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Web-Based Intervention Plays Preventive Role for Teen Depression

By Lindsey Getz

Depression is on the rise—most notably in teens and young adults. One in eight teenagers experienced at least one depressive episode in 2015, according to the National Institute of Mental Health. However, despite the critical need, a prevention-based solution to depression is still lacking. The treatment modality has remained reactive. But that may be changing. As new research is pointing toward web-based solutions as a possible answer, there seems to be an increased opportunity for providers to catch and treat depression early on.

One program in particular has been closely studied and is showing promise. Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training (CATCH-IT) was developed by a team at the University of Illinois (UI) in Chicago, led by Benjamin Van Voorhees, MD, MPH, a professor and head of pediatrics at the UI College of Medicine.

This self-guided online depression prevention program was recently evaluated and compared in a new study published in JAMA Network Open. In it, the multicenter, randomized clinical trial compared the CATCH-IT intervention with a control intervention.

More than 350 adolescents aged 13 to 18 from a mix of rural and urban areas were enrolled in the trial. Participants had either a history of depression or depressive symptoms and were followed for two years with depressive episodes tracked. While depressive symptoms were reduced across all participants, they found no difference between groups, except for among higher-risk adolescents whose depressive symptoms scored high on baseline screening. Among this group, individuals participating in the CATCH-IT intervention demonstrated greater benefit, achieving as much as 80% risk reduction for experiencing a depressive episode.

“This study tells us that the online intervention works best for teens who are experiencing worse symptoms,” says Van Voorhees, the principal investigator. “We hypothesized that there would be a benefit across all participants, but it is perhaps even more telling to see such a significant risk reduction among a smaller group of high-risk adolescents.”

A Proactive Approach
Van Voorhees adds that it’s important to move depression care away from reactive treatments and toward widespread prevention.

“We need scalable interventions such as CATCH-IT to prevent onset of common mental disorders in adolescence,” he says. “CATCH-IT, provided through primary care or school settings, can enable adolescents to learn coping skills that may prevent onset of mental disorders while parents strengthen their parenting skills in parallel.”

This creates an opportunity for all concerned to become increasingly effective at working with at-risk young people.

“Studies show that even evidence-based depression treatments are often only 50% effective, and many adolescents who receive such treatments relapse within five years of intervention,” says Tracy Gladstone, PhD, coprincipal investigator and associate director and senior research scientist at the Wellesley Centers for Women at Wellesley College, emphasizing the importance of being proactive vs. reactive. “Moreover, adolescents who have struggled with depression for a long time are less likely to benefit from these treatments. In contrast, recent research suggests that depression prevention programs can have long-term benefits, including reduced onset of depressive episodes and fewer symptoms of depression. In addition, prevention programs are less disruptive to individuals, families, and communities.”

CATCH-IT is designed to teach coping skills to teens and young adults. The intervention includes 20 modules, 15 of which are for adolescents (with the remainder being for their parents). The information in the modules is based primarily on previously validated educational materials on coping with depression and behavioral interpersonal psychotherapy methods.

The web-based modules do not identify participants for treatment. Instead, the modules serve to prevent the onset of major depressive disorder (MDD) through interactive prevention rooted in cognitive behavioral therapy, behavioral activation, and interpersonal psychotherapy.

“Trained clinical interviewers assessed all adolescents to determine their eligibility before enrollment and adolescents were excluded from the study for various reasons, including if they had a current diagnosis of MDD or dysthymia, or were receiving current therapy or taking antidepressants for depressions,” Gladstone says. “Individuals requiring treatment for elevated depressive symptoms were referred to their pediatrician to find appropriate intervention treatment. Since the aim of CATCH-IT is to prevent depression, depressed adolescents were not enrolled in this study.”

The Value of a Web-Based Model
The web-based model offers an opportunity to meet young people where they’re at, says Mary E. Johnson, MA, MHA, director of strategy and planning at the department of pediatrics at UI Health. Johnson was a clinical assessor as part of the study but also had experience with CATCH-IT when working at a nonprofit that served as a partner for Chicago Urban Resiliency Building, or CURB, the urban adaptation of CATCH-IT, which is geared toward Latino and African American adolescents.

