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Cognitive behavioral therapy (CBT) for children & adolescents with depression

Children's Mental Health: Depression
Benefit-cost estimates updated December 2017.  Literature review updated August 2017.
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Cognitive behavioral therapies (CBT) include various components, such as cognitive restructuring, scheduling pleasant experiences, emotion regulation, communication skills, and problem-solving. In this review, CBT is provided to children and adolescents aged 7 to 17 with major or minor depression, dysthymia, or subthreshold depression. We include programs such as Coping With Depression – Adolescent (CWD-A), Primary and Secondary Control Enhancement Training (PASCET), the Treatment for Adolescents with Depression (TADS) Study, and other CBT models. On average, treatments in this review provided 14 therapeutic hours per client over three months, with a range of 6 to 28 therapeutic hours per client. Therapies were provided in both individual and group modalities.
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $36 Benefits minus costs ($566)
Participants $7 Benefit to cost ratio ($0.27)
Others $37 Chance the program will produce
Indirect ($201) benefits greater than the costs 31 %
Total benefits ($122)
Net program cost ($444)
Benefits minus cost ($566)
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Crime $3 $0 $7 $1 $11
K-12 grade repetition $1 $0 $0 $0 $1
K-12 special education $9 $0 $0 $5 $14
Labor market earnings associated with major depression $2 $5 $0 $4 $11
Health care associated with major depression $25 $8 $31 $13 $77
Costs of higher education ($4) ($6) ($2) ($2) ($14)
Adjustment for deadweight cost of program $0 $0 $0 ($222) ($222)
Totals $36 $7 $37 ($201) ($122)
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $1,245 2015 Present value of net program costs (in 2016 dollars) ($444)
Comparison costs $806 2015 Cost range (+ or -) 15 %
On average, participants received 14 therapeutic hours. The per-participant cost of treatment by modality (individual or group) was weighted by the treatment Ns reported in the studies. Cost per session is $44.02/session for group and $140.90/session for individual modalities (2015 dollars). This rate is based on actuarial tables reported in Mercer (2016) Behavioral Health Data Book for the State of Washington For Rates Effective January 1, 2017. Comparison group costs are based on the average cost of psychotherapy treatment as usual for children and adolescents with depression, based on a WSIPP analysis.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^WSIPP’s benefit-cost model does not monetize this outcome.

^^WSIPP does not include this outcome when conducting benefit-cost analysis for this program.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Anxiety disorder^^ 4 55 -0.222 0.243 14 -0.102 0.117 15 -0.365 0.136
Disruptive behavior disorder symptoms 2 140 -0.049 0.125 14 -0.023 0.066 17 -0.077 0.539
Externalizing behavior symptoms 4 208 -0.005 0.101 14 -0.002 0.052 17 0.031 0.760
Global functioning^ 6 357 0.147 0.094 14 n/a n/a n/a 0.192 0.078
Hospitalization (psychiatric)^^ 1 41 -0.091 0.214 14 0.000 0.118 15 -0.143 0.504
Internalizing symptoms^^ 5 183 0.081 0.109 14 0.059 0.088 16 0.104 0.341
Major depressive disorder 18 564 -0.284 0.078 14 0.000 0.024 15 -0.484 0.001
Specialist visits^ 1 41 -0.086 0.214 14 n/a n/a n/a -0.135 0.529
Suicidal ideation^ 3 252 -0.244 0.093 14 n/a n/a n/a -0.302 0.001
Suicide attempts^ 1 41 0.000 0.232 14 n/a n/a n/a 0.000 1.000

Citations Used in the Meta-Analysis

Brent, D.A., Holder, D., Kolko, D., Birmaher, B., Baugher, M., Roth, C., . . . Johnson, B.A. (1997). A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Archives of General Psychiatry, 54(9), 877-885.

Clarke, G., DeBar, L.L., Pearson, J.A., Dickerson, J.F., Lynch, F.L., Gullion, C.M., & Leo, M.C. (2016). Cognitive Behavioral Therapy in Primary Care for Youth Declining Antidepressants: A Randomized Trial. Pediatrics, 137(5), 1-13.

