The trajectories of adolescent anxiety and depressive symptoms over the course of a transdiagnostic treatment

Accepted Manuscript Title: The Trajectories of Adolescent Anxiety and Depressive Symptoms Over Course of a Transdiagnostic Treatment Author: Alexander H. Queen David H. Barlow Jill Ehrenreich-May PII: DOI: Reference:

S0887-6185(14)00069-3 http://dx.doi.org/doi:10.1016/j.janxdis.2014.05.007 ANXDIS 1606

To appear in:

Journal of Anxiety Disorders

Received date: Accepted date:

31-1-2014 12-5-2014

Please cite this article as: Queen, Alexander H., Barlow, David H., & EhrenreichMay, Jill., The Trajectories of Adolescent Anxiety and Depressive Symptoms Over Course of a Transdiagnostic Treatment.Journal of Anxiety Disorders http://dx.doi.org/10.1016/j.janxdis.2014.05.007 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Running Head: TRAJECTORIES OF ANXIETY AND DEPRESSION

The Trajectories of Adolescent Anxiety and Depressive Symptoms

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Alexander H. Queen

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Over the Course of a Transdiagnostic Treatment

University of Miami

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David H. Barlow

Center for Anxiety and Related Disorders at Boston University

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Jill Ehrenreich-May

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University of Miami

Author Note

Alexander H. Queen & Jill Ehrenreich-May, Department of Psychology, University of Miami David H. Barlow, Center for Anxiety and Related Disorders at Boston University

Correspondence concerning this manuscript should be addressed to Jill Ehrenreich-May, Department of Psychology, University of Miami, Flipse 315, 5665 Ponce de Leon Boulevard, Coral Gables, FL 33146. E-mail: [email protected]

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2 TRAJECTORIES OF ANXIETY AND DEPRESSION Abstract Anxiety and depressive disorders commonly co-occur during adolescence, share multiple vulnerability factors, and respond to similar psychosocial and pharmacological interventions.

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However, anxiety and depression may also be considered distinct constructs and differ on some underlying properties. Prior research efforts on evidence-based treatments for youth have been

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unable to examine the concurrent trajectories of primary anxiety and depressive concerns across

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the course of treatment. The advent of transdiagnostic approaches for these emotional disorders in youth allows for such examination Thepresent study examined the separate trajectories of

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adolescent anxiety and depressive symptoms over the course of a transdiagnostic intervention, the Unified Protocol for the Treatment of Emotional Disorders in Adolescence (UP-A;

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Ehrenreich et al., 2008), as well as up to six months following treatment. The sample included 59 adolescents ages 12-17 years old (M = 15.42, SD = 1.71) who completed at least eight sessions

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of the UP-A as part of an open trial or randomized, controlled trial across two treatment sites.

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Piecewise latent growth curve analyses foundadolescent self-rated anxiety and depressive symptoms showed similar rates of improvement during treatment, but while anxiety symptoms continued to improve during follow-up, depressive symptoms showed non-significant improvementafter treatment. Parent-rated symptoms also showed similar rates of improvement for anxiety and depression during the UP-A to those observed for adolescent self-report, but little improvement after treatment across either anxiety or depressive symptoms. To a certain degree, the results mirror those observed among other evidence-based treatments for youth with anxiety and depression, though results hold implications for future iterations of transdiagnostic treatments regarding optimization of outcomes for adolescents with depressive symptoms. Keywords: anxiety, depression, adolescence, transdiagnostic, treatment

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3 TRAJECTORIES OF ANXIETY AND DEPRESSION 1. Introduction Anxiety disorders are the most prevalent psychiatric disorders in childhood and adolescence, with prevalence estimates of 10-21% in the general population in the United States

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(Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). Considered through the lens of DSM-IV (American Psychiatric Association, 2000), unipolar depressive disorders (i.e., major depressive

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disorder [MDD], dysthymic disorder) as a whole are also common mental health conditions, and

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become more prevalent during adolescence, as compared to earlier in development (Costello et al., 2002). Anxiety and depressive disorders commonly co-occur with one another in

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adolescence. Between 16% and 62% of youth with an anxiety disorder also meet criteria for depression, with the highest comorbidity rates found among treatment-seeking adolescents

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(Brady & Kendall, 1992; Ollendick, Shortt, & Sander, 2005). In addition, self-report measures of youth anxiety and depressive symptoms show moderate correlations with one another (e.g., r =

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0.34), even after controlling for overlapping items on these instruments (Stark & Laurent, 2001).

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In addition to their high comorbidity with one another, youth anxiety and depression share a number of biological, environmental, and psychological risk factors (for a more thorough review, see Garber & Weersing, 2010). For instance, behavioral inhibition in early childhood is a risk factor for the later development of both anxiety and depression (Kagan, Reznick, & Snidman, 1987), and both anxiety and depressive disorders are associated with neuroendocrine (Dahl et al., 2000; Weems, Zakem, Costa, Cannon, & Watts, 2005) and neurotransmitter dysregulation (Flores et al., 2004; Fox et al., 2005). In addition, high negative affect (NA) has shown to be a latent factor underlying all of the anxiety and depressive disorders (Brown, Chorpita, & Barlow, 1998; Trosper, Whitton, Brown, & Pincus, 2012).

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4 TRAJECTORIES OF ANXIETY AND DEPRESSION Youth anxiety and depressive disorders also demonstrate similar responses to pharmacological and psychosocial interventions. For instance, both anxiety and depression are responsive to selective serotonin reuptake inhibitor (SSRI) medications (e.g., TADS, 2004;

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Walkup et al., 2008). Prior work with cognitive-behavioral therapy (CBT) trials have found “spill-over” effects onto comorbid anxiety or depressive disorders, regardless of the principal

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disorder. For example, anxiety-focused CBT has demonstrated positive effects on comorbid

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depressive symptoms (Kendall, Safford, Flannery-Schroeder, & Webb, 2004), and a metaanalysis of CBT for youth depression found effect sizes in anxiety symptom reduction (ES =

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0.39) that were only slightly less than those for depressive symptom improvement (ES = 0.57; Weisz, McCarty, & Valeri, 2006).

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Given their frequent comorbidity, shared vulnerability factors, and similar response to treatment, some (e.g., Barlow et al., 2004) have advocated a transdiagnostic or disorder-non-

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specific treatment approach that targets higher-order psychological factors common to the

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emotional disorders. Such an approach is hypothesized to allow for greater clinical flexibility and use with patients presenting with multiple emotional disorders, as well as reduce clinician burden in learning multiple, disorder-specific treatment manuals (McHugh & Barlow, 2010). As such, recent clinical research has focused upon the development and evaluation of transdiagnostic treatments that may effectively target anxiety and depressive disorders within a single protocol. The Unified Protocol for the Treatment of Emotional Disorders in Adolescence (UP-A; Ehrenreich et al., 2008) is a developmental adaptation of the adult Unified Protocol (UP; Barlow et al., 2010), designed for adolescents ages 12-17 years old presenting with any primary anxiety disorder, unipolar depressive disorder, or their combination. The UP-A has theoretical roots in emotion regulation, cognitive science, and behavior modification, and distills common evidence-

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5 TRAJECTORIES OF ANXIETY AND DEPRESSION based techniques that cut across disorder-specific treatment manuals for youth anxiety and depression (e.g., psychoeducation, non-judgmental awareness, cognitive reappraisal, exposure, behavioral activation, etc.) within a singular protocol. The UP-A incorporates standard evidence-

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based principles within the broader function, context, and regulation of a range of positive and negative emotions (e.g., sadness, anger, fear). Therefore, it is theorized to positively effect how

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adolescents attend to, modulate, and experience emotions that cut across specific disorders.

