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Blues Program

Blueprints Program Rating: Model

A six-week group intervention focused on reducing negative cognitions and increasing engagement in pleasant activities in an effort to prevent the onset and persistence of depression in at-risk high school youth with depressive symptoms.

  • Depression
  • Illicit Drug Use

    Program Type

    • Cognitive-Behavioral Training
    • Counseling and Social Work

    Program Setting

    • School

    Continuum of Intervention

    • Selective Prevention (Elevated Risk)
    • Indicated Prevention (Early Symptoms of Problem)

    A six-week group intervention focused on reducing negative cognitions and increasing engagement in pleasant activities in an effort to prevent the onset and persistence of depression in at-risk high school youth with depressive symptoms.

      Population Demographics

      A six-week group intervention for high school youth who present depressive symptoms, or are at-risk for the onset of major depression. The program was ineffective for college-age youth.

      Age

      • Late Adolescence (15-18) - High School

      Gender

      • Male and Female

      Race/Ethnicity

      • All Race/Ethnicity

      Race/Ethnicity/Gender Details

      All samples were primarily female including between 56% (Study 2) and 70% (Study 3) girls. Study 1 included primarily White participants (72%), Study 2 included primarily White (46%) and Hispanic (33%) participants, and participants in Study 3 were 55% White, 17% Asian, 15% Hispanic, 6% Black, and 7% identified as other or mixed racial/ethnic category.

      One study included a subgroup analysis by race/ethnicity (Marchand et al., 2010). In reanalyzing data from Studies 2 and 3, it found no differences in program effects across race and ethnic groups.

      The program focuses on reducing negative cognitions and increasing engagement in pleasant activities.

      • Individual
      Risk Factors
      • Individual: Stress
      Protective Factors
      • Individual: Coping Skills

      See also: Blues Program Logic Model (PDF)

      The Blues Program (Cognitive Behavioral Group Depression Prevention) is intended to actively engage high school students with depressive symptoms or at risk of onset of major depression, includes six weekly one-hour group sessions and home practice assignments. Weekly sessions focus on building group rapport and increasing participant involvement in pleasant activities (all sessions), learning and practicing cognitive restructuring techniques (sessions 2-4), and developing response plans to future life stressors (sessions 5-6). In-session exercises require participants to apply skills taught in the program. Home practice assignments are intended to reinforce the skills taught in the sessions and help participants learn how to apply these skills to their daily life.

      The Blues Program is intended to actively engage participants, includes six weekly one-hour sessions and home practice assignments. The six weekly sessions begin with a review of concepts and the home practice assignments, and all sessions conclude with a homework assignment. Weekly sessions focus on building group rapport and increasing participant involvement in pleasant activities (all sessions), learning and practicing cognitive restructuring techniques (sessions 2-4), and developing response plans to future life stressors (sessions 5-6). Additionally, each session has a portion devoted to thought identification/recording, and the participants apply skills taught in the program. During the sessions, motivational enhancement exercises are used to maximize willingness to use the new skills, strategic self-presentation is used to facilitate internalization of key principles, behavioral techniques function to reinforce the use of the new skills, and group activities foster feelings of social support and group cohesion. The homework is used to reinforce the skills taught in the sessions and help participants learn how to apply these skills to their daily life.

      The program focuses on reducing negative cognitions because prior research has found that a negative view toward oneself, one’s experiences, and the future increase risk for onset and persistence of depression. The program’s goal of increasing engagement in pleasant activities is based on the behavioral theory of depression that posits that negative moods prompt a withdrawal from pleasant activities that exacerbates a depressed mood.

      • Cognitive Behavioral

      All studies included students with depressive symptoms (but not a major depression diagnosis) when screened prior to conducting the study. Each study involved the random assignment of participants to groups (ranging from three groups in Rohde, Stice, Shaw, & Briere, 2014 and Rohde, Stice, Shaw, & Gau, 2014, to six in Stice et al., 2006) participating in various interventions for depression, with only one study (Stice et al., 2006) including a non-intervention control group. All studies included measures of depressive symptoms and major depression onset.

      Rohde, Stice, Shaw, and Briere (2014) and Rohde et al. (2015) included 378 students from five high schools who completed self-report surveys and diagnostic interviews at pretest, posttest (upon program completion), and 6-, 12-, 18- and 24-month follow-ups.

      Stice et al. (2008) and Stice, Rohde, Gau, and Wade (2010) included 341 students from six high schools in the greater Austin, Texas area who completed self-report surveys and diagnostic interviews at pretest, posttest (upon program completion), and six-month, one-year, and two-year follow-ups.

      Stice et al. (2006) included 225 students from two high schools and one college who completed self-report surveys at pretest, posttest (upon program completion), and one-month and six-month follow-ups.

      Rohde, Stice, Shaw, and Gau (2014) included 82 students from one large state university who completed self-report surveys and diagnostic interviews at pretest, posttest (upon program completion), and 6-month and 12-month follow-ups.

      With regard to depression, the program’s primary outcome, participants completing the cognitive behavioral depression prevention program (as compared to participants in one or more comparison groups) had significantly greater reductions in interviewer-rated depressive symptoms at posttest (Rohde, Stice, Shaw, & Briere, 2014; Stice et al., 2008), six-month follow-up (Stice et al., 2008), and one- and two-year follow-ups (Stice, Rohde, Gau, & Wade, 2010). Greater reductions were also found for self-rated depressive symptoms at posttest (Stice et al., 2006; Stice et al., 2008), one-month follow-up (Stice et al., 2006), six-month follow-up (Stice et al., 2008), and two-year follow-up (Stice, Rohde, Gau, & Wade, 2010). Additionally, program participants had lower rates of major depression onset at six-month (Rohde, Stice, Shaw, & Briere., 2014; Stice et al., 2008) and two-year follow-ups (Rohde et al., 2015; Stice, Rohde, Gau, & Wade, 2010).

