Deployment-Focused Development of Depression Treatment for Victimized Youth

描述（由申请人提供）：这个修订后的R34申请的主要目标是开发和实施一种改进的认知行为治疗（m-CBT）的初步评估，用于治疗有人际创伤史的抑郁青少年。相当多的青少年在接受心理治疗或药物治疗后仍未确诊或仍有症状。值得注意的是，有创伤史的抑郁青少年对认知行为疗法（CBT）的反应比没有创伤史的青少年要差。人际创伤已被确定为严重抑郁症的一个突出的发展途径，并且在转介到社区诊所中很普遍；因此，满足这一“耐药”群体的需求是公共卫生的高度优先事项。为了满足这一“治疗抵抗”群体的需求，我们建议修改在先前的临床试验中显示有效的认知-行为方案。治疗修改是基于这样的假设，即标准CBT不能解决创伤暴露青少年抑郁的两个主要因素：1.执行功能缺陷；2)创伤相关认知。首先，在受创伤的青少年中发现的执行功能缺陷（例如，注意力，干扰控制，设定转移）被假设为干扰CBT中的技能习得。为此，通常的CBT模块将被修改为包括针对执行功能的经验支持的干预措施（例如，注意力控制训练，基于正念的认知干预）。其次，暴露于创伤的个体已被证明支持特定的创伤相关的不适应认知，这不是CBT的典型目标。为此，治疗将针对抑郁的自动思维和与创伤相关的认知。由于在社区诊所的抑郁青少年中普遍存在人际创伤史，因此该项目采用了以部署为重点的治疗发展模式，以创建“临床就绪”的干预措施。为此目的，将在社区精神卫生中心与社区临床医生和转诊青少年一起开发和测试这种治疗方法。这项研究包括两个阶段；第一项工作涉及对8名转诊青少年进行治疗手册的试点测试。可接受性、满意度、治疗依从性和抑郁症状的前后变化将被检查。经过人工优化，将对60名原发性抑郁症诊断和人际创伤史的青少年进行一项具有临床代表性条件的随机对照试验。青少年将被随机分配到新的干预（m-CBT）或折衷的常规治疗条件。将在治疗前后和3个月随访期间评估抑郁症状、整体功能和认知过程（执行功能和创伤相关认知）的变化。将使用具有重复测量的线性混合模型来评估治疗效果。在青少年时期，大约六分之一的青少年患有重度抑郁症，导致自杀、药物滥用、早育和学业失败的风险增加。儿童人际创伤是导致重度抑郁症的一个有充分证据的途径。由于暴露于人际创伤的青少年不太可能对现有的抑郁症治疗反应良好，本项目将开发和评估一种新的治疗方法，用于有人际创伤史的抑郁青少年。

DESCRIPTION (provided by applicant): This primary goal of this revised R34 application is to develop and conduct an initial evaluation of a modified cognitive-behavioral treatment (m-CBT) for depressed adolescents with histories of interpersonal trauma. A substantial number of adolescents retain their diagnoses or remain symptomatic following psychosocial or pharmacotherapy for depression. Notably, depressed adolescents with histories of trauma have been found to be less responsive to cognitive-behavioral therapy (CBT) for depression than non-exposed adolescents. Interpersonal trauma has been identified as a prominent developmental pathway to major depressive disorder and is prevalent among referrals to community clinics; thus, addressing the needs of this "treatment resistant" group is a high public health priority. In order to address the needs of this "treatment resistant" group, we propose to modify a cognitive-behavioral protocol that has been shown to be efficacious in prior clinical trials. Treatment modifications are based on the hypothesis that standard CBT does not address two factors central to depression in trauma-exposed youth: 1.) deficits in executive function; and 2.) trauma-related cognitions. First, deficits in executive functioning (e.g., attention, interference control, set shifting) found among traumatized youth are hypothesized to interfere with skill acquisition in CBT. To this end, the usual CBT modules will be modified to include empirically-supported interventions targeting executive function (e.g., attention control training, mindfulness-based cognitive interventions). Second, trauma-exposed individuals have been shown to endorse specific trauma-related maladaptive cognitions that are not typically targeted by CBT. To this end, the treatment will target both depressive automatic thoughts and trauma-related cognitions. Because a history of interpersonal trauma is prevalent among depressed adolescents in community clinics, this project uses a deployment-focused model of treatment development in order to create a "clinic-ready" intervention. To this end, the treatment will be developed and tested in a community mental health center with community clinicians and referred adolescents. The study involves two phases; the first involves pilot testing of the treatment manual with 8 referred adolescents. Acceptability, satisfaction, treatment adherence, and pre- post change in depressive symptoms will be examined. Following manual refinement, a randomized controlled trial under clinically-representative conditions will be conducted with a referred sample of 60 adolescents with a primary depression diagnosis and a history of interpersonal trauma. Adolescents will be randomized to the new intervention (m-CBT) or to an eclectic treatment-as-usual condition. Changes in depressive symptoms, global functioning, and cognitive processes (executive functions and trauma-related cognitions) will be evaluated between pre and post-treatment, and at 3-month follow-up. Linear mixed models with repeated measures will be used to evaluate the effects of treatment. Major depression affects approximately 1 in 6 adolescents during the teen years and results in increased risk for suicide, substance abuse, early childbearing, and school failure. Child interpersonal trauma is a well- documented pathway to major depression. Because youth exposed to interpersonal trauma are less likely to respond favorably to existing depression treatments, this project will develop and evaluate a new treatment for depressed adolescents with interpersonal trauma histories.