit
Cook and Campbell’s (1979) list of internal validity threats (see Chapter 8) can be used; in addition, Elliott (2002) highlights validity threats that are specific to single-case studies.
page 199 of text book go through alternative explanations
click to edit
Records of therapy sessions . Audio or video recordings, or detailed process notes, are an excellent source of information about what actually happens in sessions. (They can also be used to corroborate or clarify self-report data.) Therapeutic relationship measures can be administered every session, or less frequently (e.g., every three to five sessions). The most widely used such measure today is the revised short form of the Working Alliance Inventory (Hatcher & Gillaspie, 2006). Self-report session measures can be completed by the client or the therapist. The Helpful Aspects of Therapy Form (Llewelyn, 1988) is a qualitative measure of client perceptions of significant therapy events. The Session Evaluation Questionnaire (Stiles, 1980) and the Session Impacts Scale (Elliott & Wexler, 1994) are quantitative measures of clients’ immediate reactions to sessions. Orientation-specific measures, completed by the therapist or the supervisor after each session, can be used to assess the therapist’s adherence to the treatment model (e.g., the Revised Cognitive Therapy Scale: Blackburn et al., 2001).
Barker, Chris, et al. Research Methods in Clinical Psychology : An Introduction for Students and Practitioners, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/acu/detail.action?docID=4038573.
hey are poor at establishing typicalities or general laws.
good for looking at phenomena in depth, demonstrating that certain phenomena exist, or disconfirming theories by providing counterexamples. T
Read
Read
https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/about-rdoc
Explains problems with RCT designs
What constructs are being measured in each study and what are they using to measure them?
Small n diagnosis of MDD was established using the
Diagnostic Interview Schedule for Children (DISCIV).
Symptoms of depression were assessed every 2–4 weeks
throughout therapy using the Children’s Depression
Inventory—CDI. The Children’s Depression
Rating Scale—
CDRS-R[18] was also used to assess
depressive symptoms at baseline, termination, and
follow-up (Table 1).
Self concept Piers Harris Children’s Self-concept Scale—PHCSC,[19]
Hopelessness Scale for Children—HSC,[20] the
Dysfunctional Attitude Scale—DAS,[21] and the
Suicide Ideation Questionnaire—SIQ-Jr[
RTC To assess depression in first instance primary outcome measure was presence of a depression diagnosis based on a semi-structured diagnostic
interview, the Kiddie-Schedule for Affective Disorders and Schizophrenia, present and lifetime version40.
Secondary outcomes included depressive symptoms, severity of depression, global functioning, suicide risk,
and comorbidity.
Depression primary outcome assessed KSAD
Degree of depressive symptoms was measured by means of self-report using the Child Depression Inventory-II (CDI-2) self and parent report
Severity of depression was rated by the therapist on the one item Clinical Global Impression-severity scale (CGI-S)
Global functioning of the adolescent was assessed by the therapist on the Children Global Assessment Scale
(CGAS) both rated by therapist
Suicide criteria were assessed with the Suicide Criteria Assessment (SCA) self report
Comorbid psychopathology was assessed on two levels namely on diagnosis level with the K-SADS (present or
absent) and
on symptom level with the Youth Self Report scale (YSR)55 for adolescents and the Child Behavior
Check List (CBCL) for parents
Demographic information was gathered by questions
RTC preresgistered decreasing the potential for post hoc changes or p hacking Small n not registered
How is construct defined in both studies given constructs are not unidemensional how would this influence outcomes in both studies how do measures vary in their method of assesssing depression does this fundamentally change what is being assessed? Does the change in measures in the small n affect outcome results? What theroritical background has been used to define this construct /measure.
Same age being measured same construct being assessed same method of intervention ish RTC up to 21
Measures both use CDI for depressive symptoms however,
Face validity problem notable bias toward cognitive symptoms. [May impact CBT outcomes]
[conflicting results for internal consistency]Factor analysis casts doubt on coherence of item measures
warned that if a treatment study is conducted without a control group
(e.g., Garvin et al. 1991), a drop in CDI scores should not be accepted as sufficient evidence that treatment
has alleviated depression. Clarizio cited Meyer et al.’s (1989) study that found a significant drop in children’s
CDI scores over a 3-week period during which no form of treatment was provided
brookke 2001
Niether sty used a control group
Measure diagnosis RTC kiddie small n DISC-IV
Methodology
AB design
Requirements of single case designs
(Kazdin)
• A major requirement of single-case designs is specification of the goals
of treatment or those symptoms and areas of functioning that are to be
altered.
• Identify prior to applying treatment what sorts of changes will be used
to evaluate progress and then how these will be measured
• Use of measures that can be administered or obtained on several
occasions
• The use of repeated observations of performance over time to compare
performance under different conditions
• Since baseline performance is used to predict how the client will
respond in the immediate future, it is important that the data are
relatively stable.
• The greater the variability in the data, the more difficult it is to draw
conclusions about the effects of the treatment.
Baseline, termination follow up assessed by Children's depression rating scale.