      Measuring secondary outcomes, Stice et al., (2008) found that participants completing the cognitive behavioral depression prevention program had greater reductions in self-reported substance use at posttest and six-month follow-up, and greater improvements in social adjustment at six-month follow-up.

      Though Rohde, Stice, Shaw, and Gau (2014) found no significant program effects on primary or secondary outcomes of depression, substance abuse, and social adjustment, they did observe significantly higher scores on a measure of cognitive behavioral knowledge among cognitive behavioral depression prevention group participants when compared to control group participants at posttest.

      Compared to participants in one or more comparison groups, participants completing the cognitive behavioral depression prevention program had:

      • greater reductions in interviewer-rated depressive symptoms at posttest (Rohde, Stice, Shaw, & Briere, 2014; Stice et al., 2008), six-month follow-up (Stice et al., 2008), and one- and two-year follow-ups (Stice, Rohde, Gau, & Wade, 2010);
      • greater reductions in self-rated depressive symptoms at posttest (Stice et al., 2006; Stice et al., 2008), one-month follow-up (Stice et al., 2006), six-month follow-up (Stice et al. 2008), and two-year follow-up (Stice, Rohde, Gau & Wade, 2010);
      • lower rates of major depression onset at six-month follow-up (Rohde, Stice, Shaw, & Briere, 2014; Stice et al., 2008) and two-year follow-up (Rohde et al., 2015; Stice, Rohde, Gau, & Wade, 2010);
      • greater reductions in self-reported substance use at posttest and six-month follow-up (Stice et al., 2008).

      Effects on risk and protective factors:

      • Participants in the intervention group had significantly higher scores on a measure of cognitive behavioral knowledge than control group participants at posttest (Rohde, Stice, Shaw, & Gau, 2014), greater improvements in social adjustment at six-month follow-up (Stice et al., 2008), and reduced negative cognitions and increased reports of pleasant activities (Stice, Rohde, Seeley, & Gau, 2010).

      Stice, Rohde, Seeley, and Gau (2010) present formal tests of mediation for Study 2. In support of the posited mediation, measures of negative cognitions and pleasant activities were improved by the intervention, affected an outcome measure of depression, and when serving as controls reduced the effect of the intervention on depression. However, tests also showed that, in contradiction to the mediation model, changes in depression largely occurred before changes in the negative cognitions and pleasant activities mediators.

      Reported effect sizes ranged from small (d=.20) to large (r=.48) for the significant outcomes.

      Samples have been limited to students from five high schools in one county (state unreported, Study 1), six high schools in the greater Austin, Texas area (Study 2), two high schools and one college (state unreported, Study 3), and one large state university (Study 4).

      All studies include the following limitations:

      • Limited sample.
      • Few measures of risk and protective factors.
      • Mixed evidence of program effectiveness.

      Study 1 (Rohde, Stice, Shaw, & Briere, 2014; Rohde et al., 2015)

      • Inconsistent reporting of overall attrition.
      • Limited effects at posttest and, in particular, 6-month and 2-year follow-up.
      • No measurement of risk and protective factors.

      Study 2 (Stice et al., 2008; Stice, Rohde, Gau, & Wade, 2010; Stice, Rohde, Seeley, & Gau 2010)

      • Significant difference on one outcome measure (depressive symptoms) between conditions at baseline.

      Study 3 (Stice et al., 2006)

      • Details on attrition at each wave were not presented.
      • Randomized trial, but some conditions “were added after the study was underway,” and no details are provided on the change.
      • Marginally significantly greater attrition in the cognitive behavioral depression prevention group relative to all other (5) conditions.
      • Posttest effects are not significant at 6-month follow-up assessment in comparison to the control group and rarely significant in comparison to other conditions.
      • Limited information on implementation fidelity.
      • No measurement of risk and protective factors.

      Study 4 (Rohde, Stice, Shaw & Gau, 2014)

      • Groups differed on one secondary outcome measure at baseline.
      • No significant effects on primary or secondary outcomes at posttest or 12-month follow-up.

      • Blueprints: Model

      Organization:  New York Foundling
      Dr. Erica Smith
      Director of the Article 31 Clinic
      Erica.Smith@NYFoundling.org
      tel: 917-485-7243

      Or

      Sylvia Rowlands
      Vice president for evidence-based practices
      Sylvia.Rowlands@NYFoundling.org

      Marchand, E., Ng, J., Rohde, P., & Stice, E. (2010). Effects of an indicated cognitive-behavioral depression prevention program are similar for Asian American, Latino, and European American adolescents. Behaviour Research and Therapy, 48, 821-825.

      Rohde, P., Stice, E., Shaw, H., & Briere, F. N. (2014). Indicated cognitive behavioral group depression prevention compared to bibliotherapy and brochure control: Acute effects of an effectiveness trial with adolescents. Journal of Consulting and Clinical Psychology, 82 (1), 65-74.

      Rohde, P., Stice, E., Shaw, H., & Gau, J. M. (2014). Cognitive-behavioral group depression prevention compared to bibliotherapy and brochure control: Nonsignificant effects in pilot effectiveness trial with college students. Behaviour Research and Therapy, 55, 48-53.

      Rohde, P., Stice, E., Shaw, H., & Gau, J. M. (2015). Effectiveness trial of an indicated cognitive-behavioral group adolescent depression prevention program versus bibliotherapy and brochure control at 1- and 2-year follow-up. Journal of Consulting and Clinical Psychology, 83 (4), 736-747.

