ABSTRACT:
The purpose of this writing is to review on both qualitative and quantitative published research which will analyse the effectiveness of cognitive behavioural therapy as a form of intervention method for decreasing the likelihood of depression and suicidality amongst adolescents. (Refer to appendix one for a summary of these articles). The literature review is displayed in a thematically presented style the areas in which the positive effects of the Cognitive Behavioural Therapy are agreed. Consideration will also be given to the conflicting factors contrasting thus methods effectiveness, for instance the setting it is applied within and depression as well as suicidal factors and other mental health factors which could possibly have an influence on individuals’ cognitive ability to actively participate in cognitive-behavioural therapy treatment.
INTRODUCTION:
Within the Health and Social care context, in Great Britain cognitive behavioural therapy (CBT) is a frequently used method of intervention within practice. This method is used holistically amongst all client groups with the aim of making sense of and modifying the behaviour/s displayed by these ‘worked with’ individuals (Turner and Thomlison, 2011). Choosing to explore on CBT as a method of minimising depression and attempted suicide often displayed by youths is the main focus of the following writing (Hess, 2009). (See figure one). This method is a process which identifies displayed behaviours by individuals, which in this case are usually negative behaviours. Also it involves working alongside individuals in reaching out valuable reasons and justifications for the occurring or carried out behaviour.
It can be argued that this approach’s main focus is to identify patterns in behaviour/s providing that practitioners are supportive of this. CBT method have various way of proposing in order to get individuals thinking about their negative behaviours and aiming to ultimately modify their thinking on the concerned topic whilst being aware of the impact these behaviours have on other individuals and their surroundings (Hofmann, Et.al 2006).
In the context of working with children, young people and families, in the aim of improving service development and delivery for workers, this method is going to be explored within the area of core cognitive, affective, and behavioural techniques that can be used in suicidal ideation and behaviour in depressed adolescents. Also focusing on underlying factors of this behaviour which can involve possible exposure to significant negative life events, such as history of abuse or neglect, adverse parenting resulting from parental psychopathology and peer victimisation and bullying. These are believed to have been the factors placing youth at risk for a depressive episode (Anthony, et.al 2011). Specifically focusing more at adolescents aged 12-19 years. Within Great Britain Suicidal behaviour and depression is currently the third leading cause of death in adolescents and young adults. Suicidal behaviour precisely is a serious health problem, both suicidal and depression by those within this age group is at an all-time high compared with UK statistics from twenty years ago (Barry and McNeill, 2009).
These facts being acknowledged means various countries will explore articles which would be aimed in tackling depression and suicidal behaviour of various natures out with the use of CBT (Refer to figure two). In sum, this review aims at providing a critique of these papers and as a result, the effectiveness of the method shall be measure whilst accounting for the need of such intervention to be successfully implemented in practice and adherence being given to the policy as well as governance context in which it lies.
These outlined criteria enabled in forming the basis of this literature review leading to the following question being formulated to both guide and evaluate the qualitative and quantitative data to be critiqued:
“What reliable evidence is in place to explore the effectiveness of Cognitive -behavioural therapy as a method of depression and attempted suicide among young people?”
BACKGROUND:
FORTY YEARS AGO, the existence of depression and suicidality amongst young people was still a topic of debate. Then epidemiological research has revealed that depression and suicidality are serious and relatively common issues in adolescents since that time. With an approximate of one out of every four young people experiencing a clinically significant mood episode as well as suicidal attempts by the end of puberty (Lewingsohn, et. al 1993). According to Rohde, et.al (1994) Onset of early depression symptoms substantially have major impacts on youths’ current functioning in terms of social and education roles, this as a result may possibly impact on future adult functioning. Additionally, youth depression alone is known to be a potent risk factor for suicide, this being the third leading death for every young person, including school children, adolescents, and young adults (National Institute of Mental Health, 1999). Prior to this growing understanding of youth depression and suicidality the systems put effort in developing effective interventions. In 2002, Brent et. al reviewed 15 randomized controlled trials (RCTs) of psychosocial interventions for depressed children and adolescent. An examination of such a small body of work revealed that cognitive behavioural therapy being the research treatment of choice, among 13 of the 15 RCTs testing its effects. Overall, results of all studies showing CBT being promising as a method of intervention for depression and suicidality amongst youths and its usefulness within practice.
METHODOLOGY:
From the initial search for information based on the stated method and population group, it was necessary to undertake an ‘informal browse’ of accessible literature. The information gathered was done by using diverse approaches to relevant literature which included journals, various books focused upon ‘cognitive behavioural therapy’ and searching a broad mass of information found within Google Scholar aided in enhancing knowledge into the different styles of applying this method of intervention.
Also this search allowed for a gained insight into the settings in which it is most commonly applied. In Addition, journal articles and practice and policy guidelines were accessed alongside this element of the initial search. These resources evidenced the common terminology and intricate applications of the intervention whilst also uncovering the excessive quantity of information that is published on this topic area. (See figure one)
An electronic database known as SCOPUS was searched for the selected articles as it was more of a specific database, which also allowed result of journal articles within this allied social care profession and stated area of research. The database was used by combining the AND, or OR limiting the search and phrase search using many functions available, this is also referred to as Boolean operators (Aveyard, 2014). The functions have enabled in broadening the search and helped in narrowing down the information. Narrowing down the mass results found on this system was demonstrated by using ‘Key search terms’ as followed: Young people, depression, suicidality and cognitive behavioural therapy. Narrowing and broadening research was due to getting a good authority of the material, hence gaining enough evidence based information.
A decision was made on articles being searched to have relevance to the current approach to youth with depression and attempted suicide, for this purpose, only papers from within the last ten years were included in the search criteria.
In the search fields by typing (“Young people”) AND (“Depression”) AND (“Suicidality”) AND Cognitive behavioural therapy, a total of 120 results were found. Then narrowed them down and only focused at the first fifteen, then found eight relevant to my chosen topic. An inclusion and exclusion criteria was applied in this study to identify literature addressing the chosen topic (Aveyard, 2014). (Refer to Figure Two for inclusion and exclusion). Papers from worldwide/international authors/sources were included in the research to identify differences in the approach from different countries. (See figure two).
