Can Cognitive‐Behavioral Therapy Be Optimized With Parent Psychoeducation? A Randomized Effectiveness Trial of Adolescents With Major Depression in Puerto Rico

• Author: Eduardo Cumba‐Avilés,Mae Lynn Reyes‐Rodríguez,Natalie Rodríguez‐Quintana,Emily Sáez‐Santiago,Carmen L. Rivera‐Medina,Jeannette Rosselló,Yovanska Duarté‐Vélez,Lelis Nazario,Guillermo Bernal
• Published date: 01 December 2019
• Date: 01 December 2019
• DOI: http://doi.org/10.1111/famp.12455

Can Cognitive-Behavioral Therapy Be Optimized

With Parent Psychoeducation? A Randomized

Effectiveness Trial of Adolescents With Major

Depression in Puerto Rico

GUILLERMO BERNAL*

CARMEN L. RIVERA-MEDINA*

,–

EDUARDO CUMBA-AVIL

ES*

MAE LYNN REYES-RODR

IGUEZ

†

EMILY S

AEZ-SANTIAGO*

YOVANSKA DUART

E-V

ELEZ*

,††

LELIS NAZARIO

‡

NATALIE RODR

IGUEZ-QUINTANA*

JEANNETTE ROSSELL 

O*

This is a longitudinal randomized control trial on the impact of adding a parent

psychoeducation intervention (TEPSI) as part of cognitive-behavioral therapy (CBT) for

adolescents with Major Depressive Disorder (MDD) in a Puerto Rican sample . We tested

the efficacy of adding 8 group sessions of TEPSI to 12 sessions of individual CBT on reduc-

ing depressive symptoms, MDD diagnosis, and improving family functioning. Participants

(n=121) were randomized to individual CBT with or without TEPSI. No main group

effects were found for most patient domains including depression symptoms, as well as

*University of Puerto Rico, Rio Piedras Campus, San Juan, Puerto Rico.

†

Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC.

‡

University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico.

–

Department of Psychology, University of Puerto Rico Rio Piedras Campus, San Juan, Puerto Rico.

††

Duart

e-V

elez, Assistant Profesor of Research, Department of Psychiatry and Human Behavior, Brown

University, Providence, RI, 02912.

Correspondence concerning this article should be addressed to Guillermo Bernal, Institute for Psycho-

logical Research (IPsi), University of Puerto Rico, Rio Piedras Campus, 273 Uruguay Avenue, Suite 6F,

Centrum Plaza, San Juan, PR 00917-2214. E-mail: guillermobernal@icloud.com

This study was supported by NIH Research Grant R01-MH67893 and by a Research Supplement to Pro-

mote Diversity in Health-Related Research Grant 3R01-MH067893-034S funded by the National Institute

on Mental Health, Division of Services and Intervention Research, Mental Disorders, Child and Adoles-

cent Treatment and Preventive Intervention Research Branch. The content is solely the responsibility of

the authors and does not represent the official views of the NIMH or the National Institute of Health. Sup-

port was also received from the Institutional Funds for Research from the Dean of Graduate Studies and

Research at the University of Puerto Rico, R

ıo Piedras. The authors are grateful to Jos

e Noel Caraballo,

Ph.D., Terry Duncan, Ph.D. (Statistical consultants); Mar

ıa I. Jim

enez, Ph.D., Frances Centeno, Ph.D.,

Mar

ıa T. Rivera, Ph.D., Julia Gonz

alez, Ph.D., Yaritza M. Lopez, Ph.D., Karen Bonilla, Ph.D., Elisabeth

Avil

es, Ph.D. (Treatment team), Vidalina Feliciano, Ph.D., Caroline Forastieri, Ph.D., Jessica Rodr

ıguez,

Patricia Garcia, Ph.D., Karinnette Rivera, Ph.D., Shirleen M. Collazo, Ph.D., Veronica Velez (Evaluation

Team), Michelle Osuna, Ph.D., Amarilis Galloza, Samia Ortiz, and Yolanda Cruz, B.A. (Other support

team). Also, the support of the administrative and secretarial staff (Carmen Rios Reyes, Ada Rivera

Pagan, Wilmarie Santiago, Liz Bultron, & Fermarie Villegas) at the Institute for Psychological Research at

UPR-RP was invaluable. I am also thankful to Cristina Adames, my research assistant who provided

important support in the final stages of the manuscript. Most importantly we are grateful to the adoles-

cents and parents who participated in the study.