      Stice, E., Burton, E., Bearman, S. K., & Rohde, P. (2006). Randomized trial of a brief depression prevention program: An elusive search for a psychosocial placebo control condition. Behaviour Research and Therapy, 45, 863-876.

      Stice, E., Rohde, P., Gau, J. M., & Wade, E. (2010). Efficacy trial of a brief cognitive-behavioral depression prevention program for high-risk adolescents: Effects at 1- and 2-year follow-up. Journal of Consulting and Clinical Psychology, 78 (6), 856-867.

      Stice, E., Rohde, P., Seeley, J. R., & Gau, J. M. (2008). Brief cognitive-behavioral depression prevention program for high-risk adolescents outperforms two alternative interventions: A randomized efficacy trial. Journal of Consulting and Clinical Psychology, 76 (4), 595-606.

      Stice, E., Rohde, P., Seeley, J. R., & Gau, J. M. (2010). Testing mediators of intervention effects in randomized controlled trials: An evaluation of three depression prevention programs. Journal of Consulting and Clinical Psychology, 78 (2), 273-280.

      Paul Rohde, Ph.D.
      Oregon Research Center
      1776 Millrace Drive
      Eugene, OR 97403
      (541) 484-2123
      paulr@ori.org
      thebluesprogram.weebly.com/

      Study 1

      Rohde, P., Stice, E., Shaw, H., & Briere, F. N. (2014). Indicated cognitive behavioral group depression prevention compared to bibliotherapy and brochure control: Acute effects of an effectiveness trial with adolescents. Journal of Consulting and Clinical Psychology, 82, (1), 65-74.

      Rohde, P., Stice, E., Shaw, H., & Gau, J. M. (2015). Effectiveness trial of an indicated cognitive-behavioral group adolescent depression prevention program versus bibliotherapy and brochure control at 1- and 2-year follow-up. Journal of Consulting and Clinical Psychology, 83(4), 736-747.

      Study 2

      Marchand, E., Ng, J., Rohde, P., & Stice, E. (2010). Effects of an indicated cognitive-behavioral depression prevention program are similar for Asian American, Latino, and European American adolescents. Behaviour Research and Therapy, 48, 821-825.

      Stice, E., Rohde, P., Gau, J. M., & Wade, E. (2010). Efficacy trial of a brief cognitive-behavioral depression prevention program for high-risk adolescents: Effects at 1- and 2-year follow-up. Journal of Consulting and Clinical Psychology, 78 (6), 856-867.

      Stice, E., Rohde, P., Seeley, J. R., & Gau, J. M. (2008). Brief cognitive-behavioral depression prevention program for high-risk adolescents outperforms two alternative interventions: A randomized efficacy trial. Journal of Consulting and Clinical Psychology, 76 (4), 97-112.

      Stice, E., Rohde, P., Seeley, J. R., & Gau, J. M. (2010). Testing mediators of intervention effects in randomized controlled trials: An evaluation of three depression prevention programs. Journal of Consulting and Clinical Psychology, 78, (2), 273-280.

      Rohde, P., Stice, E., Shaw, H., & Briere, F. N. (2014). Indicated cognitive behavioral group depression prevention compared to bibliotherapy and brochure control: Acute effects of an effectiveness trial with adolescents. Journal of Consulting and Clinical Psychology, 82 (1), 65-74.

      Rohde, P., Stice, E., Shaw, H., & Gau, J. M. (2015). Effectiveness trial of an indicated cognitive-behavioral group adolescent depression prevention program versus bibliotherapy and brochure control at 1- and 2-year follow-up. Journal of Consulting and Clinical Psychology, 83(4), 736-747.

      This is a long-term effectiveness trial implemented by school personnel.

      Design:

      Recruitment /Sample size: Students (approximately 8,020) from five high schools from three school districts in one county (state not reported) were recruited through direct mailings sent to all students and recruitment posters hung at the schools between 2009 and 2011. The mailing included a simplified version of the Center for Epidemiological Studies-Depression Scale (CES-D). Students who completed the CES-D and endorsed two or more depression symptoms were encouraged to participate in the study. Eligible students providing individual and parental consent (n=451) were then asked to schedule an eligibility interview with research staff to be completed at school. Of 421 students that attended the eligibility interview, 43 were excluded for meeting the diagnostic criteria for major depressive disorder resulting in an original sample of 378 students.

      Study type/Randomization/Intervention: Eligible participants (n=378) were randomly assigned, within blocks created by gender and school, to one of three conditions: (1) cognitive behavioral group depression prevention (n=126), (2) cognitive behavioral bibliotherapy (n=128), or (3) brochure control (n=124). Participants in the cognitive behavioral prevention group completed six weekly one-hour program sessions in single-gender groups of five to nine participants at school (usually after normal classes). Students in the cognitive behavioral bibliotherapy group were given a personal copy of the book Feeling Good, which provides relevant and practical cognitive behavioral techniques for preventing and reducing negative moods. Participants in the brochure control group were given a National Institute of Mental Health brochure that describes major depressive disorder and recommends treatment for depressed youth, as well as information about local treatment options.

      Assessment/Attrition: Participants completed a survey and diagnostic interview at pretest (during the eligibility interview), posttest, and 6-, 12-, 18- and 24-month follow-ups. At posttest, all participants in the cognitive behavioral prevention group completed assessments, but the cognitive behavioral bibliotherapy and brochure control groups each had an attrition rate of 8%. At six-month follow-up, attrition rates were reportedly 5% for the cognitive behavioral prevention group, and 12% for each of the other two groups. From pretest to 6-month follow-up, total attrition was 9.5% in Figure 1 and 13% in the text (this total is inconsistently reported). Attrition was 7% at 1-year, 10% at 18-month, and 12% at 2-year follow-up.