Figure One – Initial Browse
Figure Two – Literature Search Strategy
| Search terms (include Boolean operators and truncation) | Cognitive Behavioural Therapy AND Depression AND Suicidal.
Cognitive Behavioural Therapy NOT Behaviour Therapy. CBT AND Adolescents. Cognitive Behavioural Therapy, Effective, Minimising depression and suicidal UK. CBT. Cognitive Behavioural Therapy |
| Databases searched | SCOPUS |
| Part of journals searched | Cognitive Behavioural Therapy, CBT, Young People, Youth, Depression, Suicidal, Effective, Positive, Minimising, Tackling, Reducing. |
| Years of search | 2000 – 2013 |
| Language | English – To fully assist me to critically review content and for clear understanding of what is written |
| Types of studies to be included | Qualitative and Quantitative studies |
| Inclusion criteria | UK, USA, AUS, International journals
Those published within the last ten years – to compare results or changes Related articles to general studies about the topic area – In order to limit search further to help find relevant reviews |
| Exclusion criteria | Journals older than 20 years
Generic behaviour therapy methods of intervention
|
Following the ‘CASP’ assessment tool to facilitate my understanding in critically analysing the six journals of both, qualitative and quantitative methods (see appendix one) selected for this review and the series of steps it outlines was used. “CASP implements a narrow model of qualitative inquiry” – (Denzin and Lincoln, 2011). A use of qualitative and quantitative research was sought to gain insight into thoughts, feelings and experiences (Siviter, 2008). According to Denzil and Lincoln (2011) initially the CASP tool collaborated for the use of those less familiar with the concept and process of quantitative research. Arguably, the tool facilitates review as it enabled me to break all SIX articles into sections which offered me the opportunity to closely examine them and as a result it has enabled me to absorb the literature that could have been missed. Compromising of ten steps designed, this appraisal tool allows selected research or evidence to be found, appraised then acted upon or concluded (Wooliams and Appleton, 2009). These steps/questions are formulated checklist which is followed within this review to measure validity, relevance and the results being presented appropriately. (Refer to appendix one for findings).
Selected studies appear to have described the extent and nature of youth depression and suicidality also identifying other family variables correlates with this. These studies managed to cover questions which have been of interest to explore on, by reviewing them carefully will help enhance my knowledge. Moreover, the chosen topic can be viewed from different perceptive due to studies’ different aims and objectives. All studies were published in appropriate journals which aimed the issues at professionals needing awareness of the effectiveness or depression and suicidality amongst young people. A similarity between all selected articles is that their aim is to find out the effectiveness of CBT in decreasing youth suicidal ideation and suicidal attempts.
Major depressive behaviour with a point prevalence of 5% in adolescents, is associated with significant morbidity and family burden as well as suicidal behaviour and completed suicide (Angold, et.al 1998). Within the study of TADS, through a randomised, controlled trial was found that CBT was less effective alone than combination therapy or fluoxetine therapy alone and was not significantly more effective than placebo at week 12. Whereas the secondary analyses at 12 weeks shows superiority for combined treatment with respect to speed of response, quality of life and functioning, remission, and overall safety (Vitiello, et.al 2006). On the other hand, Stanley, et. al (2009) notes that despite the public health problem, there are no empirically supported individual psychotherapies for adolescents shown effective in reducing suicidal behaviour through randomised control trials. This may imply that importing empirically supported treatments for adolescents with depression to suicidal adolescents may not significantly be appropriate. Possibly due to the trials in which efficacy was established which excluded suicidal adolescents, though author did not clarify the reason for exclusion of those particular adolescents. This study consists of 6 “acute” group sessions organised around specific themes. Results show no differential treatment effect on depression, suicidal ideation, or global outcome. Including a family-based treatment which associates with fewer suicide attempts but not greater reductions in suicidal attempts but not greater reductions in suicidal ideation, hopelessness, or depression. However, results appear to be difficult to interpret as an approximate of 50% of the subjects receiving multisystem therapy required emergency hospitalisation, and thus, the lower suicide attempt rate, as a result this makes the overall result inconclusive. According to Keyvanara, et.al (2010) as being one of the world’s ten leading causes of death, suicidal and depression have significant impacts on adolescents and their families’ wellbeing. 10 to 40 times, suicidal attempts are more prevalent than committed (completed) suicide. Alavi, et. al (2013) notes that depressive disorders have been reported in up to 95 percent of the adolescents who attempt suicides. In his study, aiming to only compare the mean scores of the used instruments shows that from all 30 patients (15 patients in each group), with female being dominant in each group the mean age and SSI, BHI, and DBI score of the patients in the two groups before the intervention had no differences according to his findings. Despite the fact the purpose of this review was not to review gender or race differences, Alavi, et. al (2013) study shows there were no significant differences between the two groups regarding age and sex distribution. Meaning that the two groups were similar and comparable and the observed differences after the intervention can be attributed to the designed intervention. This study as well as Stanley, et. al (2009) found that CBT was effective in decreasing hopelessness and depression scores of suicidal in adolescent.
In regards to race/ethnicity differences, Weersing et. al (2006) on the other hand acknowledges the value in additional research testing the effectiveness of CBT for depressed adolescents who are members of ethnic minority groups. For instance, in his STAR sample, African-American teens had a slower rate of improvement than Caucasian youths. In comparison to Weersing and Weisz sample in 2002 showed that ethnic minority youths also had worse outcomes than Caucasian youths, despite the fact trajectories for both groups still closely resembled natural remission. However, author failed to provide further evidence or explanation as to why this may be the case. It appears as though it was due to the fact minority group members attended significantly fewer therapy sessions, raising the possibility that differences in therapy attrition might relate to the ethnic difference in outcome. Nonetheless, CBT appears to have produced positive effects, additionally there is benefit in future transportability studies which considers a broader range therapist, system and outcome variables than was possible in the current investigation. Weersing, et. al (2006) notes that service system issues could have an effect on CBT effectiveness, occurring when intervention is transported to and tested in a more general outpatient setting. For instance, the Centre provided therapy free of charge to adolescents as part of a state-funded mental health initiative. Resulting in therapists not being unduly burdened by insurance demands or paperwork, including issues of therapist “productivity” being less pronounced than in other service systems such as mental health care. However, study’s overall results appear promising as STAR youth participants have reported depression symptoms at intake comparable to youths in the Brent clinical trial and in the adolescent depression literature at large. STAR youths have been able to achieve significant symptom change over the course of treatment, improving at a rate of .62 BDI points per week. (See appendix one).