832

Family Process, Vol. 58, No. 4, 2019 ©2019 Family Process Institute

doi: 10.1111/famp.12455

presence of adolescent’s MDD diagnosis at posttreatment. Results did show a main effect of

CBT over time for depression symptoms, suicide ideation, family criticism, and the pres-

ence of MDD diagnosis decreasing from pre- to postintervention. A year post treatment,

almost 70% of adolescents in both conditions (CBT and CBT +TEPSI) remained in remis-

sion. A main effect was obtained for treatment in the adolescent’s perception of familism

and family emotional involvement. The primary hypothesis that family psychoeduca tion

would optimize CBT for depression in adolescents was not supported. Both conditions

yielded similar clinical end points. The culturally adapted CBT was found effective with

Latino/a adolescents showing clinically significant improvements from pretreatment to

posttreatment and remained stable at a 1-year follow-up. Regarding family outcomes, ado-

lescents in CBT +TEPSI remained stable from pretreatment to posttreatment on family

emotional involvement, while adolescents in CBT-alone showed an increase. The implica-

tion of these findings is discussed.

Keywords: Efficacy; Family Psychoeducation; Cognitive-Behavioral Therapy; Adolescent

Depression; Cultural Adaptation; Latinos/as

Fam Proc 58:832–854, 2019

Depression in adolescents can have a devastating impact on their development, fami-

lies, and society. Adolescents with depression face serious challenges such as

decreased school performance, withdrawal from social relations, increased family conflict,

and an increased risk of suicide (Brent et al., 1988; Stark, Laurent, Livingston, Boswell, &

Swearer, 1999). In addition, depression often occurs in conjunction with other psychiat ric

disorders, particularly conduct and anxiety disorders, further complicating their develop-

mental trajectory. While many adolescents recover from Major Depressive Disorder

(MDD), they remain at a high risk for recurrent episodes and are likely to suffer from

depression as adults (Harrington, Fudge, Rutter, Pickles, & Hill, 1990). In short,

adolescent depression has a deleterious effect on individuals, families, and aftercare cost.

In a review of 106 meta-analyses, cognitive-behavioral therapy (CBT) showed a higher

response rate compared to other treatment conditions, suggesting that CBT is a strong

approach for a variety of mental health conditions (Hofmann, Asnaani, Vonk, Sawyer, &

Fang, 2012). One way to potentiate the effects of CBT for adolescent depression could be

through the participation of parents in psychoeducational interventions. Yet, the results

of psychoeducation with CBT are inconsistent (e.g., Stark, Banneyer, Wang, & Arora,

2012). Another review of 16 years of psychosocial interventions studies for child and ado-

lescent depression reveals that 70% (23 out of 33) employ some kind of parent involvement

in the treatment of child and adolescent depression (David-Ferdon & Kaslow, 2008;

Kaslow & Thompson, 1998; Stark et al., 2012; Wells & Albano, 2005). Few studies have

tested a family treatment condition (Brent et al., 1997; Diamond, Reis, Diamond, Sique-

land, & Isaacs, 2002), while others have included a parent involvement condition (Brent

et al., 1997; Harrington et al., 1998; Lewinsohn, Clarke, Hops, & Andrews, 1990;

Lewinsohn, Clarke, Seeley, & Rohde, 1994; Sanford et al., 2006; Stark et al., 2012).

Brent and collaborators (1997) included both family therapy and parental psychoeduca-

tional intervention. Participants were assigned to one of three conditions: (1) CBT, (2) sys-

temic behavior family therapy (SBFT), and (3) nondirective support treatment (NST). A

family psychoeducation intervention was provided to all treatment conditions. Results

showed no differences in improvement on depression diagnoses by conditions, although

change in depressive symptoms was greater for CBT. Also, suicidality decreased more in

the CBT and SBFT conditions. While the effects of parent psychoeducation were unclear,

parental involvement was considered to help parents comprehend the seriousness of their

Fam. Proc., Vol. 58, December, 2019

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