Alcohol use disorders (AUDs) continue to be a significant public health concern among American adolescents. AUDs are commonly accompanied by co-occurring psychiatric disorders including depression. This co morbidity has been associated with increased severity of AUD, earlier treatment termination, poorer outcomes, and increased suicidal risk. Presently there is neither a consensus nor a standard, evidence-based intervention to address the need for an effective and feasible treatment for both disorders. However, cognitive behavior therapy (CBT) has been found to be effective for each of these disorders, separately. In addition, in some, but not all, adolescents with both disorders, depression appears to respond rapidly to CBT that targets only alcohol or substance abuse. This suggests that early depression responders (EDRs) may not need additional treatment that targets depression directly, unlike their non-early responding NEDR counterparts. However, no studies have compared longer term outcomes of adolescent EDRs to NEDRs. Moreover, no randomized, controlled studies have tested the hypothesis that an integrated CBT intervention for co-occurring AUD and depression will be effective for both disorders, in NEDR adolescents. In this two-site study, submitted in response to PA: PAS-10-251, we will recruit 170 eligible adolescents (102 at the University of Connecticut and 68 at Duke University), ages 13 to 18, with AUD and clinically significant depression. All subjects will receive 12-weeks of Motivation Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT-12), a standard, evidence-based intervention for alcohol or drug abuse. After four weeks, NEDR adolescents will be randomized to depression treatment augmentation, either with seven sessions of CBT (CBT-D), integrated with MET/CBT-12, or with enhanced depression-treatment-as-usual in the community (D-ETAU). We estimate that 120 adolescents will be randomized;we will stratify randomization on gender, age, and presence/absence of a Major Depressive Episode. We will assess all 170 participants at baseline, weeks 4, 8, and 12 (after treatment), and at 3-, 6-, and 9-month follow-up.
The first aim of this study is to describe the percentage of depressed AUD adolescents who demonstrate EDR during alcohol abuse treatment alone, examine EDR durability and EDR predictors. The second and third aims test the hypotheses that, for NEDR teens, an integrated treatment augmentation (CBT- D) will lead to better depression and alcohol outcomes, respectively, than augmentation with D-ETAU. We will compare outcomes of all three groups (EDRs;and NEDRs in each augmentation), on alcohol use, depressive symptoms, alcohol-related functional impairment, maintenance of alcohol treatment gains, and depression remission rates over time, and will analyze the temporal ordering of changes in alcohol use and depression during and after treatment. This is the first study to test an adaptive treatment model with depressed AUD youths, and thus has significant potential to guide clinical practice.
Adolescents with alcohol abuse have more severe problems and higher likelihood of relapse after treatment, if they are also depressed. Moreover, this combination places them at higher risk for suicidal thoughts and behaviors. However, there is no evidence-based psychosocial intervention for clinicians to use to address this frequent combination of alcohol abuse and depression. This study will provide motivational enhancement (MET) and cognitive-behavior therapy (CBT) for alcohol abuse to adolescents who also have depression. If their depression does not respond rapidly to this treatment, the study will then tes the effectiveness of integrating CBT for depression with ongoing CBT for alcohol abuse. If successful, this integrated CBT can then be used by clinicians working with depressed, alcohol abusing adolescents.