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A Randomized Trial of a Group Cognitive Intervention for Preventing Depression in Adolescent Offspring of Depressed Parents
Gregory N. Clarke, PhD;
Mark Hornbrook, PhD;
Frances Lynch, PhD;
Michael Polen, MS;
John Gale, MD;
William Beardslee, MD;
Elizabeth O'Connor, PhD;
John Seeley, MS
Arch Gen Psychiatry. 2001;58:1127-1134.
ABSTRACT
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Background Adolescent offspring of depressed parents are at high risk for development
of depression. Cognitive restructuring therapy holds promise for preventing
progression to depressive episodes.
Methods A randomized, controlled trial was conducted to prevent depressive episodes
in at-risk offspring (aged 13-18 years) of adults treated for depression in
a health maintenance organization (HMO). Potential adult cases were found
by reviewing the HMO pharmacy records for dispensation of antidepressant medication
and the mental health appointment system. Medical charts were reviewed for
a depression diagnosis. Recruitment letters signed by treating physicians
were mailed to adults. Eligible offspring had subdiagnostic depressive symptoms
insufficient to meet full DSM-III-R criteria for
affective disorder and/or a past mood disorder. These youth were randomized
to usual HMO care (n = 49) or usual care plus a 15-session group cognitive
therapy prevention program (n = 45).
Results We detected significant treatment-by-time (program) effects for the
Center for Epidemiological Studies Depression Scale (P = .005)
and the Global Assessment of Functioning scores (P = .04).
Survival analysis of incident major depressive episodes during a median
15-month follow-up found a significant advantage (P = .003) for
the experimental condition (9.3% cumulative major depression incidence)
compared with the usual-care control condition (28.8%).
Conclusion A brief, group cognitive therapy prevention program can reduce the risk
for depression in the adolescent offspring of parents with a history of depression.
INTRODUCTION
DEPRESSION IS common among adolescents, with a point prevalence estimated
at 3% to 8%.1 By 18 years of age, as many as
25% of adolescents have had at least 1 depressive episode.2
Most adults with recurrent depression have their initial depressive episodes
as teenagers,3 suggesting that adolescence
is an important developmental period in which to intervene.
Research on the treatment of youth depression supports the efficacy
of medication4 and psychotherapy.5, 6, 7
Emerging evidence also exists that psychosocial interventions may prevent
depression.8, 9, 10
Recently, intervention research has focused on groups at high risk for affective
disorder, including children and adolescents with a depressed parent, in whom
depression is up to 6 times more likely to develop than in other children.11, 12 Most offspring studies were noninterventional,
limited to investigations of relative risk and longitudinal course.12 Recently, however, Beardslee and colleagues8 conducted a trial of a family-based, cognitive intervention
for offspring of depressed parents. They found positive effects on functional
outcomes of parent and child, but did not report effects for depression diagnoses.
Another frequently studied risk group includes individuals who do not
meet full criteria for a DSM affective episode, but
who report significant "subsyndromal" depressive symptoms. "Full-blown" depression
is more likely to develop in these individuals with subsyndromal symptoms,13, 14, 15 who have been the
subject of several targeted prevention interventions.9, 10
This report presents the results from a new prevention trial conducted
with the subsyndromal adolescent offspring of parents treated for depression.
This study was similar to the investigation by Beardslee et al8
in that both trials attempted to treat or prevent depression in the at-risk
offspring, and both used manual-based, psycho-educational interventions. However,
Beardslee et al8 used an individual, family-based
intervention, provided by psychiatrists or primary care providers, and offered
at a similar level of intensity to all youth regardless of depression severity
level. In contrast, this study examined the effectiveness of a group cognitive-behavioral
treatment program provided by therapists with master's degrees. Furthermore,
this investigation categorized offspring into 3 depression severity groups
(low, medium, and high severity), and matched the intervention dose to the
severity of the presenting depression.
This report presents the overall design of the study (Figure 1), and the outcome findings for the group with medium-severity
depression, ie, adolescents who presented with subsyndromal depression symptoms
but had no active depression episodes. The aim of the randomized trial with
these youth was to prevent progression to future episodes of major depression.
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Figure 1. Study flowchart. HMO indicates
health maintenance organization. Depression categories are described in the
"Subjects and Recruitment" subsection of the "Subjects and Methods" section.