On the other hand, Clabby (2006) in his study finds that CBT is effective when delivered by physicians with significant instructions, although a great many physicians do not have the time or interest to pursue such training. He adds, CBT techniques can be unpacked and made clear and accessible for busy physicians, and that is his article main objectives. (See appendix two for case report presented to illustrate the application of CBT in primary care). He notes that this helps workers as many may get discourages due to the fact CBT techniques can appear overly abstract, overwhelming in number, and difficult in a succession of visits. Him, as well as the other authors concludes that CBT works to relieve adolescents’ depression and suicidality. To be precisely his CBT techniques description appears to have been drawn from the tradition of relieving the mentioned issues amongst youth. Additionally, based upon their own style, physicians are able to select 1 or more of these approaches from the menu. The 7 different procedures can be offered singly or in various combinations during 1 or several patients’ visits. Also, Clabby (2006) notes that those (workers) who can stretch themselves to include 1 or more of these brief CBT procedures could become strong catalysts for positive emotional health for their patients.
Aiming to focus upon answering the outline research question it is evident that the overall agreed consensus from this papers and definition of the use of cognitive behavioural therapy with adolescents is a method that, when appropriately used, is a “highly effective intervention for reducing the likelihood of depression and suicidality” (Carroll, et al. 2009).
In targeting and reducing “depression and suicidal thoughts and behaviour” amongst adolescents Spirito et al (2011) identified CBT to be one successful intervention due to the fact its focus is on the behaviours towards often these distressing thoughts and behaviours. Evidence shows that such symptoms require psychological treatment, while there is also some debate over the best means of targeting these distressing thoughts and behaviours. The paper published by the TADS (2008) whose main focus was on intervention with those young people with major depression disorder. The objective of this paper was to report effectiveness outcomes across thirty-six weeks of randomised treatment. Thus paper implies that although cognitive behaviour therapy alone was less effective than combination therapy or fluoxetine therapy and was not significantly more effective than placebo, results also reveals that amongst adolescents with moderate to severe depression, treatment with fluoxetine alone or in combination with CBT accelerates the response. Addition of CBT to medication enhances the safety of medication. Considering benefits as well as harms, combined treatment appears superior to either monotherapy as treatment for major depression in adolescents (the TADS, 2008). Following the 1 year follow up with TADS (2008), sixty-six percent of the eligible subjects participated in at least stage IV assessment. The benefits seen at the end of active treatment (week 36) persisted during follow up on all measures of depression and suicidality. In contrast to earlier reports on short-term treatments, in which worsening after treatment is the rule, the longer treatment in the TADS was associated with persistent benefits over one year of naturalistic follow-up (TADS, 2009). Focusing upon adolescents with depressive disorders and a history of suicidal behaviour, they are particularly high risk group for repeated and completed suicide, for this purpose the CBT is adopted within the rehabilitation approach and as part of the cognitive method which provides social and academic learning on the matter at hand. Shock statics as well as statistical information is often regarded as a tool needed to proceed in changing particular thoughts or behaviours. Educational programs alone are believed to produce knowledge and attitude change among young people that are suffering with depression disorder and suicidal behaviour for the first time as well as those with past history (Stanley et. Al 2009).
The process in which cognitive-behavioural therapy is delivered to young people in diverse, one reason being due to it often being conflicted in its delivery setting (Townsent, et al. 2010). Although the effectiveness of CBT is measured within the facilities explored in the said journal papers, they may need to be combined in order to draw an overall statistic or proven ethos which will provide an overall measurement with adolescents with depression and suicidal ideations across the board. Both, Alavi, et al (2013) and Stanley, et al (2009) summarise within the context of their review that the delivery of CBT within a group setting with those in clinical trials/ specialty clinic has seen as result of decreased suicidal attempts/ideas as the past. This minimised number supports this claim whilst accounting for the positive influence peers have in the process of this method delivery. However, explored in the writing of Weersing, et.al (2006) they have discussed the idea that as a method of intervention, cognitive behavioural therapy is less effective whilst being delivered in a clinical setting. The writing on the subject matter details how peer groups and influences can negatively have an impact on suicidal thoughts and behaviour whilst such a method of behavioural modification being implemented in a group. This being due to the fact individuals who have received the best result from this intervention can be influenced more superiorly by those who they feel to relate best with, in this case being others with depressive disorders and a history of suicidal behaviour. There is often a label or stigma and discrimination young people experience which they live up to within their community or family members, and they do not fit well with the image they feel to have (Carrington and Pereira, 2011). For this purpose, CBT effectiveness being measured effectively is based on limited results, as few can be witnessed and tested before released from an institution/clinical setting. An evident theme across the selected journal articles is that CBT aids the uncovering of often misinterpreted reasons for suicidal attempts and depressive disorders prior to such cognitive treatment (Alavi, et.al 2013). Spirito, et.al (2011) supports this claim believing that one of the most highly regarded characteristics of youth suicidal thoughts or engagement in suicidal behaviours and depressive disorders is due to “reciprocity among maladaptive cognition, behaviour, and affective responses to stressors” (p.2). These also can result from a significant genetic predisposition towards psychopathology and/or exposure to significant negative life events, such as a history of abuse or neglect, adverse parenting which results from parental psychology and peer victimisation and bullying (King and Merchant, 2008). Cognitive behavioural therapy is regarded as a key element which identifies the underlying causes and contributing factors of adolescents’ depression and suicidality. With its main focus being on the attitudes and beliefs an individual has in which contributes to their behaviours it is therefore a method not looking solely at the prolific encounter, which would be suicidal thoughts and depressive behaviour. A recent study of Hamill-Skoch, et.al (2012) emphasis that the use of this method of intervention with adolescents in the treatment of resistant depression (TRD) and those with history of depression and suicidal attempts is purposely used to identify where their attitudes lie within the nature of other and related behaviour which stem from primary negative learning. As previously mentioned, factors such as family stressors, parental psychopathology, and ongoing stressful life event have significant impact on a child’s behaviour. It is also known that a history of childhood trauma is linked to an increased risk of chronic depression, and several studies also support this as they have found that traumatic events early in life can possibly lead to worse treatment outcomes. Hamill-Skoch, et.al (2012) again backs this notion in agreeing that factors such as increased hopelessness and history of abuse is associated with poorer response to