According to the DSM-5 (American Psychiatric Association, 2013), the diagnostic criteria for major depressive disorder include five or more of the following symptoms present for a two week time frame: depressed mood, diminished pleasure, significant weight loss or gain when dieting is not present, insomnia or hypersomnia, psychomotor impairment, fatigue or loss of energy, feelings of worthlessness or excessive guilt, diminished ability to concentrate/indecisiveness, and recurrent thoughts of death/recurrent suicidal ideation. The symptoms also must cause significant distress in important areas of functioning, they can’t be due to the effects of a substance or a medical condition, the occurrence of the depression isn’t caused by another mental health disorder, and there has not been a manic or hypomanic episode.
The diagnostic criteria for generalized anxiety disorder includes excessive worry for more than six months, the worry is difficult to control, the worry/anxiety is associated with three or more of the following symptoms: restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance, the anxiety causes distress in important areas of functioning, the disturbance is not attributed to substance use or another medical condition, and the disturbance is not explained by another mental disorder (American Psychiatric Association, 2013).
Research Regarding Depression and Anxiety in Adolescents
This writer sought to find the research that exists in regards to anxiety and depression as it occurs with clinical samples of adolescents, and of those found two articles discussed the comorbidity of anxiety and depression in adolescents. Garber & Weersing (2010) addressed comorbidity in youth and subsequently what the treatment and prevention implications would be. Cummings et al. (2013) sought to compile the research that has been conducted since Brady and Kendall conducted their research regarding comorbidity of anxiety and depression in youth in 1992. They also wanted to review the current models that conceptualize this comorbidity, and propose another conceptualization model, the multiple pathways model, to further understand comorbidity of anxiety and depression in youth.
Garber & Weersing (2010) began with explaining the extent of comorbidity and the prevalence of this occurrence, and continued by explaining some of the conceptualization models used to understand comorbidity. They then explained the correlation between depression and anxiety and the areas in which they overlap. Garber & Weersing (2010) proposed that the subsequent implications for treatment include evidence-based practices such as pharmacotherapy, cognitive behavioral therapy, and more behavioral interventions that include ‘graded engagement’ (Garber & Weersing, 2010). In regards to this article, the writers do include well researched interventions for adolescents with comorbid anxiety and depression. However, they neglected to address if combined interventions were effective in treating adolescents with comorbid depression and anxiety. The writer of this proposal will be addressing in the research proposed if combined interventions (such as CBT, DBT, and interpersonal process groups) are effective in treating depression and anxiety in adolescents.
Cummings et al. (2013) decided to compile twenty years worth of research that had been conducted about comorbidity of depression and anxiety in youth (children and adolescents) since one of most well known studies had been done in 1992. Similarly to Garber & Weersing (2010), Cummings et al. (2013) began their article by noting the situation at hand and summarizing comorbidity. They also explained several existing theoretical models, including the tripartite model, the behavioral activation system and behavioral inhibition system model, and the multiple pathways model. Much of the article briefly introduces a myriad of different research studies conducted between the years of 1992 and 2013. Cummings et al. (2013) followed the conversation of existing research with details regarding treatment response which, like Garber (2010), included medication treatment and cognitive behavioral therapy. Though they noted that some studies show that individuals with a primary diagnosis of anxiety with depressive symptoms do not respond as well to CBT. Furthermore, Cummings et al. (2013) proposed that transdiagnostic treatment would be useful in addressing anxiety-depression comorbidity. The writer of this proposal found this compilation of comorbidity research to be broadly encompassing and integral in giving an overview of the present research available detailing comorbidity of anxiety and depression in youth.
Research Regarding CBT, DBT, and PHP Programs
Straub et al. (2014) developed a pilot study about cognitive behavioral therapy for adolescent outpatients with depression, in order to determine the program’s feasibility and outcomes. The program mentioned in Straub et al. (2014)’s research had similar elements as that of Deerfield Behavioral Health; not only do they implement CBT, they also conduct individual sessions with adolescents who report current suicidal ideation before they leave programming for the day.