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SUBJECTS AND METHODS
SUBJECTS AND RECRUITMENT
The sampling frame included approximately 410 000 members enrolled
in the Kaiser Permanente Northwest health maintenance organization (HMO),
centered around Portland, Ore. The study research center is located within
the HMO but is self-governed. The Human Subjects Committee for the HMO approved
all study procedures.
To refresh the available pool of depressed parents and youth, case finding
was conducted in 6 separate cohorts across a 2-year recruitment period (September
1994 through October 1996). Each cohort began by identifying those adults
aged 30 to 65 years who had been HMO members for at least 6 months, had covered
dependents aged 13 to 18 years, and lived reasonably close to the study center.
To generate the initial pool of depressed adults, we searched the HMO
computerized pharmacy database for adults who had received at least 2 dispensations
of an antidepressant medication within the past 12 months. Nearly all HMO
member prescriptions are filled at HMO pharmacies.16
Across all cohorts, this step identified 4706 potentially depressed parents.
We also searched the mental health appointment database, identifying 1316
adults with at least 2 mental health visits in the past 12 months. Approximately
17% of adults (n = 1003) were identified using both methods, resulting in
a nonoverlapping total of 5954 potentially depressed adults.
Medical chart reviews determined that 3935 of these adults (66.1%) had
a depression diagnosis and/or symptoms recorded in association with the medication
prescription or the mental health visits. Each parent's physician mailed introductory
letters to those adults they judged appropriate for the study (n = 2995).
A postpaid refusal postcard was returned by 458 adults (15.3%). Study staff
attempted to telephone the remaining adults for a brief screening of study
criteria. The adolescent offspring of 2083 contacted adults were also asked
about their interest in participating. Interested families were invited for
an intake evaluation; a written consent was signed by the parent(s) and the
adolescent. Up to 2 qualifying siblings from each family could participate.
Interviews were scheduled with 744 families (966 youth) and completed with
481 parents (64.7%) and 551 adolescents (57.0%). This assessment confirmed
the parent diagnosis of depression and assessed adolescent psychiatric diagnoses,
symptoms, and psychosocial functioning.
To qualify for the study, parents could either be in a current episode
of major depression and/or dysthymia, or have had an episode in the past 12
months that touched chronologically on their current course of antidepressant
medication and/or psychotherapy. The latter subjects were those who had effectively
responded to their depression treatment, were no longer depressed, but were
still taking medication or receiving treatment. Parent diagnosis of depression
and other disorders was assessed using the Family Schedule for Affective Disorders
and Schizophrenia (F-SADS), modeled after the Family History Research Diagnostic
Criteria.17 Parents were asked a series of
structured questions probing for the presence or absence of symptoms of psychiatric
disorders listed in the DSM-III-R.18
Interviewers assigned appropriate psychiatric diagnoses according to DSM-III-R decision rules. The F-SADS demonstrated excellent
interrater reliability for lifetime diagnoses in another study (Peter Lewinsohn,
PhD, unpublished data, August 1994), with  = 0.92 for unipolar depression
and = 0.93 for nonaffective disorders.
Of 551 interviewed youth/parent dyads, 79 were disqualified, usually
because the interviewed parent did not meet criteria for major depression
or dysthymia (n = 70). The remaining 472 youth were classified into 1 of 3
mutually exclusive depression severity groups based on adolescent information
gathered during the intake assessment.
A high-severity depression group (n = 116; 24.6%), called depressed
youth, consisted of adolescents with current DSM-III-R18 diagnoses of major depressive disorder (MDD) and/or
dysthymia. A separate randomized treatment trial was conducted with this sample
but is not reported herein.
A medium-severity depression group (n = 123; 26.1%) was called subsyndromal
youth,13 who reported some subdiagnostic levels
of depressive symptoms that were insufficient to meet full criteria for a DSM-III-R affective diagnosis, and/or had a Center for
Epidemiological Studies–Depression Scale (CES-D)19
score of greater than 24.9 These youth are
the focus of this report.
A low-severity depression group was identified (n = 233; 49.4%), called
resilient youth, with no significant depression symptoms and no history of
depressive disorder.20 These youth were not
subsequently followed up in this study.
