Predicting Future Risk of Depressive Episode in Adolescents: The Chicago Adolescent Depression Risk Assessment (CADRA)

This is a wonderful paper 1 demonstrating 21st century science at work designed to provide public health intervention aimed at mental health problems. When I worked on the Institute of Medicine’s Report on Reducing Suicide: A National Imperative 2 we learned the maxim “Risk Factors Are Not Predictive Factors Due To Protective Factors.” Simply explained: 1) 24,000/100,000 adolescents will experience a depressive episode by the age of 24 years 3. 2) 2,800/100,000 people report suicidal ideation per year 4. The current suicide rates for adolescents are 20/100,000. Thus, something must be protecting the 23,980/100,000 adolescents who experience a depressive episode by age 24 and something must be protecting the 2,798/100,000 people who report having suicidal ideation per year. Thus, risk factors for suicide are not automatically predictive of suicide completion due to protective factors.

Based on “health behavior change” research 5, for nearly a decade, I have been suggesting, rather than trying to find the needle in a haystack, i.e. the child at risk for suicide, lets identify children who are depressed and provide them with protective factors to prevent their risk factors from becoming predictive factors. The model I have been advocating is based on Flay’s Triadic Theory of Influence 6, but as we wanted to test effectiveness and wanted to disseminate the prevention interventions we have been testing, we simplified the theory so it could be used in the field. The seven-field principles model designed to promote health behavior change 7 and cultivate resiliency by providing protective factors that prevent risk factors from becoming predictive factors are: 1) Rebuilding the village/Constructing social fabric 2) Providing access to modern medical technology 3) Providing opportunities to improve bonding, attachment, & connectedness dynamics 4) Providing opportunities to improve self-esteem [Operationally defined as a sense of power (which some define as self-efficacy); a sense of models; a sense of models is essentially an understanding of how things work (models help us to understand how things work as everyone knows when you know how things work it makes you feel good and builds self-esteem as it give the Ah-Ha feeling that everyone likes); a sense of uniqueness; and a sense of connectedness]. 5) Increasing social and emotional skills of target recipients of target recipients 6) Reestablishing the adult protective shield and monitoring, 7) Minimizing the residual effects of trauma. Our most recent example of successfully using this model was in Durban, South Africa in an HIV prevention intervention 8.

I raise these examples, not to tout my work, but rather to underscore that the Voorhees et al’s paper 1, is a beautiful piece of modern technology that primary care physicians could use to identify children at risk for depression. Rather than diagnose them or place them on medication, their caregivers could be told of the risk so the youth could be placed in environments that cultivate and provide protective factors as recommended by the Clinical Guide – Connected Kids: Safe, Strong, and Secure produced by the American Academy of Pediatrics 9. In addition, depression internet prevention interventions could also be suggested to at risk youth 10 - 11.

1. Van Voorhees BW, Paunesku B, Gollan J, Kuwabara S, Reinecke M, Basu A. Predicting Future Risk of Depressive Episode in Adolescents: The Chicago Adolescent Depression Risk Assessment (CADRA). Annals of Family Medicine 2008; 6: 503 - 511.

2. Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE (Eds), Committee on Psychopathology and Prevention of Adolescent and Adult Suicide (Bunney WE, Kleinman AM, Bell CC, Brent DA, Eggert L, Fawcett J, Gibbons RD, Jamison KR, Korbin JE, Mann JJ, May PA, Reynolds CF, Tsuang MT, and Frank RG), Board on Neuroscience and Behavioral Health, National Institute of Medicine. Reducing Suicide: A National Imperative. National Academy Press: Washington, D.C.: 2002.

3. Kessler RC, Walters EE. Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depress Anxiety. 1998;7 (1): 3-14.

4. Kessler RC, Berglund P, Borges G, Nock M, Wang PS. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990 -1992 to 2001-2003. JAMA 2005; 293 (20): 2487 - 2495.

5. Bell CC, Richardson J, Blount MA. Suicide Prevention. In JR Lutzker (ed). Preventing Violence: Research and Evidence-Based Intervention Strategies. Washington, D.C.: American Psychological Association, 2005, p. 217 - 237.

6. Flay BR & Petraitis J. The theory of triadic influence: A new theory of health behavior with implications for preventive interventions. In Albrecht GS (Ed.) Advances in Medical Sociology, Vol IV: A Reconsideration of models of health behavior change. Greenwich, CN: JAI Press, 1994, p. 19-44.

7. Bell CC, Flay B, & Paikoff R. Strategies for Health Behavioral Change. In J. Chunn (Ed.) The Health Behavioral Change Imperative: Theory, Education, and Practice in Diverse Populations. New York: Kluwer Academic/Plenum Publishers, 2002, p. 17 - 40.

8. Bell CC, Bhana A, Petersen I, McKay MM, Gibbons R, Bannon W, Amatya A. Building Protective Factors to Offset Sexually Risky Behaviors Among Black South African Youth: A Randomized Control Trial, Journal of the National Medical Association, Vol. 100, No. 8: 936 - 944, 2008.

9. Bell CC. “Children of Depression: Breaking the Cycle - Perspective,” Clinical Psychiatry News, Vol. 33, No. 4, p. 54, April 2005.

10. Clinical Guide – Connected Kids: Safe, Strong, and Secure. American Academy of Pediatrics. September 9, 2005 - http://www.aap.org/connectedkids 11. Van Voorhees BW, Ellis J, Gollan J, Bell C, Stuart S, Fogel J, Corrigan P & Ford DE. Development and Process Evaluation of a Primary Care/Internet-based Intervention to Prevent Depression in Adolescents and Young Adults. The Primary Care Companion to the Journal of Clinical Psychiatry, Vol. 9, No. 5: 346 - 355, 2007.

12. Van Voorhees B, Vanderplough-Booth K, Fogel J, Gladstone T, Bell C, Stuart S, Gollan J, Bradford N, Domanico R, Fagan B, Ross R, Larson J, Watson N, Paunesku E, Melkonian S, Kuwabara S, Holper T, Shank N, Saner D, Butler A, Chandler A, Louie T, Weinstein C, Collins S, Baldwin M, Wassel A, & Reinecke MA. Integrative Internet-Based Depression Prevention for Adolescents: A Randomized Clinical Trial in Primary Care for Vulnerability and Protective Factors. Journal of the Canadian Academy of Child and Adolescent Psychiatry, Vol. 17, No. 4: 184 - 196, 2008.

Competing interests:   None declared