“The adolescent populations like to do as much of their interactions as possible via technology, so a web-based intervention is very generationally sensitive,” Johnson says. “I also think that the availability of a web-based intervention plays a role in decreasing the stigma often associated with mental illness. If participants feel that their mental illness is common enough to be addressed in a web-based platform, it creates a sense that they’re not alone—that there are enough other people out there that this platform exists.”

Of course, it’s important to note that this intervention is not solely web-based; it also includes face-to-face treatments.

“The available literature suggests that internet-based prevention programs function best when paired with real-life engagement strategies,” Gladstone says. “In addition to the interactive web-based modules, the CATCH-IT intervention includes in-person motivational interviews with primary care providers. During these motivational interviews, youths discussed their personal goals and the primary care provider helped these young people develop a personal motivation for participating in the web-based intervention. Three brief face-to-face motivational interviews were completed with the primary care provider throughout the year. There are also several motivational and safety assessment phone calls completed by the social worker or master’s level counselor.”

A Successful Combination
While some providers are always reluctant about new technologies and the role they’ll play, the researchers stress that this modality is so successful because it works in conjunction with a provider’s care. For that reason, they contend that this new technology should be welcomed.

“The idea that technology could be intrusive in some way to patient care is not a brand-new notion,” Johnson says. “There will always be providers that have concerns about something new and unfamiliar to them. However, it’s important to note that it’s the combination of using face-to-face time with the web-based intervention that makes it so successful. These modules can be accessed on the individual’s own time and are a complement to what is already taking place with the provider. I truly believe this is a higher level of comprehensive care than we’ve had access to in the past. This is the future of mental health. We continue to move in the direction of web-based care that will supplement face time—not replace it.”

In fact, Gladstone says that a program such as CATCH-IT will help support social workers and other providers, such as primary care physicians, to do more.

“Rather than replacing the work of social workers or primary care providers, CATCH-IT aims to supplement their work by identifying adolescents who require support managing sub-syndromal symptoms of depression,” Gladstone says. “As a prevention program, CATCH-IT serves adolescents who have most often not yet started to work with a mental health professional because their symptoms are not severe enough to impact daily functioning. Therefore, the web-based modules are not replacing any provider work, but are instead supporting teens that have yet to reach out for professional help.”

“There is an enormous unmet demand for assistance in preventing onset of mental disorders,” Van Voorhees says. “We see this model as supplementing existent systems of care and ideally expanding what social workers can achieve in the prevention area. In the future, it is likely most primary care practices will have an embedded social worker leading a range of group, individual, and technology-based mental health interventions.”

Looking Ahead
As we move into a future in which web-based solutions will surely continue to rise, the researchers involved in the evaluation of CATCH-IT stress the importance of remaining on the path of evidence-based approaches, even in the advent of new technology.

“Our focus has been on carefully developing an evidence-based intervention and then taking it through a series of clinical trials to evaluate feasibility, efficacy, and eventually, effectiveness,” Van Voorhees says. “We will shortly commence a phase 4 comparative effectiveness trial. We believe that in the clinical domain, we should aim to employ evidence-based and carefully evaluated interventions. Like the earlier ‘self-help’ book literature, there is a proliferation of applications that individuals can use, but many have not been evaluated, but of course may be quite helpful.”

Johnson says that she’d like to see social work schools begin to implement more web-based programs such as CATCH-IT into their curricula so that social work students can begin to study and understand the potential uses and benefits.

“Knowing that this is the future, I think it’s important that future social workers are studying more about web-based interventions and the different modalities that are out there—as well as how they can be integrated into our practice as social workers,” she says. “This is not something that’s going away and should be something that we’re learning about now.”

— Lindsey Getz is a Royersford, PA-based freelance writer.