We conducted independent, planned comparisons of baseline data, contrasting
the depressed and subsyndromal youth vs the resilient youth, and the depressed
vs the subsyndromal youth. Compared with the resilient youth, the depressed
and subsyndromal youth were significantly older (P
= .003), less likely to be enrolled in school (P
= .02), and more often female (P<.001, an expected
result given the greater likelihood of depression among female subjects in
community samples2). Compared with the subsyndromal
youth, the depressed youth were older (P = .003)
and had more special education classes per week (P
= .05). Compared with the resilient families, the parents of depressed and
subsyndromal youth had lower educational levels for the parent in the household
with the highest educational attainment level (P
= .05) and were less likely to be their biological parents (P = .042).
ASSESSMENTS
Unless otherwise noted, all parent and youth instruments were administered
at intake (baseline), after treatment, and at follow-up assessments nominally
planned for 12 and 24 months after the end of treatment (actual median completion
dates were 53 and 107 weeks posttreatment). Assessors had psychology master's
degrees and were trained in the use of the diagnostic instruments and received
weekly supervision from one of us (G.N.C.) for the duration of the study.
Assessors were unaware of the experimental condition of interviewed subjects.
Parent Assessment
The Achenbach Child Behavior Checklist (CBCL) consists of several social
competence items and 113 youth behavior and emotional problem items that parents
rate as being not true, sometimes or somewhat true, or very or often true.21, 22 The CBCL has good test-retest reliability,
and discriminates between clinic-referred and nonreferred children.23 Scores are reported for an extracted depression subscale
created to match DSM-III-R criteria for major depression
(the CBCL-D24) and the standard CBCL externalizing
and internalizing symptom subscales.
Adolescent Assessment
The SADS for School-Age Children, Epidemiological Version (K-SADS-E25) was administered to adolescents26
to obtain DSM-III-R diagnoses. Interviewers completed
a rigorous program in the use of the K-SADS-E and F-SADS and demonstrated
a minimum interrater reliability level27 of
= 0.80 in 2 practice interviews before conducting study assessments. A random
20% of interviews were rerated by a senior diagnostic interviewer. Interrater
reliability for the K-SADS-E was excellent for mood disorders ( = 0.87
for current diagnoses, = 1.00 for past diagnoses at baseline, and
= 0.90 for diagnoses made at follow-up assessments) and good for all other
nonaffective disorders ( = 0.74, = 0.67, and = 0.90,
respectively).
The CES-D19 is a self-report measure
of the frequency of 20 depressive symptoms during the past week. It has good
psychometric properties when used with adults28, 29
and adolescents.30, 31 Parents
and adolescents completed self-rated versions during separate administrations
of the CES-D.
Interviewers completed a 14-item "extracted" version of the Hamilton
Depression Rating Scale (HAM-D).32, 33
We extrapolated HAM-D item scores from corresponding K-SADS-E depression symptom
ratings. Reliability for the extracted HAM-D ranged from r = 0.87 to r = 0.94 in adults32; 
= .83 for adolescents.24
Interviewers rated severity of impairment using the Global Assessment
of Functioning scale (GAF). The GAF scores range from 1 to 90 and include
behavioral examples that serve as anchor points. Scores below 40 reflect major
impairment.
Youth in both conditions were free to continue or initiate use of any
other health services. We used computerized HMO data systems to obtain data
on extraexperimental health services, including, eg, inpatient and outpatient
services, prescriptions, and emergency department visits. Research staff interviewed
subjects monthly regarding health care services obtained from non-HMO sources.
PROCEDURES
Qualifying subsyndromal youth were randomized to conditions using a
blocked procedure to ensure that group assignments were never significantly
imbalanced. Group assignment was preprinted using a computer program and sealed
in sequentially numbered envelopes, which were opened in sequential order
by the project coordinator (M.P.). All subjects, regardless of their degree
of future participation, were considered part of the study from the point
of randomization (an intent-to-treat design). Of 123 qualifying and invited
youth, 29 declined to participate before randomization. Of the remaining youth,
45 were randomized to the experimental condition and 49 to the usual-care
control condition. The 94 randomized youth did not differ from the 29 declining
youth by parent age or sex, youth sex, or youth baseline GAF, HAM-D, or CBCL-D
scores. However, randomized youth had higher baseline CES-D scores (mean of
24.4 vs 19.2; P = .01) and were roughly a year younger
than the nonrandomized youth (mean age of 14.6 vs 15.5 years; P = .003).