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Similar to the UP, the UP-A targets five higher-order principles thought to be latent constructs underlying lower-order specific anxiety and depressive disorders: (1) increase present-focused

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awareness of emotions, (2) enhance cognitive flexibility, (3) prevent emotional avoidance and maladaptive emotion-driven behaviors, (4) increase acceptance of uncomfortable emotion-

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related physiological sensations, and (5) facilitate exposure to bodily and environmental triggers of emotional experiences (Barlow et al., 2010).

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A prior open trial of the UP-A established initial efficacy, with subjects demonstrating

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significant pre-post reductions in clinician-rated diagnostic severity across anxiety and depressive disorder diagnoses (Trosper, Buzzella, Bennett, & Ehrenreich, 2009), and an immediate treatment (TX) condition of the UP-A has found to outperform an 8-week, treatmentdelayed waitlist (WL) condition in clinician-rated diagnostic severity for the principal disorder, in a recently completed randomized controlled trial (RCT; Ehrenreich-May, Queen, Rodriguez, & Rosenfield, 2012). Analyses from this RCT also found that the presence of a depressive disorder did not moderate treatment outcomes in the UP-A (Ehrenreich-May et al., 2012), whereas many previous CBT trials for youth anxiety have found poorer outcomes for patients with comorbid depression (e.g., Berman et al., 2000; Ginsburg et al., 2011; O’Neil & Kendall, 2012).

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6 TRAJECTORIES OF ANXIETY AND DEPRESSION To summarize, youth anxiety and depression are known to commonly co-occur with one another, share multiple vulnerability factors, and may be effectively treated with a unified treatment approach. However, despite their similarities, anxiety and depression have also shown

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to be distinct constructs. For instance, factor analytic studies with school-based (Crowley & Emerson, 1996) and clinical samples (Stavrakaki, Vargo, Boodoosingh, & Roberts, 1987) have

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found stronger support for two-factor models of anxiety and depression compared to single

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factor models. In addition, while both anxiety and depression are characterized by high negative affect, low positive affect has shown stronger associations with depressive symptoms than with

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anxiety symptoms (for more comprehensive reviews, see Anderson & Hope, 2008; De Bolle & De Fruyt, 2010). Given these important differences, a next step in investigating transdiagnostic

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treatment approaches is to examine the separate trajectories of symptom change for anxiety and

rates of change.

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depression over the course of treatment, in order to assess if they show similar or differential

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The present study examined the separate trajectories of anxiety and depressive symptoms over the course of the UP-A, and up to six months following the end of treatment, for adolescent subjects completing the UP-A as part of the open trial or RCT investigation. We used piecewise latent growth curve modeling (LGCM) to model these trajectories over two separate time periods: during the course of treatment (“treatment slope”) and up to six months after treatment ended (“follow-up slope”). Piecewise LGCM is often recommended when examining change during treatment and follow-up, given likely non-linear change (Brown, 2004).Separate models were conducted for anxiety and depressive symptoms. Separate models were also conducted for self-rated and parent-rated symptoms, in order to examine informant differences in symptom change trajectories. Therefore, a total of four piecewise LGCMs were conducted.

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7 TRAJECTORIES OF ANXIETY AND DEPRESSION 2. Method 2. 1 Participants Participants were 59 adolescents (57.6% female) ages 12-17 years old (M = 15.42, SD =

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1.71) who received at least eight sessions of the UP-A and completed at least one post-baseline assessment. Given the aim of the study was to examine separate trajectories of anxiety and

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depression symptom change for those completing the intervention, we decided to restrict

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analyses to those receiving at least 8 sessions as this represented the minimum dosage possible to be considered a treatment completer. This subsample of 59 participants was culled from a total

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sample of 67 participants who were enrolled in either the open trial or RCT investigation of the UP-A. Eight (11.94%) of the 67participants that did not complete at least eight sessions of the

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intervention were part of the open trial (n = 2) or RCT (n = 6), respectively, and did not have any post-baseline assessment data. T-test and chi-square analyses revealed that those completing at

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least eight sessions (n = 59) did not significantly differ from those who dropped out prior to eight

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sessions (n = 8) with regard to age, gender, ethnicity, severity of principal diagnosis, depressive disorder comorbidity status, or baseline levels of anxiety or depressive symptoms (child or parent report).

Participants were evenly divided between Hispanic/Latino (n = 26; 44.1%) and White, Non-Hispanic ethnicities (n = 26; 44.1%). The remaining subjects identified themselves as having Black/African-American (n = 2; 3.4%), Asian-American (n = 1; 1.7%), and “other” ethnicity (n = 4; 6.8%). The median reported annual family income was $100,000 (SD = $80,000). The majority of participants had parents who were married (n= 40; 67.8%). Remaining participants had parents who were separated/divorced (n = 13; 22.03%), widowed (n = 2; 3.4%), or never married (n = 4; 6.78%).

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8 TRAJECTORIES OF ANXIETY AND DEPRESSION Eligibility requirements for both the open trial and RCT included being between 12-17 years old (participants could be 18 if they were still in high school) and having a primary diagnosis of any DSM-IV anxiety and/or unipolar depressive disorder. Adolescents with other

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psychiatric difficulties, including attention-deficit/hyperactivity disorder (ADHD), eating disorders, and non-treatment-interfering substance abuse were eligible for participation.

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However, the primary diagnosis had to be an anxiety or depressive disorder. Exclusion criteria

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included bipolar disorder, treatment-interfering substance abuse, severe suicidal ideation or recent psychiatric hospitalization, treatment-interfering cognitive functioning (e.g., IQ below 80),

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and a prior course of CBT for anxiety or depression. Participants and at least one parent were also required to read and comprehend English well enough to complete study measures. Those

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concurrently receiving psychiatric medication were required to have been on a stable dosage of

prior to study enrollment.

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an SSRI medication for three months and/or a stable dosage of a benzodiazepine for one month

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Adolescents completing the UP-A as part of the open trial participated at a universitybased clinic in a large urban area in the Northeastern United States (n = 15), while those in a subsequent RCT participated at a university-based clinic in a large urban area in the Southeastern United States (n = 44). There were no significant site differences with regard to gender, depressive disorder comorbidity, treatment length, or severity of anxiety and depressive symptoms. However, subjects in the RCT were slightly older (M = 15.69, SD = 1.70) than open trial participants (M = 14.63, SD = 1.55), t(57) = 2.13, p = .04, d = 0.64. In addition, as expected based upon demographic characteristics of the surrounding communities, RCT participants were more likely to be Hispanic/Latino (61.36%), whereas all of the open trial participants were White, Non-Hispanic, χ2 (3) = 25.53, p <.001. There were no differences among ethnicities

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9 TRAJECTORIES OF ANXIETY AND DEPRESSION withregard to any study variables at any time points. Principal/co-principal diagnoses and comorbid diagnoses at baseline are displayed in Table 1. (Diagnoses assigned as co-principal are included for totals within the principal diagnosis

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category.) The most common principal diagnoses were Generalized Anxiety Disorder (n = 23; 38.98%), followed by Social Phobia (n = 19; 32.20%), and Major Depressive Disorder (n = 11;

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18.64%). Sixteen participants (27.12%) were assigned co-principal diagnoses, with the most

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common combination being Generalized Anxiety Disorder and Social Phobia (n = 4). All of the DSM-IV anxiety disorders were represented with either a principal/co-principal or comorbid

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diagnosis, including Obsessive-Compulsive Disorder (n = 8; 13.56%), Panic Disorder (n = 7; 11.86%), Specific Phobia (n = 8; 13.56%), Separation Anxiety Disorder (n = 2; 3.39%), and

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Post-Traumatic Stress Disorder (n = 1; 1.69%).