Intervention manual CBT - not stated what manual used -CBT only condition- extra sessions offered (up to 12) if not remitted at 12 sessions
Also met criteria for GAD, separation anxiety disorder and ADHD what is really at play is depression result of others? Maybe check DSM criteria for differencial diagnosis
Lack of progress during goal setting time management may be ADHD related - however mention of incomplete homework and possible internalised symptoms may impact
Greatest stressor family problems - familt therapy may have confounded results - cultural familismo - correlates with teen depress- may be a confound
Pre mid post Measures of Depression CDI- measured symptoms 2 to 4 weeks but graph is not clear as to when.
test-retest reliability of the CDI varies quite considerably and somewhat unsystematically with the length of the intertest interval and the characteristics of the sample being studied brook 2001
This variation between measurments may also be misleading
Self concept PHCSC Disfunctional attitude DAS, suicide ideation SIQ-jr
only reports pre post and fllow up does not state mid measures
This may have helped better understand what parts of treatment were impacting what outcomes
s 1-4 Pyschoeducation cog restructuring
homework log pos neg thoughts daily
identify dysfunctional thoughts
dep measure-36-26
New school-suggested to impact these results
s 5-8 Behavioural activation
pleasant activities, time management, goal setting
Homework
log pleasant activities, weekly planner, goals and steps to complete them.
Barriers pleasant act-neg thoughts, parental permission
Dep score 26-25
Mention of previous medication but no dose offered nor mention of meds during study
states in discussion antidepressants were used but does not give detail regarding dose or consistency of use
s 9-12 psychoed interpersonal relationships
maintaining social support
assertive communication skills
Still guilt, anger, sadness re parents relat
dep score 25-25
further sessions
s 13-16
four sessions around parents relationship- not part of manual?
Restructing thoughts
role play
No longer MDD
dep score 25-19
Somewhere in here there was a family therapy session
Could this confound results later
extra session-no mention of when
Modifided the manual to address family problems can this be appropriately measured - is the reduction of MDD based on family therapy and
Look at this study using this lense
Hermeneutic Single-Case
Efficacy Designs
• Aim to:
• (1) demonstrate that change occurred;
• (2) examine the evidence for concluding that therapy
was responsible for the change;
• (3) examine alternative explanations for the change; and
• (4) examine which processes in therapy might have
been responsible for change.
click to edit
Example of Latency of Change
(Kazdin) • The closer in time that the change occurs after
the intervention has been implemented, the
clearer the intervention effect.
Opposite potential problem with visual inspection –
sensitive to detecting small intervention effects
• Effect size may not have any relation to a change that is
important or clinically significant in the lives of clients
(Kazdin, 2017).
• The general relevance of statistical inference to single-case
data remains a highly controversial topic (Ator, 1999; Baron,
1999; Fisch, 2001).
Preregistered
CBT v TAU
Method
Study aim
This case study aims to
explore variables associated with a partial or limited
treatment response to CBTand illustrate the challenges and variability in CBT treatment for major depressive disorder (MDD) in adolescence.
Does this study answer the aim?
No it does not because it doesn't investigate the specific variables that may impact outcomes for this client. Alt diagnosis- meds-cult-family therapy-school change.
stated later DISC-V assessement Mdd criteria no longer met was reason to stop treatment.
primary outcome was depressive or dysthymic disorder based on the KSADS
Only for 6 to 18 the participants are 12 to 21 does this effectively assess older people?
Drop out rate seemed high
19 completing treatment in the CBT condition only 4 attended all 15 sessions
26 completing treatment in the TAU condition
D(o)pression course
Study Aim The aims of this study were to
investigate the (1) effectiveness and (2) potential moderators and predictors (age, gender, educational level of
the adolescent and the parent, suicide criteria, comorbidity and severity of depression) of CBT versus TAU
Explained randomisation process
Randomization was conducted after pre-treatment
assessment and was executed per adolescent by computer generated block randomization and stratified per
mental health care center by the primary researcher (no involved in other assessments)
Assessment schedule
The following assessments took place; prior to treatment (pretreatment assessment), within treatment (mediator
assessments), immediately after treatment or after 15 sessions (post treatment assessment), six months after
treatment (six-month follow-up) and 1 year after treatment (1 year follow-up). In this paper, we will present the
post treatment and six-month follow-up results.
Final study underpowered
44 per condition
Power calculations in STATA
indicated that 70 adolescents per condition (assuming an alpha of 0.05, a statistical power, 1-beta, of 0.80 and a
drop-out of 20% would be required to detect a difference in depression diagnosis between conditions.
(24 cbt) (25 tau) post assess
14c,18t follow up1
14c,15t follow up 2
The intervention contains
representative CBT components
namely: psycho-education (information about depression and the rationale
for the etiology of the complaints and the treatment of them), setting attainable goals (translate large goals into
realistic short term goals), self-monitoring (registration of the mood, activities and thoughts), activation (planning
frequent, joyful activities), improving social skills and communication skills (improvement and stimulation of social behavior), relaxation techniques, cognitive restructuring (identifying and changing unrealistic negative
thoughts about the self, others and events), role play and problem solution skills (teaching the creation of solutions
for problems via brainstorm, choosing, trying and evaluating) and relapse prevention.
Integrity of treatment between therapists was assessed and found to be good but no statement regarding continuity for client (same therapist every time)
Treatments in both conditions were delivered by psychologists with at least one year of experience
within professional mental health care. The therapist in the CBT condition had also at least one year of
experience in conducting CBT. two day training this manual
37 therapists in each condition -no overlap
Initial diagnosis of MDD based on :
Small n- DISC-IV- ICD- appropriate for participant age
RTC K-SADS-DSM- ICD inappropriate for participants over 18 (don't know how many) valid reliability not great- Brooks 2001
Small n does not mention how CDRS was administered just gives scores important due to poor levels of interinformant reliability. brook 2001
Should have P T child interview. Multiinformant
6-12 not age appropriate
The CDRS-R may not be the most sensitive
instrument for monitoring changes in severity in older children and adolescents.
this study did not conduct any statistical analyses, therefore findings could only be inferred.