      Sample characteristics:

      The sample included high school students who ranged in age from 13 to 19 years, with a mean age of 15.5 years at pretest. Sixty-eight percent of participants were female, 72% were Caucasian, 6% Hispanic, 2% Asian, 1% African American, 1% Native American, and 18% identified as other or mixed racial/ethnic category. Educational attainment of parents was 39% high school graduate or less, 26% some college, 22% college graduate, and 13% graduate degree. Thirty-seven percent of participants had received treatment services for mental health problems during the 12-month period preceding the study.

      Measures:

      Validity of measurements: All measures and scales have been used in prior published work and reliability and validity has been established.

      Primary outcomes: An adapted version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), a 16-question semi-structured diagnostic interview assessing major depressive disorder (MDD) symptoms, was used to determine whether participants met diagnostic criteria for MDD. In addition to identifying the onset of MDD, K-SADS data were used to calculate a continuous depressive symptom composite by averaging the severity ratings for each symptom.

      Secondary outcomes: Substance use was measured with 10 items from a previous study in which participants were asked to report the frequency of alcohol and drug use.

      Social adjustment in school, work, peer, spare time, and family domains was measured using an adapted version of the Social Adjustment Scale-Self-Report for Youth.

      At pretest, after receiving a description of the three conditions, participants completed four items assessing credibility (this concept is undefined), expected improvement from each condition, satisfaction with regard to the condition to which the participant was assigned, and preferred group assignment.

      Analysis:

      Statistical methods/baseline control/correct unit of analysis: The primary outcome of major depressive disorder onset was analyzed using Cox proportional hazard regression models with missing data taken into account with right-censoring.

      All other outcomes (depressive symptom severity, social adjustment, and substance use) were evaluated using repeated measures analysis of covariance (ANCOVA) with pretest value of the outcome as covariate. These analyses used multiple imputation to replace missing values. Long-term 2-year effects from posttest were evaluated with random effects growth models in a hierarchical modeling framework that adjusted for clustering within treatment groups.

      F tests were used to investigate the main effect of condition and group-by-time interactions for the depressive symptom severity and the secondary outcomes.

      Intention-to-treat: Multiple imputation was used to replace missing values in all ANCOVAs and multilevel models. Additionally, deliberate efforts were made to maintain contact with participants to reduce attrition.

      Outcomes:

      Implementation fidelity: Program facilitators were trained, observed, recorded (and provided feedback on their performance), and rated for competency in and adherence to the program. Half of the audio-recorded sessions were randomly selected for review by the researchers. Using 1 to 10 point scales, mean adherence was 7.0, and mean competence was 7.1, with less than 2% of items rated as “minimal adherence” or “minimal competence.” Students in the cognitive behavioral prevention group attended an average of 5.3 sessions, with 48% attending all six. Additionally, individual make-up sessions were offered to students who missed scheduled sessions—with 94% of participants missing a session receiving the make-up—and 80% of program homework assignments were recorded by the group leader as completed.

      Baseline Equivalence: At baseline, participants in the three conditions did not significantly differ on outcome measures, demographic variables, or receipt of mental health treatment one year prior to enrollment in the study.

      Differential attrition: The study reports that attrition did not differ between the three groups at posttest or at any follow-up, and missingness was not significantly related to any of the study variables at pretest with one exception. Participants who completed assessments at all six time-points had significantly lower baseline substance use compared to those that did not.

      Posttest: Cox proportional hazard regression analysis indicated that the onset of major depressive disorder at six-month follow-up was significantly greater in both the brochure control (p=.023, one-tailed) and cognitive behavioral bibliotherapy (p=.024, one-tailed) comparison groups than in the treatment group. Controls for school, mental health treatment, and intervention expectancies did not change the significance of the hazard regression coefficients.

      ANCOVAS revealed that the cognitive behavioral prevention group had significantly lower depressive symptom severity than the brochure control group at posttest (d=.29), but not six-month follow-up (both without and with controls). Depressive symptom differences between the cognitive behavioral prevention group and the cognitive behavioral bibliotherapy group were marginally significant at posttest (p=.06), with lower severity among the prevention group, but non-significant at six-month follow-up. No other significant differences were found for other outcome measures of social adjustment or substance use.

      Additionally, less powerful exploratory F tests were used as a check on the ANCOVA group comparisons. The tests found no overall main effect of condition or group-by-time interaction effects for depressive symptom severity, social adjustment, or substance use.

      Long-term effects: Cox proportional hazard regression analysis indicated that the onset of major depressive disorder through the 2-year follow-up was significantly greater in the cognitive behavioral bibliotherapy (p=.006, one-tailed) comparison group than in the treatment group but not in the brochure only comparison group. The hazard models showed the same results for the onset of major depressive disorder or minor depression.

      No additional effects were found, suggesting that posttest effects were largely equalized during the long-term follow-up period.

      Limitations:

      • Sample limited to students from five high schools in one county (with the state unreported).
      • Inconsistent reporting of overall attrition.
      • Risk and protective factors not measured.
      • Limited effects at posttest and, in particular, during follow-up period.

      Marchand, E., Ng, J., Rohde, P., & Stice, E. (2010). Effects of an indicated cognitive-behavioral depression prevention program are similar for Asian American, Latino, and European American adolescents. Behaviour Research and Therapy, 48, 821-825.

      Stice, E., Rohde, P., Seeley, J. R., & Gau, J. M. (2008). Brief cognitive-behavioral depression prevention program for high-risk adolescents outperforms two alternative interventions: A randomized efficacy trial. Journal of Consulting and Clinical Psychology, 76 (4), 97-112.