cognitive behavioural therapy or combined treatment among adolescents with TRD. Clabby (2006) supports this notion in agreeing that CBT is of upmost effect at addressing where their beliefs towards their attitude and behaviour have emerged from. Often this would require that practitioners adopt the right skills in order to deliver tasks/work focusing on sensitive matters often being family issues and past victimisation of abuse. As part of the rehabilitation process, social workers would deliver CBT and are required to have the appropriate skills with confidence to be able to successfully deliver such censored treatment in a professionally manner, also having accurate knowledge of social and complex issues which are affecting their clients or service users (Corcoran and Walsh, 2010).Having this knowledge requires workers to be mindful that these adolescents, despite their dysfunctional automatic thought or behaviour are still considered as clients/service users, therefore should work alongside them. The ability to acknowledge this implication during the delivery of CBT in an appropriate environment means that social workers are adhering ultimately to one of the known ‘Scottish Social Services Council (SSSC) Codes of Practice’. Code 4.3 of these codes of practice requires workers to take necessary steps where required to help minimise the risks of service users from doing actual or potential harm to themselves or others (Scottish Social Services Council, 2003). During the process of CBT delivery, the code’s purpose is to accurately summarise which is regarded as an essential step towards protecting individuals from any form of abuse. In sum, within selected papers the steps appropriately explore the underlying causes or factors where adolescents’ attitude and behaviour emerged from, also stemming from stigmatizing. This ties in with the notion ‘Suicidal crisis amongst adolescents can occur from environmental factors including problematic peer or romantic relationships; physical, verbal, or sexual abuse; dysfunctional family beliefs; high family expectations and low reinforcement; or poor school performance’ in relation to suicide prevention and feasibility to prevent the recurrence of suicidal behaviour in adolescents with recent attempted suicide (Stanley, et.al 2009). In regards to the papers, CBT is ultimately portrayed its effectiveness in both identifying issues which leads to depressive behaviour and suicidal ideation, and adapts them prior to further attempts/features of depression being carried out. Furthermore, only with given thought to the initial reasons for youths’ issues; including environmental factors, this would allow the factors and initial thoughts towards the study groups’ actions to be taken on board, worked towards/with them and altered (Weersing, et.al 2006; Clabby,2006). It appears that CBT can be effective as long as contributing factors are acknowledged and considered by workers. Neither of the studies explores ‘cognitive theories’, this shows a potential reader that consideration is not given to the causes of depressive behaviour. Thus making the content of the article itself a valid source of qualitative research which accounts for a result of the nature of adolescent depression alone and also the thoughts of the young people and where they stem from in the context of dysfunctional cognitive patterns (i.e., “I made a mistake and therefore I am a failure”), as well as maladaptive behavioural patterns (i.e., withdrawal, social isolation).
Adjusting and modifying such behaviour and thinking is where CBT deliverance would display positive methods which make changes to depressive behaviour and suicidal ideation by young people measurably effective. Referring to figure one found in the initial search; CBT is deemed an effective measure in the context of social justice, also its implications have influenced policy in ‘promoting a just society by challenging injustice and valuing diversity’ within the UK (Toowoomba Catholic Education, 2006). TADS (2008) within his published literature emphasises on the implications which influence policy and practice regarding youth adequate behavioural health care. Whilst focusing on CBT being delivered within a 13 academic and community site, which is a diverse, range settings. Concluding that as a method of intervention in adolescent depression and suicidality, CBT is a tested and acknowledged as an effective tool in tackling/minimising the likelihood of ideation leading to suicidal attempt and depressive behaviour. As a result of this the Government have acknowledge CBT to be one of the effective tools hence forming the key principles outlining new legislation related to the restorative justice process (Clark, 2011). Social worker’ practice have since begun to adopt this, influencing much of the rehabilitation work delivered by them (social workers).
Contrasting with this idea is the way in which CBT has influenced practice out within the United Kingdom. Alavi, et.al (2013) conducts research in Iran and the effectiveness of this method in this part of the Islamic Society using youths with suicidal ideation and depression in a clinical trial as his study population. The main difference which was found between the ways in which thus method has significantly impacted politically on professional practice from both countries is the perception in which the Government takes from this intervention, for this purpose differing in both countries delivery of restorative measures for reducing suicidal ideation in the depressed adolescents with suicidal attempts. The Iran professionals merely use CBT with the youth of their societies to guide person centred work within professional settings. It appears as though the method does not have much influence on Iran’s society nor system to adapt current legislation.
Within the reviewed papers, the contributing factors regarding an adolescent’ state of mind from a mental health clinical perceptive is found to be given little attention. According to Mitenberger (2011) it is a complex area of practice to be able to modify negative behaviours in which unpredicted matters and factors may be uncovered. From a personal understand, by simply focusing at learned behaviours may possibly in return be enough to understand where particular traits and attitude emerge from as a worker (Hardcastle, et.al 2011). Nonetheless, mental health issues for instance, could be a lot more compounded in the fact that medically from illness (often undiagnosed) can affect ones’ (young person that is) ability to cognitively process the negativity and deviance for the actions. As a result of this they are unable to understand the provisions of CBT as well as behavioural modification which make intervention more likely to be ineffective or inappropriate for use in some cases. Based on the ideas of Clabby (2006) and Weersing, et.al (2006) the need for a regular specialised training to be in place before implementing CBT on patients (young people in this case) is vital. Within both papers, it is emphasised that as primary givers you are required to overcome a paucity of efficient screening tools and systems. This also is proven by research that cognitive behavioural therapy to have been effective when delivered by physicians who have received significant instructions. Hence Weersing, et.al (2006) ‘Symptom trajectory and predictors of treatment response’ (STAR) therapists to have been provided with training in cognitive behavioural therapy at the beginning of employment in the STAR centre. Additionally, they were also provided with two days of background in cognitive theory and two additional days of technique-focused training and role-play. Reviewing this particular paper revealed that CBT techniques can be unpacked and made clear and accessible for busy physicians, and that is the main objective of this article. All the articles’ content for the purpose of this literature review failed to explore mental health in any depth as being a conflicting factor in the process system of delivering cognitive behavioural therapy. Mental health problems are known to be associated with further co-occurring suicidality and depressive disorders (Mitchell, et. al (2011), therefore an acknowledgement of mental health’s influence and impact upon thus process is of major importance.