Compared with the initial pool of potential cases (N = 3374 youth),
randomized subsyndromal youth were an average of 5 months older (P = .04) and were more likely to be female (60% of subjects [56/94]
vs 46% of the initial pool [1558/3375]; P = .01).
Experimental Intervention
The prevention program34 was an abbreviated
version of an adolescent depression treatment program35
that had been tested in a series of previous controlled outcome investigations.6, 36 The intervention consisted of 15 one-hour
sessions for groups of 6 to 10 adolescents, led by a therapist with a master's
degree who was trained in the approach. Sessions were conducted at the HMO
clinic offices. Adolescents were taught cognitive restructuring techniques37, 38 to identify and challenge irrational
unrealistic or overly negative thoughts, with a special focus on beliefs related
to having a depressed parent (eg, "I'm doomed to become depressed because
my father is depressed, and there's nothing I can do about it."). The prevention
program had been tested in a previous randomized trial9
in which it reduced the risk for future depressive episodes in youth with
subdiagnostic depressive symptoms. Youth attended an average of 9.5 treatment
sessions (median, 12; range, 0-15) and had completed homework assignments
at an average of 46% of the sessions they attended.
We conducted 3 separate parent informational meetings at the beginning,
middle, and end of each adolescent group. Parents were informed about the
general topics discussed and skills taught in the adolescent groups and the
rationale for their use. The parents' own depression was not directly discussed
in these parent meetings.
All intervention sessions were audiotaped, and 2 or 3 sessions were
randomly selected from each group and rated by a senior supervisor on a 10-item
fidelity scale39 to assess therapist adherence
to the study protocol. Mean therapist compliance was 95.9% (SD, 3.9%; range,
90.0%-100.0%) across 15 rated sessions, indicating excellent compliance.
Usual-Care Control Condition
All youth, whether randomized to receive the experimental cognitive-behavioral
treatment intervention or not, were permitted to initiate or continue any
nonstudy mental health or other health care services provided by the HMO and/or
outside health care providers (including antidepressant medication, of which
there was very little). This usual care in the comparison group constituted
the control condition. Information regarding the degree and type of usual-care
treatment was collected as described above, for examination as a potential
covariate of outcome.
Of the 94 randomized participants, 2 did not participate in any of the
follow-up interviews. Four, 9, and 16 participants did not participate in
the posttreatment and the 12- and 24-month diagnostic interviews, respectively.
We found few baseline or treatment interaction differences between participating
subjects and those unavailable for follow-up at any follow-up point on any
of the key demographic, major affective, or psychopathological measures. None
of the few differences were consistent across time, suggesting that there
was no systematic bias in dropout. As a further check on bias as a result
of attrition, primary outcome analyses were conducted that included only participants
who completed all 4 assessments. The pattern of results did not change when
the sample was limited in this way, lending further confidence that missing
data did not bias results.
ANALYSIS PLAN
Outcomes for continuous depression and functioning measures were examined
using random-effect regression analyses, modeling an unstructured covariance
matrix with slope and intercept as random effects.40, 41
We estimated linear and quadratic effects for our data, as this approach was
the model that best fit the data. The linear trend indicated the direction
and rate of change, whereas the quadratic trend indicated whether the rate
of change increased or decreased at some point during the observation period.
Significance was reported only for linear trends, as this is relevant for
hypothesis testing. Episodes of major depression were the primary outcome
and were examined during follow-up using survival analyses42
and using Pearson  2 analyses for cross-sectional comparisons
at particular assessment points. All significance tests were 2-tailed, with
an of .05 (P<.05).
RESULTS
CHARACTERISTICS OF THE EXPERIMENTAL GROUPS
The 2 experimental conditions did not differ at baseline on rates of
current and past psychiatric disorder or on any other key demographic, depression
severity, functioning, or other psychosocial measure (Table 1 and Table 2),
after correction for multiple comparisons.