      Stice, E., Rohde, P., Gau, J. M., & Wade, E. (2010). Efficacy trial of a brief cognitive-behavioral depression prevention program for high-risk adolescents: Effects at 1- and 2-year follow-up. Journal of Consulting and Clinical Psychology, 78 (6), 856-867.

      Stice, E., Rohde, P., Seeley, J. R., & Gau, J. M. (2010). Testing mediators of intervention effects in randomized controlled trials: An evaluation of three depression prevention programs. Journal of Consulting and Clinical Psychology, 78 (2), 273-280.

      Design:

      Recruitment /Sample size: Participants were recruited through mass mailings, handbills, and posters targeting students experiencing sadness at six high schools in the greater Austin area in Texas between 2004 and 2007. Interested students were given a depressive symptom screen (the Center for Epidemiological Studies-Depression Scale [CES-D]). Students who scored above a pre-determined cutoff point for inclusion (20 or above) and had individual and parental consent were invited to complete a pretest assessment. Those who met criteria for major depression during pretest were excluded and given treatment referrals. In total, 698 students were assessed for eligibility, and 341 students (40 to 75 per school) were randomly assigned to condition.

      Study type/Randomization/Intervention: Using blocks created by gender and school, eligible participants were randomly assigned to one of four conditions: (1) cognitive behavioral depression prevention (n=89), (2) supportive-expressive intervention (n=88), (3) bibliotherapy intervention (n=80), or (4) educational brochure control group (n=84). Participants in the cognitive behavioral depression prevention group participated in the six-week cognitive behavioral program. Students in the supportive-expressive intervention group participated in a six-week program, including weekly one-hour sessions, that provided a supportive group for participants to identify, express, and discuss their feelings. Subjects in the bibliotherapy intervention group were given a copy of the book Feeling Good, and encouraged to use the book as a self-help resource. Students in the brochure control condition were given a brochure that describes major depression, recommends treatment, and provides information about local treatment options.

      Facilitators attended a two-day training. During the groups, one of the program developers conducted separate weekly supervision meetings with the CB and supportive-expressive facilitators to provide corrective feedback.

      Assessment/Attrition: Measures included diagnostic interviews and participant-completed surveys at pretest, posttest (upon program completion), six-month follow-up (Stice et al., 2008), and one- and two-year follow-ups (Stice, Rohde, Gau & Wade, 2010). Attrition rates were 3% at posttest, 7% or 9% at six-month follow-up (this total is inconsistently reported), 15% at one-year follow-up, and 22% at two-year follow-up.

      Sample characteristics:

      Participants ranged in age from 14 to 19 years (with a mean age of 15.6 years) at pretest. Fifty-six percent of participants were women (44% men), 46% were Caucasian, 33% Hispanic, 9% African American, 2% Asian, and 10% identified as other or mixed racial/ethnic category. Educational attainment of parents was 26% high school graduate or less, 17% some college, 35% college graduate, and 18% graduate degree. Twenty-eight percent of the sample had received treatment services for emotional/behavioral problems during the 12-month period preceding the study.

      Measures:

      Validity of measurements: All measures and scales have been used in prior published work and reliability and validity has been established.

      Primary outcomes: An adapted version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), a 16-question semi-structured diagnostic interview assessing major depressive disorder (MDD) symptoms, was used to determine whether participants met diagnostic criteria for MDD. During interviews with trained professionals who were blind to condition, participants reported the peak severity of each symptom over their lifetime (pretest) or since the last interview (posttest and follow-ups) using a four-point scale.

      In addition to identifying the onset of MDD, K-SADS data were used to calculate a continuous depressive symptom composite by averaging the severity ratings for each symptom.

      Depressive symptoms were also measured using self-reports from the 21-item Beck Depression Inventory (BDI).

      Secondary outcomes: Social adjustment (for all assessments except posttest) was measured using an adapted version of the Social Adjustment Scale-Self-Report for Youth assessing social impairment in school, peer, spare time, and family domains.

      The following measures are only reported for posttest and six-month follow-up analyses (Stice et al., 2008):

      Substance use was measured with 10 items from a previous study in which participants were asked to report the frequency of alcohol and drug use. Items were averaged to form an overall substance use measure.

      Bulemic pathology was measured using the Eating Disorder Diagnostic Interview. Items assessing symptoms of bulimia nervosa were summed to create an overall index of the disorder’s behavioral symptoms.

      Stice, Rohde, Seeley, and Gau (2010) examined several measures of mediating risk and protective factors:

      • Negative cognitions with 12 items from the Automatic Thoughts Questionnaire (alpha = .93)
      • Pleasant activities with 12 items from the Pleasant Events Schedule (alpha = .73)
      • Emotional expression with 9 items developed for the study (alpha = .82)
      • Loneliness with 8 items from the Loneliness Scale (alpha = .83)

      Analysis:

      Statistical methods/baseline control/correct unit of analysis: Omnibus repeated measures analysis of covariance (ANCOVA) models (with baseline interviewer-rated depressive symptoms used as a covariate) with group-by-time interactions were used to test for differential changes in the continuous outcomes. For outcomes with significant group-by-time interactions, separate follow-up repeated measures ANCOVA models tested whether groups differed from each other from pretest to posttest and pretest to six-month follow-up (Stice et al., 2008), and from pretest to one-year follow-up and pretest to two-year follow-up (Stice, Rohde, Gau, & Wade, 2010).

      Cox proportional hazard regression models controlling for interviewer-rated depressive symptoms at baseline were used to analyze the onset of major (or minor (Stice, Rohde, Gau, Wade, 2010)) depression.

      The reliable change index was used to analyze change scores—testing for clinically significant change—in interviewer-rated depressive symptoms and social adjustment from pretest to six-month follow-up (Stice et al., 2008), and interviewer-rated and self-rated depressive symptoms from pretest to two-year follow-up (Stice, Rohde, Gau, & Wade, 2010).