According to Liabo and Richardson (2007) CBT being implemented as a method of intervention in order to modify depressive behaviour and suicidal ideation, as well as decrease the risk of future suicidal attempts and depressive disorders amongst adolescents within the health and social care professions is a complex approach to person centred practice. The question in which this research is guided was a clear focus on the need to review the effectiveness of cognitive behavioural therapy intervention and to critically appraise and review the findings which the analysed articled have suggested. With the use of appropriate ‘types’ of study reviewed, a display of both consensuses of themes and indications for practice has been displayed acutely. From the appropriate relevant studies quality in their writing was displayed from professional statistics many findings suggested in which evaluate the effectiveness of CBT, also the appropriate referencing was displayed throughout. In the context of the feasibility and acceptability of implementing this cognitive behavioural therapy for suicidal prevention (CBT -SP) Stanley, et.al (2009) found that as a developed element this is believed to have been an appropriate intervention for adolescents at risk for repeated suicide attempts, therefore it has been developed and manually based, with the use of further testing of its efficacy being feasible. Her CBT was effective in decreasing ‘hopelessness’ and depression scores of the suicidal adolescents. TADS as well as other articles also managed to show efficacy of CBT in decreasing severity of depression and suicidality. On a medical context TADS from the acute treatment (stage 1) and now the naturalistic 1year follow-up stage (stage 2) central findings are the following: 1) combined treatment meaningfully accelerates recovery from depression relative to CBT and fluoxetine, 2) longer-term treatment results in improved outcomes relative to short -term treatment, 3) longer-term treatment may decrease the chances of relapse or recurrence when treatment is discontinued, and finally 4) adding CBT to fluoxetine minimises persistent suicidal ideation and treatment-emergent suicidal events associated with medication monotherapy. Therefore, implying that this method is an effective, appropriate, and acceptable treatment modality for the adolescents with recent suicidal attempts and current suicidal ideas, if implemented accordingly can allow for behavioural adjustments to be made to ones thinking on a simpler basis.
Overall, in this instance of review combined results were minimal although the exploration of CBT against no intervention being implemented being explored. Spirito, et.al (2011) found that published evidence and reviewed research which formed the basis of his study concluded that CBT has emerged as a well-established treatment approach for children and adolescents (David-Ferdon and Kaslow, 2008). Adding that although a definitive treatment for adolescent suicide attempters has yet to be established, the limited literature suggests that suicidal thoughts and behaviour to have been directly addressed for optimal treatment outcome. He suggests that training adolescents in specific coping skills and affect regulation techniques that can be applied to thoughts and behaviours associated with suicidality, which as a result would show some initial promise.
However, the level of adolescent’s engagement was found to have determined in the suitability of cognitive behavioural therapy deliverance by Stanley, et.al (2009). The lack of empirically based psychotherapies is further complicated by high rate of treatment refusal and drop out by adolescents (Rotheram-Borus, et.al 2000). However, despite the difficulties in engaging and retaining in treatment, suicidal individuals, irrespective of age, also refuse or drop out of treatment quickly (King, et.al 2006). The task of engaging and retaining patients who are both adolescent and suicidal appears to be extremely daunting! Hence the need for healthcare professionals to gain significant instructions, for an effective delivery of CBT.
Moreover, found through the review of papers forming the basis of this study was that family issues are addressed to be the extent that they are viewed by the patient, family and clinician to be relevant to the case conceptualisation and the prevention of future suicide. Previously specifying factors including problematic peer or romantic relationships; physical, verbal or sexual abuse; dysfunctional family beliefs; high family expectations and low reinforcement; or poor school performance. The review of selected papers forms the basis of this study was also the positive outcomes CBT can have in tackling these different contextual concerns. Which also implies for professional practice that this therapy can be effective in a group dynamic including individuals with similar perceptions or thoughts on a narrow subject issue (Bieling, et.al 2009). In reference to the different contextual concerns, the method also considers personal factors that can contribute to a young person’s perception of their issue and argue for the need for sensitivity along with the appropriate skills to be possessed by worker to deliver this effectively (Stanley, et.al 2009). Thus often issues influencing one’s behaviour can be uncovered due possibly not being initially interpreted, for this purpose an ongoing training is needed to be implemented within the social work and health care professions to ensure continual effective deliverance of the method at hand (Clark, 2011).
All reviewed papers consider environmental factors, however Stanley, et.al (2009) does not only consider these factors but also considers the ‘Chain Analysis’ which are identification of vulnerability factors and activating events associated with the crisis as well as the adolescents’ thoughts, feelings and behaviour in reaction to these events. One weakness of all articles as previously mentioned was the neglect of mental health being looked at and considered as a form of contributing factor to depression and suicidality. Often it is presumed that simply looking at depression and suicidality with a young person and their feelings about this experience is enough to form the basis of tackling the negative attitudes they may have towards it. In contrast with mental health which is in a broad sense, if suffered by these young people can make the impact derived from their attitude is impaired.
To be conclusive, within this report the findings outlines may be effectively applicable to the local population through cognitive behavioural therapy delivery. Further, health care professionals can adopt this method of intervention with its principled of the sound of notion which allows this method to influence on future or persistent depressive behaviour and suicidal attempts amongst young people. Stanley et.al (2009) found that multi-systematic therapy family orientated treatment which is developed for antisocial behaviour and delivered in the natural environment to have positively impacted on adolescents. According to research it is associated with fewer suicidal attempts but no greater reductions in the suicide ideation, hopelessness, or depression (Huey, et.al 2000). It is recognised widely of the correlation between antisocial behaviour and depression as well as suicidal attempts (Rowe, et.al 2006). In the context of antisocial behaviour, social workers can adopt this intervention with its notion’s principles within criminal justice, which as a result will allow this method to further influence restorative justice and help minimise offending. Also relating to ‘community pay back orders’ would require individuals to compensate their victims in different ways as a gesture of remorse for the crime committed (Guthrie, 2011). Referring to figure one, upon the initial search strategy supporting the following statement found through researching, states that such “Cognitive techniques are the most effective in helping clients to change or improve their responses to situations” (Chui and Wilson, 2006).