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Table 1. Comparison of Experimental Conditions by Baseline Demographics,
Psychopathology, and Psychosocial Constructs*
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Table 2. Prevalence of Current and Past Psychiatric Disorder for Subsyndromal
Youth at the Baseline Assessment*
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DEPRESSION OUTCOMES
Three continuous depression measures (the CES-D, the CBCL-D, and the
HAM-D) were examined for intervention effects using random-effects regression
analysis. Linear and quadratic trends of each dependent variable were examined
across the entire study period for treatment x time (main program effect)
and for number of intervention sessions x time (experimental subjects
only). There were significant main program effects (group x time) favoring
the experimental condition for the CES-D (P = .005;
parameter estimate for the linear effect, -0.15; 95% confidence interval
[CI], -0.27 to -0.04) and the HAM-D (P
= .05; parameter estimate for the linear effect, -0.04; 95% CI, -0.08
to 0.00), but not the CBCL-D (Table 3).
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Table 3. Random Effects Regression Outcome Results*
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Simple analyses of covariance predicting each of the outcomes at each
time point, adjusted for baseline scores, indicated that CES-D main effects
were principally noted across baseline to posttreatment (P = .008) and posttreatment to first annual follow-up diagnostic interviews
(P = .006). The HAM-D scores were not significantly
different at any of the cross-sectional times.
Another significant main program effect favoring the experimental condition
(P = .04) was found for the total number of suicide
items summed from the depression section of the K-SADS-E interview.
Survival analysis of incident major depressive episodes (Figure 2 and Table 4)
indicated a significant advantage (P = .003) for
the experimental condition (9.3% cumulative major depression estimated incidence)
compared with the usual-care control condition (28.8%) at the 12-month follow-up.
Because the 12-month follow-up actually occurred a median of 14 months after
randomization, when adjusted for a true-year period these rates were actually
8.0% and 24.7%, respectively. The hazard ratio of depression at 12-month follow-up
was 5.64 (95% CI, 1.56-20.39) when adjusted for sex, age, CES-D score, and
depression history (the latter 2 were the criteria for inclusion in the subsyndromal
group).
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Figure 2. Cumulative proportion of youth
remaining nondepressed for experimental and control groups during the 2-year
follow-up. Treatment conditions are described in the "Procedures" subsection
of the "Subjects and Methods" section.
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Table 4. Survival Analyses for Affective and Nonaffective Episodes
During Follow-up*
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This significant preventive effect persisted but at a diminished level
at the 18- and 24-month follow-ups (Table
4), suggesting that the preventive effects of the experimental program
had faded over time.
Because many participants were censored at the 24-month follow-up, the
median survival time is difficult to interpret. To derive a more meaningful
comparison, we computed the mean time to onset for the youth in both groups
in whom an episode of mood disorder developed and who had available 24-month
data; we compared them by condition. The 9 experimental youth in whom a mood
diagnosis developed had a mean time to onset of 14.0 months (SD, 6.5 months)
and a median of 16.0 months. The 12 control youth in whom a mood diagnosis
developed had a mean time to onset of 6.3 months (SD, 5.8 months), with a
median of 4.0 months. This represented a significant delay in onset for the
experimental youth (t19, 2.90; P = .009).
Intervention participants reported an average of 33 fewer depressed
days in the year after intake than did control participants (11 vs 44 days).
Because so many participants did not have a depression episode in the year
after the baseline assessment, and therefore had 0 depressed days, between-group
differences were tested using Poisson regression. The Wald 2
for the difference was 760.62 (P<.001).
NONAFFECTIVE OUTCOMES
There were no significant effects for any of the nonaffective continuous
mental health outcome measures, such as the CBCL internalizing and externalizing
scales, and the sum of other, nonaffective diagnoses at each assessment point
(Table 3).
There were no significant differences in time to the development of
a new episode of a nonaffective disorder (Table 4). Although the cumulative estimated incidence of new, nonaffective
episodes was higher in the control group than the intervention group at 12
(15.9% vs 4.9%, respectively) and 24 months after treatment (24.3% vs 19.5%,
respectively), this difference was never statistically significant.
FUNCTIONING OUTCOMES
Results of random-effects regression analyses indicated significant
program effects for the GAF (P = .04), although the
GAF scores were not significantly different across conditions at any of the
specific follow-up assessment points.
DOSE-OUTCOME EFFECTS
We examined the relationship between dose (defined here as number of
intervention sessions) and each major outcome variable, restricting the sample
to just the experimental youth. We were unable to detect significant dose
effects for any measures.