      Intention-to-treat: The study employs intent-to-treat analyses by using maximum likelihood estimates to impute missing data and include all randomized subjects in the analysis.

      Outcomes:

      Implementation fidelity: Among students in the cognitive behavioral prevention group, 44% attended all six sessions and 86% attended at least three (with the average participant attending 3.3 sessions), and 7% completed all homework assignments, 20% completed three or four, 25% completed one or two, and 48% completed none. Relying on checklists and scales used in prior research (with demonstrated reliability), the researchers evaluated each group facilitator during two sessions for their first group, and one session for each subsequent group, and report the following: 96% of the programs’ components were rated at full-adherence and 94% of the items were rated at ‘good’ competence (with only 1% ‘poor’).

      Baseline Equivalence: At baseline, participants in the bibliotherapy intervention group had significantly lower interview-assessed (K-SADS) depressive symptoms than participants in the other intervention groups (but not the brochure control group). Participants did not differ on demographic characteristics, treatment services received for emotional/behavior problems during the year prior to the study, or any other outcome measures at baseline.

      Differential Attrition: Attrition did not differ significantly by condition, nor was attrition related to any baseline outcomes or demographic factors.

      Posttest: Stice et al. (2008) report significant effects in Table 2 for 17 of 21 tests for the intervention condition at posttest and six-month follow-up:

      Participants in the cognitive behavioral depression prevention group had significantly greater reductions in interviewer-rated depressive symptoms than participants in all comparison groups at posttest, and greater reductions than brochure control group (only) participants at six-month follow-up. Similarly, participants in the cognitive behavioral depression prevention group had significantly greater reductions in self-rated depressive symptoms (Beck Depression Inventory) than participants in all comparison groups at posttest, and greater reductions than bibliotherapy intervention and brochure control (but not supportive-expressive intervention) group participants at six-month follow-up. Positive program effects on the Beck Depression Inventory and K-SADS were statistically equivalent across race and ethnic groups (Marchand et al., 2010).

      Participants in the cognitive behavioral depression prevention group showed significantly greater improvements in social adjustment than participants in all comparison groups at six-month follow-up (the social adjustment scale was not completed at posttest).

      Participants in the cognitive behavioral depression prevention group had significantly greater reductions in self-reported substance use than did participants in the bibliotherapy intervention and brochure control groups at posttest, and greater reductions than participants in all comparison groups at six-month follow-up. The difference between cognitive behavioral depression prevention group participants and supportive-expressive intervention group participants was marginally significant at posttest (p=.069).

      Using the reliable change index, analyses from pretest to six-month follow-up found the following: reliable change rates for interviewer-rated depressive symptoms were significantly higher among cognitive behavioral depression prevention group participants than participants in the brochure control group (OR=2.9); and reliable change rates for social adjustment were significantly higher among cognitive behavioral depression prevention group participants than participants in the bibliotherapy intervention (OR=3.1) and brochure control groups (OR=2.5).

      Cox proportional hazard regression models revealed that participants in the cognitive behavioral depression prevention group showed a significantly lower risk for the onset of major depression than participants in the brochure control group (OR=2.5) at six-month follow-up.

      A dose-response analysis revealed a significant, positive relationship between the number of sessions attended and interviewer-rated depressive symptoms for participants in the cognitive behavioral depression prevention group at posttest (r=.27).

      In formal mediation tests (Stice, Rohde, Seeley, & Gau, 2010), measures of negative cognitions and pleasant activities were improved by the intervention, affected an outcome measure of depression, and when serving as controls reduced the effect of the intervention on depression. However, tests also showed that, in contradiction to the mediation model, changes in depression largely occurred before changes in the negative cognitions and pleasant activities mediators.

      Long-term effects: Stice, Rohde, Gau, and Wade (2010) report significant effects in Table 3 for 4 of 12 tests of the intervention group at one- and two-year follow-up:

      Participants in the cognitive behavioral depression prevention group had significantly greater reductions in interviewer-rated depressive symptoms than participants in bibliotherapy intervention and brochure control groups (but not in the supportive-expressive intervention group) at one-year follow-up, and greater reductions than bibliotherapy intervention group (only) participants at two-year follow-up. The difference between cognitive behavioral depression prevention group participants and brochure control group participants was marginally significant at two-year follow-up (p=.056).

      At two-year (but not one-year) follow-up, participants in the cognitive behavioral depression prevention group had significantly greater reductions in self-rated depressive symptoms than participants in the bibliotherapy intervention group. The difference between cognitive behavioral depression prevention group participants and brochure control group participants was marginally significant at two-year follow-up (p=.087).

      Using the reliable change index, analyses from pretest to two-year follow-up found the following: reliable change rates for interviewer-rated depressive symptoms were significantly higher among cognitive behavioral depression prevention group participants than participants in the brochure control group (OR=2.21); and reliable change rates for self-rated depressive symptom were significantly higher among cognitive behavioral depression prevention group participants than participants in the brochure control group (OR=2.11).

      Cox proportional hazard regression models revealed that participants in the cognitive behavioral depression prevention group showed a significantly lower risk for the onset of major or minor depression than participants in the brochure control group (OR=2.23) at two-year follow-up. A marginally significant difference (p=.093) was observed between participants in the cognitive behavioral depression prevention group and the bibliotherapy intervention group, with participants in the latter group having a lower risk of major/minor depression onset.

      Limitations:

      • Sample limited to students from six high schools in one location (the greater Austin, Texas area).
      • Significant difference on one outcome measure (depressive symptoms) between conditions at baseline.