WORKERS’ IMPLICATIONS:
Due to CBT’s own unique obstacles, Implications for practice might be that some workers, including primary physicians would struggle to provide their patients with adequate behavioural health care. The reasons behind this, is due to many workers/physicians not having the time or interest to pursue such training (King, et.al, 2002).
LIMITATIONS:
From the used sample of all studies, neither of the selected studies’ findings could be generalised except TADS, indicating that results can be generalised (Garson, 2013). However, due to the high population, a larger sample size should have been considered to be able to capture diversity effectively, despite the fact results show that sample was representative to the population. Additionally, besides Alavi, et. al (2013) the other studies did not consider the use of Simple Random Sample. This is an appropriate sampling as it individuals are included whether they choose/not to volunteer, in contrary to convenience. Despite the inappropriate choice of sampling, due to sample size they were representative. According to Morse (1999a) it is often argued that generalisability is not the purpose for qualitative research, although in this case can be arguably of little use and will then be unlikely to be funded. Possible sources of bias and acknowledgement of limitations were recognised by all articles. Providing with detailed descriptions of findings, but further research being conducted was not mentioned; which indicates inclusive results of studies (Tourangeau, et. al 2000). As required by ethical considerations, studies’ have all appeared to have been governed by ethical considerations. Management of Social Transformations (2003) supports this as it suggests that research should always be carried out in full compliance with, and awareness of, local customs, standards, laws and regulations, should also be conducted in competent fashion and bias-free.
CONCLUSION
To conclude, selected papers shows important analysis of CBT effectiveness in treating depressions and depressive symptoms among young people, and this is believed to provide encouragement for this particular treatment (Reinecke, et.al 1998). As well as the majority of the selected papers have found from their studies, Joiner (2005) also agrees that suicide attempts habituate individuals to experience of engaging in dangerous self-injurious increases the possibility of future suicidal behaviour. This implies that if taboo against suicide is broken, it becomes easier for suicide to be viewed as a viable solution to life’s problems. In Summary, over the past several years in the treatment of depression and suicidality in adolescent, considerable progress has been made. However, neither of studies undertaken showing these increase number of efficacy for depression and suicidality have provided enough evidence based information indicating how or why these treatments work in the first place. Additionally, the number for treatment trials for adolescents with suicidality are few, as well as their efficacy to date which is rather limited, especially with regard to repeat suicidal behaviours. However, despite the need for a definitive treatment for adolescent suicide attempted to be established, the limited literature is suggesting suicidal thoughts and behaviour to be directly addressed for optimal treatment outcome. However, I believe that future trials to inform best practices to treat this high-risk population are necessary. Nevertheless, all of the selected studies used CBT approach for different individuals and reported it as being useful and effective in decreasing suicidal ideation and depressive disorder. Considering the fact that Stanley, et. al (2009) adopting such intervention from her package, the similarity with selected studies may be an expected finding.
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APPENDIX ONE
| ARTICLE | RESEARCH QUESTION | RESEARCH DESIGN | SAMPLE | DATA COLLECTION | DATA ANALYSIS | FINDINGS |
| 1. The Treatment for Adolescents With Depression Study (TADS, 2008) | Long-term Effectiveness and Safety Outcomes | Mixed-Method | Three hundred twenty-seven patients aged 12 to 17 years with a primary DSM-IV diagnosis of major depressive disorder. | Scaling design method + suicidal ideation questionnaire – Junior high school version | Analysis themes were identified.
-Evaluating the short- (0-12 weeks) and long-term (0-36 weeks) effectiveness -Adolescents with moderate depression. – Severe depression – Fluoxetine alone. – Combined with CBT.
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Short term treatment (12 weeks) outcomes reveals that combined therapy and fluoxetine therapy produces the greatest improvement in symptoms of MDD. Alone, CBT is found to be less effective than combination therapy or fluoxetine therapy alone and was significantly increasingly effective than placebo. Moreover, results from planned contrast at 6, 12, 18, 24, 30 and 36 weeks identifies early superiority for combined therapy and fluoxetine therapy relative to CBT during the 6th and 12th weeks. Meanwhile, combination therapy and fluoxetine therapy did not separate.
Regarding suicidal ideation and events, with respect to clinically significant suicidal ideal, results shows that 97 of 320 patients with a suicidal ideation questionnaire junior (SIQ-Jr) which is a percentage of 30.3, met the SIQ-Jr suicidality flag criterion at baseline, which includes 42 of 106 (39.6%) for combination therapy, 28 of 107 (26.2%) for fluoxetine therapy, and 27 of 107 (25.28%) for CBT. Comparisons pairwise indicates combination therapy has an excess of suicidal ideation at baseline relative to fluoxetine therapy and CBT. Additionally, 278 patients at week 12 and 31 who completed the questionnaire met the SIQ jr flag criterion, that includes 8 of 90 for the combined therapy, 18 of 97 for fluoxetine therapy, and 5 of 91 for CBT. Thus by weeks 12, those who were treated with fluoxetine continued showing more clinically significant suicidal ideation in comparison to patients treated with CBT or, as a trend, with combination therapy. Furthermore, fluoxetine therapy appears to be significantly different from CBT and combination therapy, which does not differ at all. In regards to generalizability, despite the range from mild to severe depression, most patients fell in the moderate to severe range of illness as characterizes by a mean Children’s Depression Rating Scale-Revised (CDRS-R) score 2.5 SD above the mean, high rates of comorbidity, and a strikingly prolonged median (42 weeks and mean (75 weeks) current episode duration. |
| 2. The Treatment for Adolescents With Depression Study (TADS, 2009) | Outcomes Over 1 year of Naturalistic Follow-Up | Mixed-Method | Three hundred twenty-seven patients aged 12 to 17 years with a primary DSM-IV diagnosis of major depressive disorder. | Scaling design method + suicidal ideation questionnaire – Junior high school version | Analysis themes were identified.