COMMENT
We obtained significant preventive effects in this at-risk group of
offspring, across continuous and diagnostic depression outcome variables,
suicide symptoms, and functioning. The adjusted risk for development of depression
in the control group was more than 5 times that of the prevention group. Preventive
effects were clinically significant43; that
is, large enough to be considered meaningful in the real world. The 8.0% total
annual rate of depression in the experimental group approximated the 6.5%
naturalistic total annual incidence rate of depression44
in a comparably aged community sample,2 suggesting
that depression risk in the prevention group had been reduced to close to
the "community-normal" range.
These positive results replicate and extend the findings of an earlier
study by our group,9 in which prospective depressive
episodes were prevented in a community sample of at-risk youth with elevated
but subdiagnostic depression symptoms. This earlier sample of youth was not
identified through having a depressed parent, and the intervention was provided
in the schools rather than in an HMO. However, the prevention program was
essentially the same in both trials.
Despite these generally positive findings, there were several limitations
of this study. By the 2-year follow-up, the conditions were beginning to converge
on many measures, suggesting that preventive effects faded over time. Clearly,
the effects were more proximal than distal. What can be done to sustain the
protective effects of the intervention? Despite previous negative findings
regarding continuation treatment,6 periodic
boosters following acute intervention may be warranted to sustain preventive
effects.
Another limitation of this program was the multistage case-finding mechanism
used to identify potentially depressed parents; this method would be difficult
to duplicate in many settings. However, alternatives such as provider and
family referrals could be substituted.
Another limitation was that only a small number of subjects were enrolled
out of a large initial pool of potential subjects. The enrolled subjects were
older and more often female, raising generalization issues. The relatively
low randomization rates also raise concern about patient interest in preventive
services. However, low participation in a research study (with its associated
assessment burden) is not necessarily equivalent to lack of interest in prevention.
Another issue relates to the very heart of outreach and prevention.
This study systematically recruited families that were not actively seeking
care for the target youth from the HMO. This is a different way of doing business
for a large health care system, although well-known exceptions include outreach
for vaccinations, well-infant visits, and mammograms. However, outreach and
prevention of this type may be particularly fruitful for health care systems
with a known, enrolled membership. If proactive mental health care can yield
more functional and less distressed members, and if these services cost the
same or less than the traditional approach, then health care systems are ahead
financially and in terms of member satisfaction.
However, there is also a cautionary side to outreach. Well-meaning but
poorly implemented outreach programs risk being perceived by families as overly
intrusive or risk inviting families to participate in unwanted services. Mindful
of this, we were cautious in our contacts with parents and did not presume
that they or their offspring were depressed. Our telephone scripts acknowledged
in advance that many people receive so-called antidepressant medication for
many other legitimate uses (eg, insomnia, smoking cessation, neuralgia).
Has this preventive intervention been sufficiently tested to warrant
adoption in nonresearch settings? We believe that some additional questions
remain to be answered. Another important hurdle would be replication of our
findings by an independent group, preferably with a more diverse sample than
ours.45
Ideally, we would like to know something about the dissemination of
this intervention in completely naturalistic settings. How important is fidelity
to the intervention? Must the program be delivered essentially as written
to achieve similar results?39 These and related
questions could be answered in early naturalistic dissemination efforts, rather
than necessitating another randomized trial.
CONCLUSIONS
Depression risk can be substantially lessened with a brief group program,
which in this study's high-risk sample reduced depression symptoms and episode
rates to the community-normal range. Future analyses will examine the impact
of this program on use of health care resources and costs.
AUTHOR INFORMATION
Accepted for publication May 2, 2001.
This study was supported in part by grant 1R01-MH51318-01A1 from the
National Institute of Mental Health, Rockville, Md (Dr Clarke).
The authors thank Kimberly Hoagwood, PhD, Lauren Haworth, Steve Berg-Smith,
Laura Fenn, Jen Coury, Peter Lewinsohn, PhD, and Lynn DeBar, PhD, for their
assistance on this project.
From the Kaiser Permanente Center for Health Research, Portland, Ore
(Drs Clarke, Hornbrook, Lynch, Gale, and O'Connor and Mr Polen); the Judge
Baker Children's Center, Children's Hospital Boston, Boston, Mass (Dr Beardslee);
and the Oregon Research Institute, Eugene, Ore (Mr Seeley).
Corresponding author and reprints: Gregory N. Clarke, PhD, Kaiser
Permanente Center for Health Research, 3800 N Interstate Ave, Portland OR
97227-1098 (e-mail: greg.clarke{at}kp.org).
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