The great majority of participants (n = 47; 79.7%) were assigned a primary anxiety

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disorder diagnosis, while nine participants (15.3%) received a primary depressive disorder

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diagnosis, and three participants (5.1%) were assigned co-principal anxiety and depressive disorder diagnoses. Although only 12 participants (20.34%) received a principal or co-principal depressive disorder diagnosis, comorbid depression was well-represented, with 23 participants (38.98%) assigned a secondary comorbid depressive disorder. Therefore, the majority of participants (n = 35; 61.02%) were assigned a depressive disorder. The majority of those with a depressive disorder were diagnosed with Major Depressive Disorder (n = 25), although Dysthymic Disorder (n = 5) and Depressive Disorder, Not Otherwise Specified (NOS; n = 6) were also present. (One participant was diagnosed with both Major Depressive Disorder and Dysthymic Disorder). In addition to anxiety and depression comorbidity, other psychiatric conditions were also present, including ADHD (n = 4; 6.78%), Oppositional-Defiant Disorder (n

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10 TRAJECTORIES OF ANXIETY AND DEPRESSION = 1; 1.69%), and Eating Disorder NOS (n = 1; 1.69%). No participants were assigned a diagnosis of a current substance abuse disorder. The majority of participants (n = 46; 78%) were not currently taking psychiatric

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medication at the time of the study. Seven participants (11.86%) were taking a SSRI medication alone, one participant (1.69%) was taking a benzodiazepine alone, and two participants (3.39%)

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were taking both an SSRI and a benzodiazepine. With regard to stimulant medication for ADHD

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symptoms, two participants (3.39%) were taking a stimulant medication alone, while one participant (1.69%) was taking a stimulant medication in combination with an SSRI medication.

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Analyses of those taking medication (n = 13) compared to those not taking medication (n = 46) revealed no significant differences on any baseline variables. In addition, medication status was

2.2 Procedure

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unrelated to anxiety or depressive symptom severity during treatment or at follow-up.

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The Institutional Review Boards of the two Universities participating in this trial granted

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approval for the study. Adolescents were referred for evaluation and treatment services at the clinics by school personnel, pediatricians, psychiatrists, other mental health care professionals, community agencies, or were self-referred through community, online, or radio advertisements. Upon contacting the clinic, the adolescent’s parent completed an initial telephone screen to assess primary concerns and rule out exclusionary criteria. If the primary concern was determined to be anxiety or mood related, the adolescent and parent were scheduled for an inperson diagnostic evaluation at the clinic. Parents of adolescents not deemed eligible were provided with appropriate treatment referrals. Figure 1 displays the CONSORT diagram outlining participant recruitment and assignment. At the initial diagnostic evaluation, the adolescent and parent separately completed

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11 TRAJECTORIES OF ANXIETY AND DEPRESSION the Anxiety Disorders Interview Schedule for the DSM-IV, Child Version, Parent and ChildReports (ADIS-IV-C/P; Silverman & Albano, 1996) with a Ph.D.-level clinical psychologist or doctoral student in clinical child psychology. In addition, the adolescent and

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parent completed paper-and-pencil questionnaires at this evaluation. After obtaining both parent and adolescent assent, the adolescent participated in the ADIS-IV while the parent completed

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measures in the waiting room. Similarly, the adolescent completed their measures while the

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parent completed their interview. Symptom data collected at this initial diagnostic evaluation were used as Time 1 data for subjects in the open trial and for those in the TX condition in the

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RCT.

Following the diagnostic evaluation, clinician-rated composite diagnoses were assigned

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by compiling information from adolescent and parent responses to the ADIS-IV-C/P. The assessor assigned a clinical severity rating (CSR) value, an indicator of diagnostic severity and

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impairment, to every composite diagnosis. CSR values can range from 0-8, with values  4

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indicating clinical levels of impairment. Only participants receiving a primary diagnosis of an anxiety or depressive disorder assigned a CSR  4 were eligible to participate in the UP-A trial. Final diagnoses and CSR values were confirmed at a weekly supervision meeting. On average, participants presented with moderately severe impairment with regard to their primary anxiety or depressive disorder diagnosis (M = 5.81, SD = 0.78, Range = 4-7). Adolescents assigned a primary diagnosis of an anxiety or depressive disorder, and who did not meet exclusion criteria, were eligible to enroll in the treatment trial. Upon obtaining written parental consent and adolescent assent, participants in the RCT were randomized to either the TX or WL condition. Participants in the open trial and TX arm of the RCT began treatment immediately. All participants and their parent completed symptom measures at Time 2

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12 TRAJECTORIES OF ANXIETY AND DEPRESSION (8 weeks after beginning treatment, considered the “mid-treatment” point for most), Time 3 (the end of treatment), Time 4 (three months after treatment termination), and Time 5 (six months after treatment termination).

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Participants in the WL condition did not receive treatment during the 8-week WL period, but did brief telephone “check-ins” with their assigned therapist to assess for clinical

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deterioration every other week. At the end of the WL period, participants and their parent

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completed symptom measures at the clinic. These data were used as Time 1 data for WL participants. Analyses revealed no significant changes in WL participants’ data from the initial

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diagnostic evaluation to the end of the WL period on symptom measures, all ps > .20. Participants in the WL arm then began the UP-A and completed assessments at the same

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intervals as those in the open trial and TX arm of the RCT.

2.2.1 Treatment structure and content.The UP-A follows a principle-based, flexible

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treatment structure. The intervention can be delivered over a varying length of time (between 8-

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21 weekly sessions administered in an individual format). There are five required modules, which correspond to the five core principles underlining the UP/UP-A (Barlow et al., 2010). Therapists are allowed to devote more sessions to a required module dependent upon patient needs, but ideally all modules are completed during the course of treatment. Therefore, while treatment length may differ among patients, all subjects receive the same five core modules and relevant skills (e.g., psychoeducation, non-judgmental awareness/mindfulness, cognitive reappraisal, exposure, behavioral activation). See Table 2 for a display of the five required modules, suggested session length for each module, including treatment skills delivered within each module and the corresponding UP/UP-A core principles targeted. Importantly, one of the unique features of the UP models is the ability to target emotion regulation deficits across a

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13 TRAJECTORIES OF ANXIETY AND DEPRESSION broader range of positive and negative emotions, compared to traditional, disorder-specific treatment manuals. In addition to the five required modules, three optional modules are available to the

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therapist as needed to address parenting skills, motivational enhancement, and clinical deterioration, and can be used at any point in treatment. At least one parent is required to be

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actively involved in treatment. While some variability is allowable, typically a parent is involved

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in the last 10-15 minutes of every session to review content and the assigned homework. Individual sessions with the parent may be used as part of an optional module if the therapist

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feels that certain parenting behaviors (e.g., overprotection, high criticism, parent-teen conflict, etc.) are counterproductive to treatment progress or as needed for exposure planning.