-Stages 1, 2 and 3 consisting of 12, 6 and 18 weeks. Moderate depression. – Severe depression
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These 3 stages consist of 12, 6 and 18 weeks of acute, consolidation and continuation treatment, respectively. Results in this study are directly relevant to stage IV analyses.
Prior to the 36 week visit which constituted the end of active treatment and the beginning of stage IV, the team within the site done a review of each subject’s clinical status and assigned an end of treatment score on the severity measure of the Clinical Global Impression (CGI) and recommended the 3 different stages/levels of treatment to patients: Level 1: Participants with a summary CGI severity score of 1 or 2 which are considered normal or borderline ill and who were otherwise well (e.g. required no treatment for other disorders or problems, received a recommendation to discontinue all treatment unless 1) in the opinion of the site team, continued treatment was indicated, for instance, due to a relapse history, or 2) there was a strong subject or family preference for continuing treatment. Level 2: Participants with a CGI severity rating of 3 (being mildly ill) of who are in need of other treatments were given a recommendation to continue TADS-like treatment and if necessary to add other treatments. Level 3: A CGI severity score of 4 or worse (moderately ill or worse). Findings reveals that among the adolescents who completed a week 36 assessment, which is the entry point into stage IV, no statistically significant between-treatment differences in demographic variables, family income, functioning, or pattern of comorbidity, along with three exceptions. Comparing to TADS previous reports for short term treatment (week 12) and longer-term treatment (week 36), the current data from stage IV regarding benefits and harms over 1 year of naturalistic follow-up has a lot more of important information, also clinically meaningful improvement even when active treatment is discontinued. Overall, the state IV results are in line with earlier reports from the TADS providing meaningful advantage for combination treatment over both monotherapies. Concluding that combination treatment is a lot more cost-effective than fluoxetine alone, in part due to the higher suicidality-driven health costs associated with medication monotherapy. Given the fact that there are substantial public health and health economic benefits that could possibly accrue from providing evidence based combined treatment to moderately to severely ill depressed young people.
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| 3. Stanley, Barbara. Brown, Gregory. Brent, A David. Wells, Karen. Poling, Kim. Curry, John. Kennard D Betsy. Wagner, Ann. F,Mary. Klomek Brunstein, Anat. Goldstein, Tina. Vitiello, Benedetto. Barnett, Shannon. Daniel, Stephanie and Hughes, Jennifer (2009). | Cognitive-Behavioural Therapy for Suicide Prevention (CBT-SP): Treatment Model, Feasibility, and Acceptable. | Qualitative | Hundred and ten recent suicide attempters with depression aged 13 to 19 years (mean 15.8 years, SD 1.6). | Questionnaires + exit interview. | Analysis themes identified.
– Predictive of future suicidal behaviour and high-risk of repetition. – Chain analysis – Safety planning – Psychoeducation
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Findings shows that CBT-SP is effective in preventing the recurrence of suicidal behaviour in adolescents with recent attempted suicide. With 44.7% participants citing the therapy alone, whilst 27.6% reporting that they felt that as a combination of the two, it was also most helpful, and only about 6.4% reporting that medication being the mist helpful component of their progress. Others believed that their relationship with the therapist has played a major role as it encouraged them to commit with the treatment. Additionally, due to frequent direct assessment of suicidality being intrinsic to the treatment approach, patients were required to be questioned about the impact of their suicidality assessed. Responses of thirty percent of the patients reported that it had no impact; and 19% felt its effectiveness, positively. In contrary, 30.9% reported that it did have a mildly negative result as they felt it was ‘boring’, ‘repetitive’ and annoying. Some finding it unpleasant and uncomfortable, although nobody had reported it to have increased their suicidal ideation. This proves to have been effective to the patients, which reveals and also confirms that the CBT-SP really does prevent recurrence of suicidal behaviour and reduces associated risk factors. |
| 4. Alavi, Ali. Sharifi, Bahare. Ghanizadeh, Ahmad and Dehborgi, Gholamreza (2013) | Effectiveness of Cognitive -Behavioural Therapy in Decreasing Suicidal Attempts. | Mixed-Method | Thirty patients aged 12 to 18 year-old adolescents who had a previous suicidal attempt in the past 3 months. Admitted in Namazi, Shooshtari, and Hafez Hospitals, Shiraz, Iran. | Scaling | Key themes as followed were identified
– Family systems, – Appropriate parenting styles – Social standards Problem solving skills
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Results reveal the similarities between the other selected papers being an expected finding. As I take a closer look, it appears as though the current changing trends within social values in the community of Iranian and some universal similarities in youths’ conflicts, other similar interventions may possibly have similar efficacy in cognitive reconstruction and rehabilitation.
This study consisting of 12 sessions of CBT for suicidal ideation following; patients in the ‘control group’ (placed on the wait list) and the patients in the ‘intervention group’ (evaluated in the final session). To add, based on the mean of the scaling instruments (SSI, BHI and BDI) patients were evaluated prior to starting the study. Results show no statistically significant differences amongst the two groups in the mean scores of SSI, BHI and BDI. Indicating that both groups were similar and comparable which means the differences observed after the treatment can be attributed to the designed intervention. Moreover, study looks into major predisposing factors in the suicidal adolescents and finds that lack of enough problem solving skills being one. Also adding that consideration of the effect of conflictual family systems, inappropriate parenting styles, changing social standards, and emotional problem on a young person’s life being of importance and taking it into consideration in any successful treatment intervention is vital. CBT once again is an effective, appropriate, also acceptable method of treatment modality for any teenagers with recent suicidal attempts and current suicidal ideas when used accordingly.
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| 5. Clabby, F John (2006). | Helping Depressed Adolescents: A Menu of Cognitive-Behavioural Procedures for Primary Care. | Qualitative.
Case report used here of a 14-year-old male student who comes to his physician for a pre-participation sports physical used to illustrate the application of CBT in primary care. (See appendix 2)
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NOT APPLICABLE | Interview | Key themes:
– Cognitively – Behaviourally. |
Clabby (2006) describes the two types of interventions found; the behaviourally oriented CBT and the cognitively oriented interventions which includes a hallmark CBT approach of teaching individuals to totally put an end on viewing situations as either ‘terrible’ ‘awful’ or ‘catastrophic, including ‘impossible’ to deal with. This way of thinking is believed to be psychologically toxic, leading to depression (Clabby, 2006).
