Carolyn Spiro-Levitt

This paper describes the implementation of Behavioral Activation (BA) as the core psychotherapy treatment within a broader clinician-led effort to establish a care pathway for adolescent depression in an academic medical center that served public and private hospital systems. This quality improvement effort required a standardized yet flexible approach to psychotherapy to be used by clinicians with a range of experience and training backgrounds while serving diverse clinical populations in child psychiatry and pediatric clinics. This paper highlights implementation of BA in treating adolescent depression across these varying systems. In particular, the paper emphasizes the application of BA as a principle-driven, treatment that enables flexibility across settings while remaining rooted in scientific evidence. The paper also reviews lessons learned from this effort that may support efforts to implement BA in other clinical settings and systems.

Adolescence represents a vulnerable developmental period for depression and an opportune time for prevention efforts. In this study, 186 adolescents with elevated depressive symptoms (M age = 14.01, SD = 1.22; 66.7% female; 32.2% racial minority) were randomized to receive either Interpersonal Psychotherapy–Adolescent Skills Training (IPT-AST; n = 95) delivered by research clinicians or group counseling (GC; n = 91) delivered by school counselors. We previously reported the short-term outcomes of this school-based randomized controlled trial: IPT-AST youth experienced significantly greater improvements in depressive symptoms and overall functioning through 6-month follow-up. Here, we present the long-term outcomes through 24 months postintervention. We examined differences in rates of change in depressive symptoms and overall functioning and differences in rates of depression diagnoses. Youth in both conditions showed significant improvements in depressive symptoms and overall functioning from baseline to 24-month follow-up, demonstrating the efficacy of school-based depression prevention programs. However, the two groups did not differ in overall rates of change or in rates of depression diagnoses from baseline to 24-month follow-up. Although IPT-AST demonstrated advantages over GC in the short term, these effects dissipated over long-term follow-up. Specifically, from 6- to 24-month follow-up, GC youth showed continued decreases in depressive symptoms, whereas IPT-AST youth showed a nonsignificant increase in symptoms. GC youth remained relatively stable in overall functioning, whereas IPT-AST youth experienced a small but statistically significant worsening in functioning. This study highlights the potential of school-based depression prevention efforts and the need for further research.

Background Amygdala–prefrontal cortex (PFC) functional connectivity may be influenced by anxiety and development. A prior study on anxiety found age‐specific dysfunction in the ventromedial PFC (vmPFC), but not amygdala, associated with threat‐safety discrimination during extinction recall (Britton et al. 8 ). However, translational research suggests that amygdala–PFC circuitry mediates responses following learned extinction. Anxiety‐related perturbations may emerge in functional connectivity within this circuit during extinction recall tasks. The current report uses data from the prior study to examine how anxiety and development relate to task‐dependent amygdala–PFC connectivity. Methods Eighty‐two subjects (14 anxious youths, 15 anxious adults, 25 healthy youths, 28 healthy adults) completed an extinction recall task, which directed attention to different aspects of stimuli. Generalized psychophysiological interaction analysis tested whether task‐dependent functional connectivity with anatomically defined amygdala seed regions differed across anxiety and age groups. Results Whole‐brain analyses showed significant interactions of anxiety, age, and attention task (i.e., threat appraisal, explicit threat memory, physical discrimination) on left amygdala functional connectivity with the vmPFC and ventral anterior cingulate cortex (Talairach XYZ coordinates: −16, 31, −6 and 1, 36, −4). During threat appraisal and explicit threat memory (vs. physical discrimination), anxious youth showed more negative amygdala–PFC coupling, whereas anxious adults showed more positive coupling. Conclusions In the context of extinction recall, anxious youths and adults manifested opposite directions of amygdala–vmPFC coupling, specifically when appraising and explicitly remembering previously learned threat. Future research on anxiety should consider associations of both development and attention to threat with functional connectivity perturbations.

Independent lines of research illustrate the benefits of social support and the negative consequences of conflict and emotional neglect across family and peer contexts with regard to depression. However, few studies have simultaneously examined negative and positive interactions across relationships. We sought to address this gap in the literature by utilizing a person-centered approach to a) understand empirical, interpersonal profiles in youth and b) understand how these profiles confer risk for prospective depression. At baseline, 678 youth (380 females; 298 males) 3rd (N = 208), 6th (N = 245), and 9th graders (N = 225) completed self-report measures for self-perceived negative/positive relationships across family and peers, anxiety symptoms, and depressive symptoms in a laboratory setting. Next, youth were called every 3 months for 18 months and completed self-report depressive and anxiety symptom forms. Two-step cluster analyses suggested that children and adolescents fell into one of three interpersonal clusters, labeled: Support, Conflict, and Neglect. Our analyses supported a convergence model in which the quality of relationship was consistent across peers and family. Furthermore, mixed-level modeling (MLM) findings demonstrated that youth in the Conflict cluster were at increased risk for prospective depressive symptoms, while the Supported and Neglected profiles demonstrated similar symptom levels. Findings were unique to depressive symptoms and consistent across sex and age. Conflict seemed to uniquely confer risk for depression as findings concerning anxiety were not significant. These findings influence our interpersonal conceptualization of depression as well as clinical implications for how to assess and treat depression in youth.