      Marchand, E., Ng, J., Rohde, P., & Stice, E. (2010). Effects of an indicated cognitive-behavioral depression prevention program are similar for Asian American, Latino, and European American adolescents. Behaviour Research and Therapy, 48, 821-825.

      Stice, E., Burton, E., Bearman, S. K., & Rohde, P. (2006). Randomized trial of a brief depression prevention program: An elusive search for a psychosocial placebo control condition. Behaviour Research and Therapy, 45, 863-876.

      This study, the first to analyze the cognitive behavioral depression prevention program, implemented a four-week version of the intervention that was later expanded to the six-week program analyzed in all later studies.

      Design:

      Recruitment /Sample size: Participants were recruited through mass mailings and e-mails, handbills, and posted fliers at two high schools and one college inviting students between the ages of 15 and 22 experiencing sadness to participate in the study. Interested students were given a depressive symptom screen (the Center for Epidemiological Studies-Depression Scale [CES-D]). Students who scored at or above a pre-determined cutoff point for inclusion (20 or above) were invited to complete the Beck Depression Inventory. Interested students with evidence of clinically significant depression were excluded and given treatment referrals. In total, 225 students were randomly assigned to condition.

      Study type/Randomization/Intervention: Using blocks created by gender and school, eligible participants were randomly assigned to one of six conditions: (1) cognitive behavioral depression prevention (n=50), (2) supportive-expressive intervention (n=19), (3) bibliotherapy intervention (n=28), (4) expressive writing (n=27), (5) journaling (n=34), or (6) waitlist control (n=67). It is stated that conditions 2-5 were “added after the study was underway,” but details regarding this process are not provided. Participants in the cognitive behavioral depression prevention group participated in the four-week cognitive behavioral program in groups composed of 6-10 participants. Students in the supportive-expressive intervention group participated in a four-week program, including weekly one-hour sessions, that provided a supportive group for participants to identify, express, and discuss their feelings. Subjects in the bibliotherapy intervention group were given a copy of the book Feeling Good, and encouraged to use the book as a self-help resource. Students in the expressive writing group were provided a quiet, private space three times over a three-week period to write about their intense emotional experiences during 45 minute sessions. The journaling intervention group was provided a journal and pen, and encouraged to write in their free time and/or to write at least once per week. Participants in the waitlist control condition were offered the cognitive behavioral depression prevention group intervention at the end of the study.

      Assessment/Attrition: Measures assessing depressive symptoms were completed at pretest, posttest (one-month later), one-month follow-up, and six-month follow-up. The study reports that 33 participants (14%) did not provide complete follow-up data (i.e., complete measures at posttest, one-, and six-month follow-up); however, detailed information on attrition is not provided.

      Sample characteristics:

      Participants ranged in age from 15 to 22 years (with a mean age of 18.4 years) at pretest. The sample was primarily female (70%, 30% male), and primarily college students (59%, 41% high school students). Fifty-five percent of the participants were Caucasian, 17% Asian, 15% Hispanic, 6% Black, and 7% identified as other or mixed racial/ethnic category. Educational attainment of parents was 20% high school graduate or less, 20% some college, 34% college graduate, and 26% graduate degree.

      Measures:

      Self-reports of the severity of depressive symptoms experienced in the past week were collected using the Beck Depression Inventory (BDI). Reliability and validity of this measure has been established in prior published work.

      Analysis:

      Statistical methods/baseline control/correct unit of analysis: Omnibus repeated measures multivariate analysis of variance (MANOVA) models with group-by-time interactions were used to test for differential change in depressive symptoms. Due to the presence of significant group-by-time interactions, separate follow-up repeated measures ANOVA models contrasted pairs of conditions at each of the follow-up periods (from pretest to each follow-up). The pairwise comparisons identify which groups significantly differed, and when.

      Operationalized as a Beck Depression Inventory score of 30 or greater, rates of severe depression onset (note that prospective participants scoring in this range at pretest were excluded from the study) were analyzed using a two-by-five chi-square model.

      Intention-to-treat: The study employs intent-to-treat analyses by using full information maximum likelihood estimation to impute missing data and analyze all randomized subjects.

      Outcomes:

      Implementation fidelity: The researchers did not collect data on implementation fidelity. The study reports that program facilitators received training and were provided detailed manuals that included session content, verbatim scripts, as well as common problems and suggested solutions. For participants that missed a program session, a brief (10-15 minute) individual session was conducted with the participant prior to their next session in order to review missed material.

      Baseline Equivalence: The groups did not differ (p > .10) on demographic characteristics, treatment-seeking rates during the study, or outcome measures at pretest.

      Differential attrition: Attrition was not related to any pretest variables or outcome measures at pretest (p > .10). However, there was a marginal difference in attrition across condition (p=.08) with a higher rate of attrition in the cognitive behavioral depression prevention group (24%) relative to all other conditions.

      Posttest: Participants in the cognitive behavioral depression prevention group had significantly greater reductions in self-rated depressive symptoms than participants in the waitlist control group at posttest (r=.48) and one-month follow-up (r=.28) (but not six-month follow-up). Participants in the cognitive behavioral depression prevention group also had significantly greater reductions in depressive symptoms than participants in the journaling intervention group at posttest (r=.23), and a marginally significant difference was observed between the cognitive behavioral and bibliotherapy intervention groups at six-month follow-up (p=.08). Positive program effects on the Beck Depression Inventory were statistically equivalent across race and ethnic groups (Marchand et al., 2010).

      The chi-square analysis revealed no significant differences in the rates of severe depression onset across conditions.

      Long-term effects: The study reports findings from measures collected through six-month follow-up, and thus does not demonstrate long-term effects.