Clarke, G.N., Hornbrook, M., Lynch, F., Polen, M., Gale, J., O'Connor, E., . . . Debar, L. (2002). Group cognitive-behavioral treatment for depressed adolescent offspring of depressed parents in a health maintenance organization. Journal of the American Academy of Child & Adolescent Psychiatry, 41(3), 305-313.

Clarke, G.N., Rohde, P., Lewinsohn, P.M., Hops, H., & Seeley, J.R. (1999). Cognitive-behavioral treatment of adolescent depression: Efficacy of acute group treatment and booster sessions. Journal of the American Academy of Child & Adolescent Psychiatry, 38(3), 272-279.

Curtis, S.E. (1992). Cognitive-behavioral treatment of adolescent depression: effects on multiple parameters.

Kahn, J.S., Kehle, T.J., Jenson, W.R., & Clark, E. (1990). Comparison of cognitive-behavioral, relaxation, and self-modeling interventions for depression among middle-school students. School Psychology Review, 19(2), 196-211.

Kennard, B., Silva, S., Vitiello, B., Curry, J., Kratochvil, C., Simons, A., et al. (2006). Remission and residual symptoms after short-term treatment in the Treatment of Adolescents with Depression Study (TADS). Journal of the American Academy of Child & Adolescent Psychiatry, 45(12), 1404-1411.

Lewinsohn, P.M., Clarke, G.N., Hops, H. & Andrews, J. (1990). Cognitive-behavioral treatment for depressed adolescents. Behavior Therapy, 21(4), 385-401.

Liddle, B. & Spence, S.H. (1990). Cognitive-behaviour therapy with depressed primary school children: A cautionary note. Behavioural Psychotherapy, 18(2), 85-102.

Listug-Lunde, L., Vogeltanz-Holm, N., & Collins, J. (2013). A cognitive-behavioral treatment for depression in rural American Indian middle school students. American Indian and Alaska Native Mental Health Research, 20(1), 16-34.

March, J., Silva, S., Petrycki, S., Curry, J., Wells, K., Fairbank, J., et al. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA, 292(7), 807-820.

Rohde, P., Clarke, G.N., Mace, D.E., Jorgensen, J.S., & Seeley, J.R. (2004). An efficacy/effectiveness study of cognitive-behavioral treatment for adolescents with comorbid major depression and conduct disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 43(6), 660-668.

Rossello, J., Bernal, G. (1999). The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Journal of Consulting and Clinical Psychology, 67(5), 734-745.

Stark, K.D., Reynolds, W.M., & Kaslow, N.J. (1987). A comparison of the relative efficacy of self-control therapy and a behavioral problem-solving therapy for depression in children. Journal of Abnormal Child Psychology, 15(1), 91-113.

Vitiello, B., Rohde, P., Silva, S., Wells, K., Casat, C., Waslick, B., et al. (2006). Functioning and quality of life in the Treatment for Adolescents with Depression Study (TADS). Journal of the American Academy of Child & Adolescent Psychiatry, 45(12), 1419-1426.

Vostanis, P., Feehan, C., Grattan, E., & Bickerton, W.L. (1996). Treatment for children and adolescents with depression: Lessons from a controlled trial. Clinical Child Psychology and Psychiatry, 1(2), 199-212.

Weisz, J.R., Southam-Gerow, M.A., Gordis, E.B., Connor-Smith, J.K., Chu, B.C., Langer, D.A., . . . Weiss, B. (2009). Cognitive-behavioral therapy versus usual clinical care for youth depression: An initial test of transportability to community clinics and clinicians. Journal of Consulting and Clinical Psychology, 77(3), 383-396.

Weisz, J.R., Thurber, C.A., Sweeney, L., Proffitt, V.D., & LeGagnoux, G.L. (1997). Brief treatment of mild-to-moderate child depression using primary and secondary control enhancement training. Journal of Consulting and Clinical Psychology, 65(4), 703-707.

Wood, A., Harrington, R., & Moore, A. (1996). Controlled trial of a brief cognitive-behavioural intervention in adolescent patients with depressive disorders. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 37(6), 737-746.

For more information on the methods
used please see our Technical Documentation.