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Motivational interviewing (Miller & Rollnick, 2002) techniques can be used in sessions as part of a second optional module for adolescents who appear reluctant to engage in treatment. Finally,

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sessions within the third optional module can be used to develop a safety plan with the

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adolescent and his or her parent in the event the patient experiences impulses for self-harm. However, adolescents who show immediate risk for suicide or other pronounced clinical deterioration could also be discontinued from the UP-A studies and referred for more intensive services, if appropriate. 2.3 Measures

Anxiety Disorders Interview Schedule for the DSM-IV-Child/Parent Version(ADIS-IVC/P; Silverman & Albano, 1996). The ADIS-IV-C/P was completed at the adolescent’s baseline assessment to determine diagnostic eligibility. The ADIS-IV-C/P is a semi-structured diagnostic interview for children and adolescents ages 7-17 years that assesses all DSM-IV anxiety disorders. The ADIS-IV-C/P also assesses for unipolar depressive disorders and externalizing

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14 TRAJECTORIES OF ANXIETY AND DEPRESSION disorders (i.e., ADHD, oppositional-defiant disorder, conduct disorder), and screens for substance abuse, schizophrenia, pervasive developmental disorders, eating disorders, and somatoform disorders. In addition, participants were screened for bipolar disorder. Inter-rater

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reliability for the primary diagnosis within this sample was very good (κ = .82, p <.001). All assessors were previously trained in ADIS-IV-C/P administration and participated in weekly

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supervision meetings, led by the second author (JEM). After an initial training workshop, new

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examiners were required to reach agreement on all clinical diagnoses CSR levels (i.e., within ± 1 CSR value) with an expert rater (JEM) on three consecutive assessments before conducting

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interviews independently.

Revised Children’s Anxiety and Depression Scale. Subjects completed the Revised

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Children’s Anxiety and Depression Scale (RCADS; Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000) at all five time points. The RCADS is a 47-item, self-report measure of anxiety

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and depressive symptoms that contains six distinct subscales based upon DSM-IV criteria:

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separation anxiety, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and major depressive disorder. Respondents are asked to indicate how much each item describes them using never (0), sometimes (1), often (2), or always (3). A Total Anxiety subscale score is comprised of 37 items and summed from responses to the five anxiety subscales. A Major Depressive Disorder (MDD) subscale score is comprised of 10 items. Raw scores were converted to T-scores using child age and gender to place the two subscales on the same metric, with T-scores of 65 or greater indicating borderline levels of clinical severity, and T-scores of 70 and above representing clinically significant elevations (Weiss & Chorpita, 2011). Internal consistency values for the RCADS Total Anxiety subscale were as follows:  = 0.94 at Time 1,  = 0.95 at Time 2,  = 0.91 at Time 3,  = 0.87 at Time 4, and  = 0.93 at Time 5.

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15 TRAJECTORIES OF ANXIETY AND DEPRESSION Internal consistency values for the RCADS MDD subscale were as follows:  = 0.85 at Time 1,  = 0.90 at Time 2,  = 0.91 at Time 3,  = 0.91 at Time 4, and  = 0.93 at Time 5. Revised Children’s Anxiety and Depression Scales-Parent version. The adolescent’s

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parent completed the Revised Children’s Anxiety and Depression Scales-Parent version

(RCADS-P; Ebesutani, Bernstein, Nakamura, Chorpita, & Weisz, 2010) at all five time points.

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The RCADS-P is a 47-item, parent-rated measure of their child/adolescent’s anxiety and

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depressive symptoms. The RCADS-P contains the same six subscales as the RCADS and has previously shown good psychometric properties with school-based (Ebesutani et al., 2011) and

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clinical samples (Ebesutani et al., 2010). For the current sample, internal consistency values for the RCADS-P Total Anxiety subscale were as follows:  = 0.92 at Time 1,  = 0.91 at Time 2, 

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= 0.94 at Time 3,  = 0.78 at Time 4, and  = 0.88 at Time 5. Internal consistency values for the

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RCADS-P MDD subscale were as follows:  = 0.78 at Time 1,  = 0.88 at Time 2,  = 0.91 at

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Time 3,  = 0.60 at Time 4, and  = 0.92 at Time 5. 2.4 Data Analytic Plan

For the present study, we used piecewise LGCM to model symptom trajectories over (1) the course of treatment and (2) during the six-month follow-up period. Several indices of model fit were used, including chi square, comparative fix index (CFI), root mean square error of approximation (RMSEA), and standardized root mean square residual (SRMR). For purposes of interpretation, indices of good model fit include a non-significant chi square (p > .05), CFI > .95, RMSEA < .06, and SRMR < .08 (Kline, 2011). Significant tests for parameter estimates were conducted with the z-statistic using a two-tailed test. LGCM analyses were conducted using MPLUS, Fifth Version (Muthen & Muthen, 2005). 3. Results

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16 TRAJECTORIES OF ANXIETY AND DEPRESSION The data were first screened for normality and to determine if there were any statistical outliers. Skewness and kurtosis levels were within acceptable ranges (Kline, 2011). No significant outliers (z ≥ 3) were identified at any time points. All subjects had complete data for

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Time 1 as well as at least one other post-baseline assessment. Fifty-five subjects (93.22%) had data at the 8-week assessment (Time 2) and 48 participants (81.36%) had data at the end of

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treatment (M = 15.58 sessions) assessment (Time 3). However, there was considerable missing

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data at the two follow-up time points, with 29 subjects (49.15%) having available data three months after treatment (Time 4), and 24 participants (40.68%) having data six months after

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treatment (Time 5), although 62.71% of subjects had available data for at least one follow-up time point. Attrition analyses revealed no significant differences between those with complete

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data and those with missing data on any indicators of symptom severity at baseline or any demographic variables (e.g., age, gender, ethnicity). Furthermore, those with and without follow-

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3.1 Descriptive Statistics

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up data did not show significant differences on any variables at the post-treatment assessment.

See Table 3 for observed means and standard deviations of RCADS/RCADS-P Total Anxiety Tscores and RCADS/RCADS-P MDD T-scores at each time point. In addition, the percentage of participants with T-scores  65 and T-scores  70 are presented. Mean T-scores on all four measures reduced to below 65 by Time 3, indicating that mean levels of both self-rated and parent-rated anxiety and depressive symptoms were within the normative range by the end of treatment. Analysis of percentages of participants with T-scores  65 and T-scores  70 also revealed reductions in those with borderline elevated and clinically elevated anxiety and depressive symptoms from baseline to the end of treatment, which were largely maintained during follow-up.