This research was done including German adolescents, a group of individuals who live in a very different culture than the adolescents that will be included in the proposed research. The research in this proposal will include adolescents living in North America. Additionally, this research (like many other studies) only analyzes one intervention, CBT, whereas the research in this proposal will be analyzing a program that implements six different interventions of group therapy. Furthermore, the attendance size for the group therapy was much lower than the typical attendance rate at Deerfield Behavioral Health. The attendance rate for the German program (six sessions) was as follows: 60% of participants attended all sessions, 20% of participants attended five sessions, 13.3% attended four sessions, and 6.6% attended three sessions (Straub et al., 2014). Though this writer does not have the data available in regards to overall attendance of adolescents to group programming, in this writer’s experience the attendance rate is rather consistent high overall.
Lenz & Del Conte (2018) researched if Dialectical Behavioral Therapy for Adolescents (DBT-A) was effective for treating adolescents in a partial hospitalization program. When comparing treatment as usual (TAU) to DBT-A, the researchers found that although treatment effects were similar, participants in DBT-A experienced a decrease in interpersonal sensitivity symptoms, anxiety symptoms, and depression symptoms. Although the researchers note that “the group differences for anxiety were not statistically significant” (Lenz & Del Conte, 2018). Unlike the other research articles mentioned in this proposal, this article was the only one that studied both depression and anxiety in adolescents. Similarly to this writer’s research proposal, Lenz & Del Conte (2018) realized that research was needed to identify if interventions such as dialectical behavioral therapy, had a correlational relationship to adolescent psychiatric symptoms. It also compared treatment as usual (TAU) to dialectical behavioral therapy for adolescents (DBT-A), so the research provided a comparison of two different interventions for an adolescent partial hospitalization program. However, it still was another study that analyzed a program that implemented only one intervention. Several studies exist that address one or a few interventions that are incorporated by Deerfield Behavioral Health, however based on the awareness of this writer none of them address the same combination of interventions that Deerfield Behavioral Health implements. Also similarly to the writer of this proposed research, Lenz & Del Conte (2018) understood that this sample of adolescents in PHP programs is an understudied population and the corresponding research is lacking.
Alike the research in this proposal, Lenz et al. (2014) wanted to determine how PHP treatment was correlated with a change in adolescent participant psychiatric symptoms (though this was not the only purpose of the study). Researchers found that participants overall experienced a decrease in severity of symptoms after participating in a six week PHP program. This research that was the most comprehensive out of the three of them, given that it discussed a PHP program that used multiple interventions, rather than just one intervention. The interventions that the PHP program used included goal setting, educational therapy/academic preparation, interpersonal process groups, family and individual therapy, art and music therapy, and recreational therapy. These interventions are almost identical to the interventions implemented by Deerfield Behavioral Health.
The PHP program in Lenz et al. (2014)’s research also administered their assessment tools (SCL-90-R and RHI-Y) prior to admission and at discharge, as this research proposal will do as well. Lenz et al. (2014) conducted research that is similar in nature to the research in this proposal, however there are enough differences that occur between the two that Deerfield Behavioral Health would still benefit from researching their own PHP program in regards to client symptoms. Further studies like that conducted by Lenz et al. (2014) could still be useful not only to the research community and the social work community, but also to other PHP programs and the general mental health community.
An overall limitation of two out of the three aforementioned studies is that the participation size of Caucasian individuals was rather high (88%), and the participation of minority individuals was rather small (ranging from only 2-6%). The third study by Straub et al. (2014) did not specify race demographics of participants. Studies that do not have a racially diverse group of participants are limited in how their results pertain to minority groups. Due to the inclusion and exclusion criteria of this research proposal, it is impossible to know what the racial demographic sizes will be for this study. However, in this writer’s experience, Deerfield Behavioral Health tends to serve racially diverse groups of clients in any given program including the PHP program. Ideally, the participant group of the proposed research would be racially diverse.
Another limitation of two out of the three aforementioned studies is that they did not use the Beck Depression and Anxiety Inventories as assessment tools for participants, the instruments they used included the CDRS-R, FBB-DES, IQLC, CGI-S, HoNOSCA, SCL-90-R, and RHI-Y (Straub et al., 2014; Lenz et al., 2017; Lenz & Del Conte, 2018). Straub et al. (2014) was the only study that used the Beck Depression Inventory (BDI-II), therefore research that utilizes the Beck Inventories in order to assess anxiety and depression in adolescents is lacking and therefore warranted.