Associate Professor Andrew Lewis1
Professor John Toumbourou 1
Associate Professor Lina Ricciardelli1
Dr Tess Knight1
Dr Melanie Bertino1
Ms Reima Pryor2
Ms Narelle Robinson1
Ms Louise McDonald1
1 Deakin University
2 Drummond Street Services
Deakin University, School of Psychology $4,000
beyondblue Victorian Centre of Excellence
Project completion year
This project builds on important previous clinical trials completed in 2010 with the support of beyondblue funding.
In this project, the researchers’ primary aim was to test the relative benefits of a Family Education program (BEST-PLUS), an enhanced adolescent cognitive therapy (SHADEY CBT), and their combination for reducing parent and adolescent depressive symptoms.
The secondary aim was to develop the family-based intervention to be a more effective means of engaging youth who initially refuse service, via initial work with their parents, and to develop means of engaging community members in treatment who have concerns about their young people but have not had access to, or benefit from, existing mental health services.
Recruitment took place via parenting seminars run in Melbourne and Geelong, which were advertised in local papers and via a network of agencies throughout Geelong and Melbourne. Measures were sent out to participants who made contact. An initial assessment interview time was made with a clinician. Eligible participants were randomised to three treatments using a randomisation technique. Those who were ineligible were referred on to appropriate local agencies.
Treatment option 1
The BEST-Plus program is a manual-based and evidence-supported treatment. It consists of an eight-week, professionally-led group program designed to assist parents concerned with youth substance use-related problems. The parent/s received four sessions of weekly intervention, then the parent and young person completed four sessions of a weekly intervention together.
Treatment option 2
In the Cognitive (SHADE-Y) option, the participant (young person) received 10 sessions of weekly individual sessions. This cognitive behavioural therapy is based on a cognitive-behavioural framework of structured and symptoms focused session content, use of structured homework tasks and the use of Aaron Beck’s model for addressing unhelpful cognitions such as negative self-appraisals. It was developed by Leanne Hides and Steven Carroll of ORYGEN youth health, for youth with co-morbid depression and substance use issues.
Treatment option 3
Cognitive SHADE-Y supplemented with BEST-Plus, run partially in parallel over 10-12 weeks.
Measures were administered to all participants pre-intervention and were repeated at post-intervention following the treatment period and at follow-up six months after treatment exit.
Parents were mailed six measures:
- demographics eliciting family details, employment and educational status, rurality and access to essential services, self-reported health and mental health status, the nature of services previously provided and difficult issues confronting the family
- parents’ mental and physical health using the Millon Clinical Multiaxial Inventory-III questionnaire (MCMI-III; Millon, Davis & Millon, 1997)
- a parent questionnaire employed in previous trials of the BEST program with questions relating to the parents’ physical health, their parenting practices, youth behaviours and parenting satisfaction
- the parenting relationship questionnaire, designed to capture a parent's perspective on the parent-child relationship
- the adult attachment-relationships questionnaire
- the relationship scales questionnaire for assessing the parents’ own attachment styles.
Youth were administered three measures:
- mental health, using the Youth Self-Report (11-18 years) or Adult Self Report (18-59 years)
- suicidality using the Beck Scale for Suicide
- substance use/abuse using the Adolescent Substance Abuse Subtle Screening Inventory (SASSI-A2).
Clinical trial outcomes Overall, 186 persons participated in this research program, known as the ‘Deakin Family Options’ study. Overall, 53 per cent of participants engaged in a treatment offered to them after an assessment. This figure may seem low but includes many circumstances where a parent would agree to participate, e.g. seeking a mental health service, but the young person in their family would refuse to participate.
Young people were disproportionately less likely to engage in treatment (60-70 per cent) in comparison to parents (20-30 per cent) who do not engage. This difference was statistically significant (χ2 (5) = 28.8, p<.001). It is also interesting to note that although a larger number of mothers (n = 70) than fathers (n = 29) presented for service within the study, those fathers who did present were more likely to be engaged in a given treatment.
There were moderate reductions in internalising symptoms for youth who received both interventions (BEST and SHADE-Y CBT), with BEST performing slightly better on this measure. Internalising symptoms here include symptoms of anxiety, depression and social withdrawal. Notably the groups were not well matched at baseline despite the randomisation process and the CBT group were rated higher on depression, anxiety and internalising and lower on externalising symptoms overall. There was, however, no statistically significant difference between the groups, suggesting approximately equivalent amounts of reduction across both groups. Externalising scores did not reduce for either group. This is perhaps understandable given the predominance of depression as the presenting issue. Results of the anxious-depressive symptoms subscale of the YSR/ASR showed a greater reduction of anxiety and depression symptoms for the CBT group, while a small reduction was achieved by the BEST group.
Overall these results are very encouraging for the capacity of the BEST program to match CBT in terms of the reduction in depressive symptoms. Effect size reductions are within the same range as that reported in the majority of meta-analyses. Notably CBT sessions require individual attendance by the young person and a direct focus on symptom reduction, while BEST does not require attendance by the young person and works via modification of the family environment as a whole.
Limitations in these findings are many and results need to be treated with caution. The first sample size in each group is small and attrition from the study considerable. The researchers were unable to make a comparison to the combined treatment group due to low sample size in this arm of treatment.
There were reductions in the mean scores on all Axis I scales of the MCMI-III with the exception of ‘drug use’ which increased by less than two points, which is most likely a trivial increase. Due to small sample size, many of these decreases in symptoms do not reach statistical significance and cannot therefore be confirmed as genuine decreases. However a meaningful pattern of reductions in symptoms which were statistically significant occurred in the areas of thought-disordered symptoms, anxiety symptoms, and the symptoms of major depression.
Two consumer reference groups were run at the end of 2011 in Melbourne and Geelong. Groups were facilitated by some of the BEST-Plus and SHADE-Y CBT therapists and were recorded by two observers. The focus groups ran for 1.5 hours and there was an opportunity for participants to meet. The focus groups were recorded with consent and transcribed and verified by two researchers. Participants were also asked to fill out a brief feedback survey. The results are reported below for Melbourne (n=9 individuals from four families) and Geelong (n=13 individuals from nine families).
Participants enjoyed the collegial atmosphere of the BEST Plus groups, where they felt that they were not alone. This helped normalise the behaviour of their young person. Participants appreciated the safe space that was created by the facilitators so that they could talk and contribute their experiences and understanding to help others in the group. It was experienced as a participatory, give and take experience.
A dominant theme that ran through both of the focus groups was learning to ‘let go’ – that the BEST- Plus group had helped parents understand the importance of actually standing back and letting go. Prior to that there was a sense of helplessness, not knowing what to do for or with their young person and being constantly caught up in conflict with their young person.
The BEST-Mood group speaks about the importance of self-care and it came across in the focus groups that self-care was something that parents were still implementing after the course had finished; that despite their situation, they recognised the need to look after themselves in order to better care for their child.
The research team have been successful in gaining an ARC linkage grant with support from beyondblue, which builds upon this current research. This collaborative project - called ‘Family Options’ - will evaluate a BEST-MOOD against a control condition using an RCT with a focus on establishing the efficacy of a family-based intervention specifically for adolescent depression in order to broaden the therapeutic approaches used for young people. The ARC Family Options study will further promote family-based intervention as a means of engaging young people and addressing family-based risk factors which both precipitates and perpetuates risk for adolescent depression.