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17 TRAJECTORIES OF ANXIETY AND DEPRESSION 3.2 LGCMs for Adolescent Self-Rated Symptoms 3.2.1 Anxiety symptoms.Self-rated anxiety and depressive symptom trajectories (observed and estimated) are displayed in Figure 2. The piecewise LGCM for self-rated anxiety symptoms was

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modeled by specifying three latent factors: an intercept (baseline levels of anxiety symptoms), a treatment slope factor (change during the UP-A), and a follow-up slope factor (change during

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follow-up). All loadings from the intercept to observed variables were fixed at 1. Loadings for

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the treatment slope factor were fixed at 0, -1, -2, -2, and -2. Loadings for the follow-up slope factor were fixed at 0, 0, 0, -1.5, and -3. These loadings can be interpreted as a period of eight

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weeks per one unit change. The final model imposing equality constraints for the residual variances of the first three indicators and last two indicators demonstrated acceptable model fit

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by most indices, χ2 (9) = 13.63, p = 0.14, CFI = 0.97, RMSEA = 0.09, SRMR = 0.19. There was a significant mean intercept (Mi = 53.68, SE = 1.65, p <.001), treatment slope

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factor (M s1 = 4.76, SE = 0.74, p <.001), and follow-up slope factor (M s2 = 1.48, SE = 0.50, p

Ac ce pt e

<.01). The means of the slopes indicated that, on average, participants’ RCADS Total Anxiety Tscores decreased by 4.76 units every eight weeks during treatment, and by 1.48 units every eight weeks during the follow-up period. The variances for the intercept (di = 130.72, SE = 29.91, p <.001), treatment slope factor (d s1 = 15.32, SE = 6.23, p = .01), and follow-up slope factor (d s2 = 5.15, SE = 2.17, p <.02) were all statistically significant. This indicated significant variation in participants’ baseline anxiety symptom levels, as well as variability in the rate of change in anxiety symptom reduction during treatment and follow-up. The intercept and treatment slope factor were significantly correlated with one another, r = 0.59, p <.001, indicating that participants who reported greater anxiety symptom severity at baseline demonstrated faster symptom reduction during treatment. In addition, the treatment and follow-up slopes were

Page 17 of 36

18 TRAJECTORIES OF ANXIETY AND DEPRESSION significantly and negatively correlated, r = -0.51, p = .01. Participants who demonstrated faster anxiety symptom reduction during treatment showed slower change during follow-up. The intercept and follow-up slope factor were not significantly correlated, r = -0.23, p >.30.

ip t

3.2.2 Depressive symptoms.The final model for self-rated depressive symptoms demonstrated acceptable fit by most indices, χ2 (7) = 10.42, p = 0.17; CFI = 0.98; RMSEA =

cr

0.09; SRMR = 0.06. The residual variances of the final two indicators were constrained equal;

us

however, imposing equality constraints on the residual variances of the first three time indicators did significantly worsen model fit, 2D (2) = 14.29, p <.001, and therefore these residual

an

variances were freely estimated.

There was a significant mean intercept (Mi = 57.91, SE = 1.81, p <.001) and treatment

M

slope (Ms1 = 4.82, SE = 0.82, p <.001). However, contrary to the LGCM for adolescents’ selfrated anxiety symptoms, the mean follow-up slope was not statistically significant, (M s2 = 0.67,

d

SE = 0.55, p >0.20). The non-significant slope indicated that on average, participants did not

Ac ce pt e

display significant reductions in self-rated depressive symptoms after treatment ended. The variances of the intercept (di = 184.25, SE = 42.74, p <.001) and treatment slope factor (d s1 = 27.16, SE = 10.89, p = .01) were statistically significant, while the variance of the follow-up slope factor approached statistical significance (d s2 = 4.24, SE = 2.54, p = .09). Similar to the LGCM for self-rated anxiety, the intercept and treatment slope factor were significantly and positively correlated, r = 0.48, p <.01, while the intercept and follow-up slope were nonsignificantly correlated, r = -0.20, p = .42. However, in contrast to the LGCM for self-rated anxiety symptoms, the treatment and follow-up slopes for self-rated depressive symptom were not significantly correlated, r = -0.24, p = .35. 3.3 LGCMs for Parent-Rated Symptoms

Page 18 of 36

19 TRAJECTORIES OF ANXIETY AND DEPRESSION 3.3.1 Anxiety symptoms.Parent-rated anxiety and depressive symptom trajectories (observed and estimated) are displayed in Figure 3. The piecewise LGCM for RCADS-P Total Anxiety T-scores demonstrated poor fit, χ2 (6) = 14.27, p = 0.03; CFI = 0.91; RMSEA = 0.18;

ip t

SRMR = 0.23. In addition, the follow-up slope factor mean was non-significant (Ms2 = -1.16, p = 0.32) and had a non-significant negative residual variance, forcing the residual variance to be

cr

fixed at 0. Given poor model fit and little growth or variability during the follow-up period, an

us

LGCM with a single slope factor to represent change during both treatment and follow-up. The first three loadings were fixed at 0, -1, and -2, while the last two time points were

an

freely estimated. Based upon modification indices, we fixed the residual variances for the first and last time points to be equal, and the residual variances for the second, third, and fourth time

M

points to be equal. These equality constraints did not significantly worsen model fit, and this final model showed acceptable fit, χ2 (11) = 15.85, p = 0.15; CFI = 0.96; RMSEA = 0.10; SRMR

d

= 0.23. The loadings for the last two time points of the single slope factor were estimated at -2.97

Ac ce pt e

and -3.26, respectively, indicating that reductions in RCADS-P Total Anxiety T-scores quickly leveled out following the end of treatment.

There was a statistically significant intercept mean (Mi = 64.82, SE = 2.14, p <.001) and slope mean (Ms1 = 4.09, SE = .70, p <.001). The variance of the intercept was statistically significant (di = 188.95, SE = 43.83, p <.001), but the variance of the slope did not reach statistical significance (d s = 4.03, SE = 3.01, p = 0.18). Similar to the LGCM for adolescent-rated anxiety, there was a significant and positive correlation between the intercept and slope, r = 0.81, p <.001. 3.3.2 Depressive symptoms.The piecewise model displayed poor fit, χ2 (7) = 21.14, p = .004; CFI = 0.86; RMSEA = 0.21; SRMR = 0.21, and the follow-up slope factor mean was non-

Page 19 of 36

20 TRAJECTORIES OF ANXIETY AND DEPRESSION significant (Ms2 = 0.004, p = 0.99), indicating virtually no continued reduction in RCADS-P MDD T-scores after the end of treatment. Therefore, we specified a single slope factor and allowed the loadings for the final two time points to be freely estimated. Modification indices

ip t

suggested allowing the residual variance of the final time point to be freely estimated, while constraining the residual variances of the first four time points did not significantly worsen

cr

model fit. In addition, it was recommended to allow the residual variances of the fourth and fifth

us

time points to co-vary, and the residual variances of the third and fourth time points to co-vary. The final model demonstrated acceptable fit, χ2 (9) = 13.82, p = 0.13; CFI = 0.95; RMSEA =

an

0.11; SRMR = 0.14. The loadings for the final two time points were estimated at -2.19 and -2.41, respectively, indicating very little continued reduction in RCADS-P MDD T-scores during the

M

follow-up period.

The intercept mean was statistically significant (Mi = 68.15, SE = 2.44, p <.001), as was

d

the slope mean (Ms1 = 4.78, SE = 1.02, p <.001). The variance of the intercept was statistically

Ac ce pt e

significant (di = 207.52, SE = 55.27, p <.001), but the variance of the slope failed to reach statistical significance (d i = 207.52, SE = 55.27, p <.001). The intercept and slope were significantly and positively correlated, r = 0.71, p <.01. Controlling for their shared association with the latent factor, the residual variances for the fourth and fifth time points were significantly and negatively correlated, r = -0.75, p <.01, while the residual variances for the third and fourth time points were significantly, positively correlated, r = 0.64, p <.001. 4. Discussion

This study examined the separate trajectories of adolescent anxiety and depressive symptom reduction over the course of a transdiagnostic, emotion-focused intervention, as well as up to six months following treatment. We conducted separate piecewise LGCMs for adolescent

Page 20 of 36

21 TRAJECTORIES OF ANXIETY AND DEPRESSION self-rated and parent-rated symptoms. Results from LGCMs for self-rated symptoms revealed similar rates of change in anxiety (M = 4.76) and depressive symptoms (M = 4.82) during the course of the UP-A. However, one notable difference was that whereas anxiety symptoms

ip t

continued to show significant reduction during follow-up, depressive symptoms showed little change after treatment. In addition, the correlations between change during treatment and change

cr

during follow-up were stronger for anxiety symptoms, compared to depressive symptoms.

us

Results from LGCMs for parent-rated symptoms showed poor model fit for piecewise growth curves due to very small symptom reduction in the six months following the end of treatment.

an

This was true for both parent-rated anxiety and depressive symptoms.