      Limitations:

      • Sample limited to 225 students from two high schools and one college from an unknown location.
      • Details on attrition at each wave were not presented.
      • Randomized trial, but some conditions “were added after the study was underway,” and no details are provided on the change.
      • Marginally significantly greater attrition in the cognitive behavioral depression prevention group relative to all other (5) conditions.
      • Posttest effects are not significant at 6-month follow-up assessment in comparison to the control group and rarely significant in comparison to other conditions.
      • Limited information on implementation fidelity.
      • Risk and protective factors not measured.

      Rohde, P., Stice, E., Shaw, H., & Gau, J. M. (2014). Cognitive-behavioral group depression prevention compared to bibliotherapy and brochure control: Nonsignificant effects in pilot effectiveness trial with college students. Behaviour Research and Therapy, 55, 48-53.

      This study explores the impact of the Cognitive Behavioral Group Depression Prevention Program in a college sample, using a design that parallels the effectiveness trial conducted in Study 1.

      Design:

      Recruitment /Sample size: Students from a large state university were recruited in 2010-2011 through direct mailings sent to a subset of first and second year students (no information is provided on the identification or characteristics of this subset), and recruitment posters hung on campus. The mailing included a depression screener based on the Center for Epidemiological Studies-Depression Scale (CES-D). Students who completed the CES-D and endorsed two or more depression symptoms were encouraged to enroll in the study. Eighty-five students met both the criteria for enrollment and completed a pretest interview assessing depressive symptoms. Following the pretest interview, three students were excluded from the study due to having a current diagnosis of major depressive disorder or acute suicidal ideation. The number of students (if any) who enrolled in the study but did not complete a pretest interview is not reported.

      Study type/Randomization/Intervention: Eligible participants (n=82) were randomly assigned to one of three conditions: (1) cognitive behavioral group depression prevention (n=27), (2) cognitive behavioral bibliotherapy (n=22), or (3) brochure control (n=33). Participants in the cognitive behavioral depression prevention group completed six weekly one-hour program sessions in mixed-gender groups of four to eight participants. Students in the cognitive behavioral bibliotherapy group were given a personal copy of the book Feeling Good, which provides relevant and practical cognitive behavioral techniques for preventing and reducing negative moods. Participants in the brochure control group were given a National Institute of Mental Health educational brochure that describes major depressive disorder symptoms and treatment, and provides referral information.

      Three female masters-level graduate students in clinical psychology completed a 4-hour workshop after reading the intervention script and supporting documents.

      Assessment/Attrition: Participants completed a survey and diagnostic interview at pretest, posttest, and 6- and 12-month follow-ups. Attrition rates were 8.5% at posttest, 15.9% at 6-month follow-up, and 13.4% at 12-month follow-up.

      Sample characteristics:

      Participating students, all enrolled in college at a state university, were between 17 and 22 years of age (with a mean age of 19.0), and primarily female (69.5%). The sample was composed of 81% Caucasians, 11% Asian Americans, 3% African Americans, and 5% other or mixed race.

      Measures:

      Validity of measurements: All measures and scales have been used in prior published work and reliability and validity has been established. Assessors were blinded to subject condition.

      Primary outcomes: Diagnostic interviews, using an adapted version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), were used to assess the severity of major depressive disorder (MDD) symptoms and to determine whether participants met diagnostic criteria for MDD.

      Secondary outcomes: Substance use was measured with 10 items from a previous study in which participants were asked to report the frequency of alcohol, drug, and cigarette use. Responses were averaged to form a substance use measure.

      Social adjustment was measured using 13 items adapted from the Social Adjustment Scale-Self-Report for Youth.

      Manipulation check: A manipulation check of the degree to which participants in the cognitive behavioral depression prevention and the cognitive behavioral bibliotherapy conditions acquired knowledge of the intervention concepts was completed using 15 True/False items designed for this study to assess knowledge regarding adolescent depression and cognitive behavioral interventions.

      Analysis:

      Statistical methods/baseline control/correct unit of analysis: Multilevel random effects growth models—with level one including individual change in outcomes and level two the predictor of condition—with pretest scores as a covariate were used to analyze program effectiveness. The examined parameters included a condition variable reflecting change in the outcome measure at posttest, and a group-by-time interaction variable reflecting change in the outcome measure from posttest to 12-month follow-up. The study appeared to take account of the clustering of intervention subjects within program groups of 4-8 subjects with random effects for condition.

      Intention-to-treat: Multiple imputation was used to replace missing values so that all subjects were included in the analysis.

      Outcomes:

      Implementation fidelity: Among cognitive behavioral depression prevention participants, four students (14.8%) attended no sessions, 70% attended four to six sessions, and the mean attendance was 3.9 of 6 sessions. All group sessions were audiotaped and half were randomly selected for review for program adherence and facilitator competence. Using 1 to 10 point scales, mean adherence was 7.9, and mean competence was 7.3, with 1% of items rated as “minimal adherence” and 3% as “minimal competence.”

      Baseline Equivalence: At baseline, the groups did not differ on any demographic variables; however, the groups did differ on the measure of social adjustment at baseline.

      Differential attrition: Attrition was not related to condition, nor did attriters significantly differ on any of the pretest study variables from participants who provided data.

      Posttest and 12-month follow-up: No significant program effects were observed at posttest or 12-month follow-up (as measured at posttest by group and at follow-up by group-by-time interactions) for the primary or secondary outcomes.

      Analyses of the manipulation check revealed that at posttest participants in the cognitive behavioral depression prevention program had significantly higher scores on the measure of cognitive behavioral knowledge when compared to participants in the brochure control condition.

      Limitations:

      • Sample limited to 82 students from one large state university.
      • Groups differed on one secondary outcome measure at baseline.
      • No significant effects on primary or secondary outcomes at posttest or 12-month follow-up.