The more behaviourally oriented CBT interventions is more about procedures enhancing self-control, including breathing, developing social skills e.g. comporting individuals’ body posture and eye contact in different social situations, also encouraging to partake in activities which bring young people a sense of pleasure or mastery. Clabby (2006) finds that these CBT procedures is the emphasis on practical technique. The 7 techniques are as followed: 1) BATHE: Background, Affect, Trouble, Handle, and Empathy. 2) CARL: Change It, Accept IT, Reframe It, or Leave It. 3)BEST: Body Posture, Eye Contact, Speech, and Tone of Voice. 4) EDGAR: Emotions, Description, Goal, Anticipation, and Rehearsal. 5) Cognitive-Behavioural Therapy Journaling 6) Talking Sense to Myself 7) BE FAST: Best, Exercise, Fun, Active, Solve, and Talk.
7-CBT-procedure menu appears to be appropriate when used correctly; this includes the order in which they are used. Thus, writer advises that the order in which the techniques are presented with Jay is not the order in which practitioners should use them. Personally, I believe that this order is appropriate and should be followed if not an expert to avoid confusion. In regards to case report provided, and techniques illustrated displayed, CBT can be effective, I would also argue with the fact this order should be recommended. BATHE being the first technique plays a major role as it is used at the first interview to assess, which did help Jay connect as it prioritises feelings, concerns and solutions. Also, Cognitive-Behavioural Therapy Journaling is one of the important approaches because it focuses on writing down thoughts and feelings, also reinforcing the social problem-solving skills taught in EDGAR and interpersonal presentation skills taught in BEST. This being an important technique due to the fact evidence proves of its successfulness when used amongst adolescents who have not yet learned these skills. This being said, it appears as though the majority of patients would rather take the opportunity to reflect on past incidents. Here, physician’s duty is to create a worksheet that would incorporate many CBT elements. Patients would then take copies of this worksheet to write their ideas and feelings as required within the CBT approach journaling. Dr Regan advises that these CBT could be used either alone or in combinations, which would depend on one’s personal preferences and time. However, study’s illustration reveals the first question gives the opportunity for clients to identify the issue specifically in order for the situation to be easily understood by client themselves including others. Following the next three questions which helps identify their feelings, solution used and current consequences. As this is being done, the young person suddenly recalls physical signs of stress, and recognises that they may have used a calming technique, either belly breathing of diaphragmatic. Finishing off with some reflection regarding their achievement and how well it all worked out, including offering alternative solutions if necessary. Overall, this menu can be helpful for many teens like Jay who are continuously and constantly confronted with unwanted changes in their relationships with friends, teachers, or family members. At times can see themselves as NOT measuring up to performance expectations in an organised sport for instance. Once there is indication of adolescent chronically feeling incompetent or usually helpless at handling such stress, physician should then commence worrying about depression. Often when physicians feel that they are failing to chronically deliver all they think they could to their depressed patients they become more vulnerable to them. In this case, it is not the best choice ignoring asking about the disorder, although it can be difficult for some to know how to provide time-efficient and effective ‘talk’ therapy. Overall, this menu is supporting that CBT is effective, and relieves from depression amongst young people if used appropriately and professionally.
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| 6. V. Robin Weersing, Satish Iyengar, David J. Kolko, Boris Birmaher, and David, A. Brent | Effectiveness of Cognitive-Behavioural Therapy for Adolescent Depression: A Benchmarking Investigation | Qualitative | Eighty youth age 15 who have been treated with CBT in an outpatient depression specialty clinic, Services for Teens at Risk Center (STAR) then compared with a “Gold Standard” CBT research Benchmark. | Beck, Steer, and Garbin (DBI, 1988 self-report), and semi structured interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Life time Versions , K-SADS-PL, 1985) | Identified key themes:
– Settings – Referral source
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DBI was used first to help identify significantly depressed subjects at intake into STAR. Then BDI scores from session-by-session were used to construct outcome measure-depression symptom trajectory over treatment course. K-SADS-PL is then used to identify youth with current major depressive disorder (MDD). STAR youths second stage of analysis for the linear effects of time were used with the purpose of predicting within-subject BDI scores, also symptom trajectories were estimated for each and every one of the participants. According to the results, a linear time model accounted for a majority (68%) of within-subject variance in BDI scores. In sum, each individual participant in STAR had made significant improvement over the course of treatment, per week. That is the STAR sample as a whole making the improvement. Result shows that in comparison to benchmark, youth provided CBT in STAR improved significantly slower than youth in the clinical trial. The reason behind this could be due to referral source of the youth provided treatment. For instance, all of the STAR youth were referred from clinical sources, which could mean that they sincerely sought services. Whereas, in the clinical trial, it appears a third of the sample was recruited to the study from sources such as newspaper advertisement. These non-referred youth could also be a lot more likely in recovering from MDD than clinically referred teens (Brent, et.al 1998). Overall, the effect of CBT appears promising in reducing youth depression. Thus within this study it appears that, both, settings and referral source account in part for the gap in outcome between STAR and randomized controlled trial (RCT).
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APPENDIX TWO
Case Report.
Jay Somerset* is a 14 year old ninth-grader. Jay and his family have just moved to the community, and he is visiting Dr. Regan, a family physician, for the first time. Jay is trying out for his high school’s freshman soccer team, and the school district requires a pre-preparation physical. His step mother accompanies him.
Jay has been quiet so far. Mrs. Somerset energetically takes the lead. She works at home taking care of her family, a career she has taken on with remarkable determination and patience. She married Jay’s father 2 years ago. In addition to Jay from Mr Somerset’s first marriage. Jay’s natural mother has been out of touch with him since the divorce 4 years ago.
Mrs. Somerset tells Dr. Regan about Jay’s medical history including the successful heart surgery he had 1 year ago. She reports that Jay seems unenthused about soccer and says that, “He’s been looking sad lately.” She has had difficulty getting Jay out of bed on time for school. Jay tells her that he feels “bored”. Dr. Regan thanks Mrs. Somerset for bringing in the medical records. He then suggests that she step outside while he examines Jay.
(Clabby, 2006)