These findings may offer important implications. First, mean rates of change for anxiety

M

and depressive symptom reduction were nearly equivalent during the treatment phase of the UPA. These results suggest that the UP-A may effectively target anxiety and depressive symptoms

d

for adolescents with emotional disorders. These results are similar to prior work showing

Ac ce pt e

improvements in both anxiety and depressive symptoms, regardless of the principal diagnosis, in both anxiety-focused and depression-focused CBT interventions (e.g., Kendall et al., 2007; Weisz et al., 2006). However, this study differed in two important ways from prior work that may offer particularly compelling evidence for this transdiagnostic treatment. First, we actively recruited a more comorbid sample than has been typically reported in prior CBT trials (e.g., Walkup et al., 2008), with participants showing a high rate of anxiety and depressive disorder comorbidity. Second, to our knowledge, this was the first study to examine the separate rates of change in anxiety and depression symptoms during treatment and follow-up. Thus, our findings add to prior work by suggesting that not only do anxiety and depressive symptoms improve

Page 21 of 36

22 TRAJECTORIES OF ANXIETY AND DEPRESSION within a evidence-based, transdiagnostic intervention, but that they also change at similar rates during treatment. Although anxiety and depressive symptoms showed similar rates of change during

ip t

treatment, our work also highlights they may show important differences in reduction after treatment. Specifically, within LGCMs for self-rated symptoms, anxiety symptoms showed

cr

continued and significant reduction during follow-up, whereas depressive symptoms showed

us

non-significant reduction after treatment. Although speculative in nature, there are potential explanations for these findings. Since this was a primarily anxious sample, it is possible that

an

relapse prevention efforts were focused upon techniques geared more for anxiety (e.g., exposure work) than depression (e.g., behavioral activation). As a result, adolescents may have perceived

M

more opportunities to practice treatment strategies more relevant to anxiety than depression during the follow-up phase. It is important to note that other trials have also observed a plateau in

d

depressive symptom reduction for depression-focused CBT (TADS, 2009) and anxiety-focused

Ac ce pt e

CBT (Kendall et al., 1997). Thus, our findings are consistent with prior work. Another interesting difference was that while the treatment and follow-up slopes were significantly and negatively correlated for self-rated anxiety symptoms, their correlation was non-significant for depressive symptoms. This finding suggests that the rate of change during treatment is more strongly associated with change during follow-up for anxiety symptoms compared to depressive symptoms for adolescents receiving the UP-A. However, this result may also be explained by less variance in follow-up slope for depressive symptoms compared to anxiety symptoms. The negative correlation observed for anxiety symptoms may be explained by less room for improvement for participants who had greater symptom change during treatment.

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23 TRAJECTORIES OF ANXIETY AND DEPRESSION Finally, there were observed differences between adolescent self-rated and parent-rated symptom change. Parent-rated symptom models showed poor fit to piecewise growth curves as a result of little continued symptom improvement after the UP-A. One potential methodological

ip t

explanation for this finding is the weaker internal consistency values of the RCADS-P during the follow-up period, particularly at Time 4 ( = 0.60), which may have contributed to poor fit. This

cr

finding may also, however, highlight important differences in adolescent versus parent

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perceptions of symptom improvement following treatment. This may be particularly true for anxiety symptoms, where self-rated symptoms showed significant growth in the follow-up phase.

an

It may be that adolescents are more attuned to internal correlates of anxiety (e.g., physiological hyperarousal) that are not as directly observable by parents. Thus, adolescents may have been

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more aware of continued improvement in their anxiety symptoms and were therefore able to report on them more easily than their parents. Future work will be an important avenue to

d

determine if this finding is replicated in larger samples. If so, findings could hold important

Ac ce pt e

implications for how clinicians should integrate self and parent ratings of symptom improvement following treatment. 4.1 Limitations

Findings should be tempered by study limitations. First, the sample size was relatively small for LGCM analyses, and thus statistical power to detect significant growth in the follow-up period in some models may have been limited. Replication with a larger sample is certainly warranted. Second, as a result of the small sample, we were unable to model growth curves of anxiety and depressive symptoms within a single model. This approach would have allowed us to impose equality constraints on the means of the treatment and follow-up slopes to test if growth rates were statistically significantly different between anxiety and depressive symptoms.

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24 TRAJECTORIES OF ANXIETY AND DEPRESSION Although our findings cannot address this question, they do offer preliminary evidence that anxiety and depressive symptoms may show similar rates of change during treatment in the UPA, but perhaps important differences during follow-up.

ip t

Third, while depressive comorbidity was well represented within our sample, most subjects had a principal anxiety disorder diagnosis. Therefore, caution should be taken when

cr

seeking to generalize findings to principally depressed adolescents. Future work should seek to

us

examine these symptom trajectories among adolescents seeking treatment for primary depression. Fourth, although our sample was ethnically diverse, the majority of subjects came

an

from families of middle to upper middle class socioeconomic status (SES), as assessed by annual family income. Findings may not generalize to adolescents from lower SES families. Fifth and

M

finally, we used RCADS/RCADS-P Total Anxiety T-scores as measures of global anxiety symptoms, which aggregate scores across five heterogeneous anxiety disorders. Thus,

d

examination of separate trajectories for each type of anxiety disorder symptomatology was lost

Ac ce pt e

as a result of total score. However, our smaller sample size limited modeling these multiple trajectories. Future work with larger samples should attempt such modeling. 4.2 Conclusion

We examined the separate trajectories of symptom change for anxiety and depression over the course of a transdiagnostic intervention for adolescents with emotional disorders, including up to six months post-treatment. Among self-reported symptoms, anxiety and depression showed similar rates of change during the UP-A, but whereas anxiety symptoms continued to show significant improvement after treatment, depressive symptom change plateaued. Models of parent-rated symptoms showed poor fit to piecewise latent growth curves, indicating that parents reported little change in their adolescent’s anxiety and depressive

Page 24 of 36

25 TRAJECTORIES OF ANXIETY AND DEPRESSION symptoms after treatment. Findings appear to support the efficacy of the UP-A as a transdiagnostic treatment, given similar rates of change in anxiety and depressive symptoms during the intervention. However, findings may also highlight the greater need for helping

ip t

adolescents continue to improve their depressive symptoms following treatment termination. Although findings must be interpreted alongside study limitations, they offer exciting and

cr

preliminary support for the UP-A as a potentially efficacious psychosocial intervention for

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adolescents suffering from multiple emotional difficulties, and may offer important guidance into how to improve future iterations of this treatment.

