Of the 35 eligible clinicians, 25 agreed to participate in the study and were randomized to intervention (n = 11) versus usual care (n = 14). However, of those randomized, 21 attended the introductory session, 18 completed consent forms and pre-intervention assessments, and 17 actually continued in the study. Thus, nine clinicians (three from Center A and six from Center B) completed the training, and eight clinicians (three from Center A and five from Center B) were assigned to usual care. All 18 consenting clinicians were female, with one exception. They all held at least a master's degree in social work (n = 10), counseling (n = 7), or psychology (n = 1). Two were African American; one was Asian American; and 15 were Caucasian. Non-participants included psychologists, social workers, and counselors; however, no other data were collected from these individuals.
Responses to the Provider Attitudes Survey prior to initiation of the study (n = 18) indicated that 14 clinicians (78%) had no experience with a treatment manual for CBT, 12 (66%) had no formal CBT training, and 16 (88%) had no prior CBT supervision. Twelve clinicians (66%) indicated they intended to use CBT treatment manuals sometimes, often, or always in their clinical practice in the next six months. Eight (44%) said they never or rarely used evidence-based or empirically-supported treatments for youth depression in clinical practice, and five (27%) said they planned to never or rarely use evidence-based or empirically-supported treatments for youth depression in the next six months. There were no differences between the two sites or clinicians assigned to the intervention versus usual care groups on any of these variables.
Training consisted of the rationale for using CBT in treating depression, session-by-session review of the manual, interactive discussions, role-playing, and exploration of barriers and strategies to assist in CBT implementation. Clinicians received continuing education credits for their participation in the training. Post-training surveys from intervention clinicians indicated that the majority understood the basics of CBT (62%), were aware of barriers that may occur in providing CBT in their settings (87%), and possessed a set of skills to address the barriers (95%). Although all clinicians indicated they had a positive attitude toward CBT, only one-half stated they felt prepared to implement CBT on a regular basis. In order to facilitate provision of CBT, they were asked to establish goals and monitor their implementation success following training, e.g., practice with an adolescent by the next monthly supervision meeting. Supervision was provided based on the case presentation of the clinicians and their stated needs (e.g., difficulty implementing CBT with adolescents in crisis).
During the study, 66 adolescents screened positive on the CDI, 49 agreed to be contacted by the research team, 39 were deemed eligible for the study, and 34 completed formal consents and assents (parents and adolescents, respectively). Sixteen were assigned to intervention clinicians. Twenty-one (62%) were female, and 22 (65%) were Caucasian; mean age was 13.5 years. Most were enrolled in either sixth (27%) or seventh grades (27%), although there were also adolescents in fifth grade (6%), eighth grade (12%), ninth grade (12%), tenth grade (6%) and eleventh grade (6%). A large majority (82%) lived at home with their parents; 6% lived with their adoptive parents; 6% lived with other relatives; 3% lived with friends; and 3% lived with someone other than the above. There were no significant differences on demographics or depression severity for adolescents assigned to intervention versus usual care conditions.
Following training during the adolescent enrollment stage, intervention clinicians were asked to initiate screening for depression, introduce the intervention to adolescents and parents, engage in manualized CBT, and participate in monthly supervision. At the close of the study, three (19%) of the charts indicated no provision of CBT, three (19%) of the charts indicated the clinician followed the CBT manual one to three sessions, two (12%) of the charts indicated the clinician followed the CBT manual four to six sessions, and eight (50%) of the charts indicated the clinician followed the CBT manual more than six sessions (see Table ). Average number of therapy sessions was 16 (S.D. = 21.82). Three clinicians did not enroll any adolescents in the study; one clinician enrolled two adolescents in the study but did not provide CBT to either. There were no differences between clinicians who followed the manual for at least six sessions and clinicians who followed the manual fewer than six sessions on their prior training in CBT with adolescents. As expected, none of the adolescents in the usual care arm received CBT as determined by medical record review
CBT implementation by clinician according to Medical Record Review (MRR), audiotape and interview
Five of the six clinicians who enrolled adolescents in the study submitted an audiotape of at least one of their sessions. Results of the audiotapes indicated that five of the six clinicians provided at least one session of manualized CBT.
Although all nine clinicians participated in at least three sessions of monthly CBT supervision, attendance gradually declined, resulting in attendance by only one clinician from each clinic (both of whom engaged in CBT with high fidelity) by the end of the study. (Of note, one of the intervention clinicians had left the agency; another had been reassigned to residential care.)
During the qualitative interviews, eight of the nine clinicians in the intervention group reported that they continued to provide CBT for depressed adolescents in an outpatient or school-based setting. Of these, five reported they adhered consistently to the manual, while three reported they used "CBT components" adapted from the manual. Notably, as Table indicates, there were three clinicians who did not use CBT in the study but reported in interviews that they were still using CBT. One clinician reported using CBT with adults, given that there were only a few adolescents on her caseload. Another clinician who did not enroll any adolescents in the study said she nonetheless has followed the manual with at least two adolescents.
Data derived from supervision notes and key informant interviews suggest that multiple inhibiting or activating variables at each phase contributed to or inhibited successful implementation of CBT. These were categorized into consumer (adolescent or parent), clinician, intervention, organization, and external environment characteristics, similar to the domains identified by Schoenwald and Hoagwood [51
]. Examples from clinicians' qualitative interviews are delineated in Table 2 [see Additional file 1
In seven of the nine interviews, intervention clinicians stated that productivity demands and recent changes in paperwork requirements by the clinic's primary payer had limited their ability to participate in the study and specifically engage in new learning. Eight of the nine intervention clinicians had difficulty due to the adolescent's cognitive deficits, family crises or co-morbid psychiatric problems. Five clinicians stated that their caseload changed during the course of the study so that they were not treating as many depressed adolescents as originally anticipated; these therapists were either seeing younger or behaviorally-disordered children. Other categories cited as problems by the majority of clinicians fell into the following categories: consumer (problems with adherence and acceptance), intervention (complexity), and provider (difficulties in coping with professional stressors). Four of the clinicians commented positively on the effectiveness of the intervention with the adolescents.
Clinicians who were able to adopt and sustain CBT reported they were able to balance between adolescent and family needs, deal effectively with clinical crises within the context of CBT, and adapt to external requirements and constraints, e.g., meeting productivity, completing paperwork, etc. Not only were they competent in their roles, but they displayed positive attitudes about the intervention from the initial to final stages of the project. They remarked, "I really enjoyed doing the CBT;" "I feel like I've learned a lot doing this;" and "I can now add this to my clinical repertoire." Of the clinicians who consistently provided CBT, none stated that organizational factors facilitated their adoption of the intervention.