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References

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Anderson, E., & Hope, D. A. (2008). A review of the tripartite model for understanding the link between anxiety and depression in youth. Clinical Psychology Review, 28(2), 275-287. doi:10.1016/j.cpr.2007.05.004

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Barlow, D.H., Farchione, T.J., Fairholme, C.P., Ellard, K.K., Boisseau, C.L., Allen, L.B., & Ehrenreich-May, J. (2010). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide. New York, NY: Oxford University Press. Brady, E. U., & Kendall, P. C. (1992). Comorbidity of anxiety and depression in children and adolescents. Psychological Bulletin, 111(2), 244-255. doi:10.1037/00332909.111.2.244 Brown, T. A. (2004). Advances in latent variable analysis: Applications to clinical research. Behavior Therapy, 35(2), 289-297. doi:10.1016/S0005-7894(04)80040-6 Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relationships among dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology, 107(2), 179-192. doi:10.1037/0021-843X.107.2.179 Chorpita, B. F., Moffitt, C. E., & Gray, J. (2005). Psychometric properties of the Revised Child Anxiety and Depression Scale in a clinical sample. Behaviour Research and Therapy, 43(3), 309-322. doi:10.1016/j.brat.2004.02.004 Chorpita, B. F., Yim, L., Moffitt, C., Umemoto, L. A., & Francis, S. E. (2000).

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26 TRAJECTORIES OF ANXIETY AND DEPRESSION Assessment of symptoms of DSM-IV anxiety and depression in children: A revised child anxiety and depression scale. Behaviour Research and Therapy, 38(8), 835-855. doi:10.1016/S0005-7967(99)00130-8

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Costello, E., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60(8), 837-844. doi:10.1001/archpsyc.60.8.837

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Costello, E., Pine, D. S., Hammen, C., March, J. S., Plotsky, P. M., Weissman, M. M., & ... Leckman, J. F. (2002). Development and natural history of mood disorders. Biological Psychiatry, 52(6), 529-542. doi:10.1016/S0006-3223(02)01372-0

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Crowley, S. L., & Emerson, E. N. (1996). Discriminant validity of self-reported anxiety and depression in children: negative affectivity or independent constructs. Journal of Clinical Child Psychology, 25(2), 139-146. doi:10.1207/s15374424jccp2502_2

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Dahl, R. E., Birmaher, B., Williamson, D. E., Dorn, L., Perel, J., Kaufman, J., & ... Ryan, N. D. (2000). Low growth hormone response to growth hormone-releasing hormone in child depression. Biological Psychiatry, 48(10), 981-988. doi:10.1016/S00063223(00)00932-X

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De Bolle, M., & De Fruyt, F. (2010). The tripartite model in childhood and adolescence: Future directions for developmental research. Child Development Perspectives, 4(3), 174180. doi:10.1111/j.1750-8606.2010.00136.x Ebesutani, C., Bernstein, A., Nakamura, B. J., Chorpita, B. F., & Weisz, J. R. (2010). A psychometric analysis of the Revised Child Anxiety and Depression Scale—Parent Version in a clinical sample. Journal of Abnormal Child Psychology: An Official Publication of the International Society for Research in Child and Adolescent Psychopathology, 38(2), 249-260. doi:10.1007/s10802-009-9363-8 Ebesutani, C., Chorpita, B. F., Higa-McMillan, C. K., Nakamura, B. J., Regan, J., & Lynch, R. E. (2011). A psychometric analysis of the Revised Child Anxiety and Depression Scales—Parent Version in a school sample. Journal of Abnormal Child Psychology: An Official Publication of the International Society for Research in Child and Adolescent Psychopathology, 39(2), 173-185. doi:10.1007/s10802-010-9460-8 Ehrenreich, J. T., Buzzella, B. A., Trosper, S. E., Bennett, S. M.,Wright, L. R., & Barlow, D. H. (2008). The Unified Protocol fortreatment of emotional disorders in adolescents. Unpublishedmanuscript, Boston University. Ehrenreich-May, J., Queen, A.H., Rodriguez, J.H., & Rosenfield, D. (2012, November). A randomized controlled trial of the Unified Protocol for Adolescents: Depression

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27 TRAJECTORIES OF ANXIETY AND DEPRESSION as a moderator of treatment outcomes. Paper presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, National Harbor, MD.

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Flores, B. H., Musselman, D. L., DeBattista, C., Garlow, S. J., Schatzberg, A. F., & Nemeroff, C. B. (2004). Biology of mood disorders. In A. F. Schatzberg, C. B. Nemeroff, A. F. Schatzberg, C. B. Nemeroff (Eds.) , The American Psychiatric Publishing Textbook of Psychopharmacology (3rd ed.) (pp. 717-763). New York, NY US: American Psychoanalytic Association.

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Fox, N. A., Nichols, K. E., Henderson, H. A., Rubin, K., Schmidt, L., Hamer, D., & ... Pine, D. S. (2005). Evidence for a gene-environment interaction in predicting behavioral inhibition in middle childhood. Psychological Science, 16(12), 921-926. doi:10.1111/j.1467-9280.2005.01637.x

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Garber, J., & Weersing, V. (2010). Comorbidity of anxiety and depression in youth: Implications for treatment and prevention. Clinical Psychology: Science and Practice, 17(4), 293-306. doi:10.1111/j.1468-2850.2010.01221.x

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Ginsburg, G. S., Kendall, P. C., Sakolsky, D., Compton, S. N., Piacentini, J., Albano, A., & ... March, J. (2011). Remission after acute treatment in children and adolescents with anxiety disorders: Findings from the CAMS. Journal of Consulting and Clinical Psychology, 79(6), 806-813. doi:10.1037/a0025933

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Kagan, J., Reznick, J., & Snidman, N. (1987). Temperamental variation in response to the unfamiliar. In N. A. Krasnegor, E. M. Blass, M. A. Hofer, N. A. Krasnegor, E. M. Blass, M. A. Hofer (Eds.) , Perinatal development: A psychobiological perspective (pp. 421440). San Diego, CA US: Academic Press. Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M., Southam-Gerow, M., Henin, A., & Warman, M. (1997). Therapy for youths with anxiety disorders: A second randomized clinical trial. Journal of Consulting and Clinical Psychology, 65(3), 366-380. doi:10.1037/0022-006X.65.3.366 Kline, R. B. (2011). Principles and practice of structural equation modeling (3rd ed.). New York, NY US: Guilford Press. Ollendick, T. H., Shortt, A. L., & Sander, J. B. (2005). Internalizing disorders of childhood and adolescence. In J. E. Maddux, B. A. Winstead, J. E. Maddux, B. A. Winstead (Eds.) , Psychopathology: Foundations for a contemporary understanding (pp. 353-376). Mahwah, NJ US: Lawrence Erlbaum Associates Publishers. O'Neil, K. A., & Kendall, P. C. (2012). Role of comorbid depression and co-occurring depressive symptoms in outcomes for anxiety-disordered youth treated with cognitivebehavioral therapy. Child & Family Behavior Therapy, 34(3), 197-209. doi:10.1080/07317107.2012.707086

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28 TRAJECTORIES OF ANXIETY AND DEPRESSION Silverman, W.K., & Albano, A.M. (1996). Anxiety disorders interview schedule for DSM-IV: Child and parent versions. San Antonio: Psychological Corp.

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Stark, K. D., & Laurent, J. (2001). Joint factor analysis of the Children's Depression I Inventory and the Revised Children's Manifest Anxiety Scale. Journal of Clinical Child Psychology, 30(4), 552-567. doi:10.1207/S15374424JCCP3004_11

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Stavrakaki, C., Vargo, B., Boodoosingh, L., & Roberts, N. (1987). The relationship between anxiety and depression in children: Rating scales and clinical variables. The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie, 32(6), 433-439.

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Treatment for Adolescents with Depression Study (TADS) Team. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. (2004). JAMA: Journal of the American Medical Association, 292(7), 807-820. doi:10.1001/jama.292.7.807

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Trosper, S. E., Buzzella, B. A., Bennett, S. M., & Ehrenreich, J. T. (2009). Emotion regulation in youth with emotional disorders: Implications for a unified treatment approach. Clinical Child and Family Psychology Review, 12(3), 234-254. doi:10.1007/s10567-009-0043-6

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Trosper, S. E., Whitton, S. W., Brown, T. A., & Pincus, D. B. (2012). Understanding the latent structure of the emotional disorders in children and adolescents. Journal of Abnormal Child Psychology, 40(4), 621-632. doi:10.1007/s10802-011-9582-7 Walkup, J. T., Albano, A., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., & ... Kendall, P. C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. The New England Journal of Medicine, 359(26), 2753-2766. doi:10.1056/NEJMoa0804633 Weems, C. F., Zakem, A. H., Costa, N. M., Cannon, M. F., & Watts, S. E. (2005). Physiological response and childhood anxiety: Association with symptoms of anxiety disorders and cognitive bias. Journal of Clinical Child and Adolescent Psychology, 34(4), 712-723. doi:10.1207/s15374424jccp3404_13 Weiss, D.C., & Chorpita, B.F. (2011). Revised Children’s Anxiety and Depression Scale: User’s guide. Unpublished manuscript, University of California at Los Angeles. Weisz, J. R., McCarty, C. A., & Valeri, S. M. (2006). Effects of psychotherapy for depression in children and adolescents: A meta-analysis. Psychological Bulletin, 132(1), 132-149. doi:10.1037/0033-2909.132.1.132

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29 TRAJECTORIES OF ANXIETY AND DEPRESSION

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Figure 1. UP-A CONSORT Flow Diagram Figure 2. Self-Rated Symptom Change Trajectories During the UP-A and Follow-Up Figure 3. Parent-Rated Symptom Change During the UP-A and Follow-Up

Page 29 of 36

30 TRAJECTORIES OF ANXIETY AND DEPRESSION Table 1. Frequencies of Diagnoses at Baseline Diagnosis Diagnoses (%) Total (%)

Principal Diagnosis (%)*

Comorbid

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Generalized Anxiety Disorder 23 (38.98%) 15 (25.42%) 38 (64.41%) Social Phobia 19 (32.20%) 7 (11.86%) 26 (44.07%) Major Depressive Disorder 11 (18.64%) 14 (23.73%) 25 (42.37%) Obsessive-Compulsive Disorder 4 (6.78%) 4 (6.78%) 8 (13.56%) Panic Disorder with Agoraphobia 3 (5.08%) 3 (5.08%) Specific Phobia 3 (5.08%) 5 (8.47%) 8 (13.56%) Panic Disorder without Agoraphobia 2 (3.39%) 2 (3.39%) 4 (6.78%) Tic Disorder 1 (1.69%) 1 (1.69%) Anxiety Disorder NOS 5 (8.47%) 2 (3.39%) 7 (11.86%) Dysthymic Disorder 2 (3.39%) 3 (5.08%) 5 (8.47%) Trichotillomania 1 (1.69%) 1 (1.69%) ADHD, Combined Type 1 (1.69%) 2 (3.39%) 3 (5.08%) Separation Anxiety Disorder 2 (3.39%) 2 (3.39%) Depressive Disorder NOS 6 (10.17%) 6 (10.17%) Post-Traumatic Stress Disorder 1 (1.69%) 1 (1.69%) Enuresis 1 (1.69%) 1 (1.69%) ADHD, Inattentive Type 1 (1.69%) 1 (1.69%) Oppositional-Defiant Disorder 1 (1.69%) 1 (1.69%) Eating Disorder NOS 1 (1.69%) 1 (1.69%) ______________________________________________________________________________ ________________________ *Note. Percentages do not add to 100 because some subjects had co-principal diagnoses.

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31 TRAJECTORIES OF ANXIETY AND DEPRESSION

SuggestedNumber of Sessions 1-3

Techniques/Skills Psychoeducation of emotions, functional assessment of

Core UP/UP-A Principle(s) Targeted Present-focused emotional awareness

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Required Module 1

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32 TRAJECTORIES OF ANXIETY AND DEPRESSION

3

1-3

Identifying thinking traps, detective thinking skills, generating alternative thoughts, problem-solving skills

4

4+

Interoceptive exposures, invivo exposures, behavioral activation

5

1-2

Optional Module 1 2

Suggested Number of Sessions As needed 0-3

Skill consolidation, relapse prevention Techniques/Skills

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Preventing emotional avoidance, acceptance of physiological sensations, facilitating exposure to interoceptive and in-vivo emotional triggers

Motivational enhancement Safety planning, crisis management Parenting skills

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3

Present-focused awareness, preventing emotional avoidance, acceptance of emotionrelated physiological sensations Enhancing cognitive flexibility

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1-3

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2

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antecedents, behaviors, and consequences associated with emotional experiences Generalized emotion exposures, practice of nonjudgmental awareness

0-3 (At least 1 recommended) Table 2. UP-A Structure and Content

Table 3. Observed Means and Standard Deviations of Anxiety and Depressive T-scores at Follow-up Time Points ______________________________________________________________________________ _______________________ RCADS M (SD) Minimum Maximum % T  65* % T  70* Baseline Total Anxiety T 53.12 (12.38) 34 89 20.34 15.25

Page 32 of 36

33 TRAJECTORIES OF ANXIETY AND DEPRESSION 50.24 (12.25)

28

87

44.04 (10.00)

27

69

39.11 (9.27) 38.17 (9.96)

27 27

63 66

Baseline MDD T 25.42 20.34 8-Week MDD T 23.64 16.36 Post MDD T 14.58 8.33 3-Month MDD T 10.34 6-Month MDD T 12.50 12.50 RCADS-P % T  65* % T  70* Baseline Total Anxiety T 30.51 23.73 8-Week Total Anxiety T 25.45 12.73 Post Total Anxiety T 12.50 8.33 3-Month Total Anxiety T 3.45 6-Month Total Anxiety T 8.33 4.17

57.88 (13.78)

32

55.11 (15.02)

30

48.85 (14.18)

29

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97 84

29

68

29

83

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46.00 (15.81)

Minimum

Maximum 106

62.14 (13.11)

44

102

57.50 (15.86)

38

103

51.83 (9.03)

41

70

51.87 (9.78)

39

72

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42

d

64.77 (14.38)

89

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44.68 (13.31)

M (SD)

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8-Week Total Anxiety T 9.09 5.45 Post Total Anxiety T 2.08 3-Month Total Anxiety T 6-Month Total Anxiety T 4.17

Baseline MDD T 67.80 (15.77) 42 104 45.76 32.20 8-Week MDD T 65.03 (16.06) 42 110 29.09 21.82 Post MDD T 58.38 (14.06) 38 94 20.83 14.58 3-Month MDD T 55.71 (11.93) 41 88 10.34 6.90 6-Month MDD T 57.20 (19.54) 38 107 12.50 8.33 Note. RCADS = Revised Children’s Anxiety and Depression Scale; RCADS-P = Revised Children’s Anxiety and Depression Scale, Parent version; MDD = Major Depressive Disorder *Percentages calculated based upon n for each time point

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