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The acceptability of treatments for adolescent depression to a multi-ethnic sample of girls

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Title:
The acceptability of treatments for adolescent depression to a multi-ethnic sample of girls
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Book
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English
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Caporino, Nicole
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University of South Florida
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Tampa, Fla
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Subjects / Keywords:
Barriers to treatment
Service utilization
Culturally sensitive treatment
Hispanic
Acculturation
Dissertations, Academic -- Psychology -- Masters -- USF   ( lcsh )
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non-fiction   ( marcgt )

Notes

Abstract:
ABSTRACT: An efficacious treatment is diminished in value if clients will not seek it out and adhere to it (Kazdin, 1978). Thus, the acceptability of a treatment to consumers is an important indicator of the quality/effectiveness of the treatment (APA, 2002). The purpose of this study was to examine acceptability of treatments for depression to adolescent females and to explore factors that might be associated with acceptability. Sixty-seven high school students (36 Hispanic and 31 non-Hispanic White) were recruited from communities in New Jersey and Florida, and interviewed by telephone. Participants were presented with a vignette describing a depressed adolescent and asked to use the Abbreviated Acceptability Rating Profile to indicate their opinion of four single treatments (cognitive-behavioral therapy, interpersonal therapy, family therapy, and pharmacotherapy) for depression and three treatment combinations. Consistent with hypotheses, psychotherapy approaches were generally more acceptable to adolescents than combinations of psychotherapy and pharmacotherapy. Pharmacotherapy used alone was not acceptable, on average. There was preliminary evidence to support the hypotheses that treatment acceptability is related to ethnicity, acculturation, and perceived causes of depression; however, contrary to expectations, treatment acceptability was not associated with symptom severity in this study. Implications for increasing the utilization of mental health services in this population are discussed and directions for future research are offered.
Thesis:
Thesis (M.A.)--University of South Florida, 2008.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Nicole Caporino.
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Title from PDF of title page.
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Document formatted into pages; contains 130 pages.

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aleph - 002005309
oclc - 362165361
usfldc doi - E14-SFE0002702
usfldc handle - e14.2702
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ABSTRACT: An efficacious treatment is diminished in value if clients will not seek it out and adhere to it (Kazdin, 1978). Thus, the acceptability of a treatment to consumers is an important indicator of the quality/effectiveness of the treatment (APA, 2002). The purpose of this study was to examine acceptability of treatments for depression to adolescent females and to explore factors that might be associated with acceptability. Sixty-seven high school students (36 Hispanic and 31 non-Hispanic White) were recruited from communities in New Jersey and Florida, and interviewed by telephone. Participants were presented with a vignette describing a depressed adolescent and asked to use the Abbreviated Acceptability Rating Profile to indicate their opinion of four single treatments (cognitive-behavioral therapy, interpersonal therapy, family therapy, and pharmacotherapy) for depression and three treatment combinations. Consistent with hypotheses, psychotherapy approaches were generally more acceptable to adolescents than combinations of psychotherapy and pharmacotherapy. Pharmacotherapy used alone was not acceptable, on average. There was preliminary evidence to support the hypotheses that treatment acceptability is related to ethnicity, acculturation, and perceived causes of depression; however, contrary to expectations, treatment acceptability was not associated with symptom severity in this study. Implications for increasing the utilization of mental health services in this population are discussed and directions for future research are offered.
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The Acceptability of Treatments for Adoles cent Depression to a Multi-Ethnic Sample of Girls by Nicole Caporino A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Psychology College of Arts and Sciences University of South Florida Major Professor: Marc Karver, Ph.D. Jason Beckstead, Ph.D. Vicky Phares, Ph.D. Joseph Vandello, Ph.D. Date of Approval: July 17, 2008 Keywords: barriers to treatment, service ut ilization, culturally se nsitive treatment, Hispanic, acculturation, causal beliefs Copyright 2008, Nicole Caporino

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i Table of Contents List of Tables ................................................................................................................ ..... iv List of Figures ............................................................................................................... ...... v Abstract ...................................................................................................................... ........ vi Introduction .................................................................................................................. ....... 1 Depression Among Adolescents ..................................................................................... 1 Prevalence ............................................................................................................... 1 Consequences of Depression .................................................................................. 2 Gender and Adolescent Depression ........................................................................ 2 Ethnicity/Culture and A dolescent Depression ........................................................ 3 Treatment of Adolescent Depression .............................................................................. 4 Efficacy ................................................................................................................... 4 Efficacy with Hispanic Adolescents ....................................................................... 6 Conclusions.…………………………………..…..…….. ...................................... 7 Client Variables .............................................................................................................. 7 Treatment Acceptability .................................................................................................. 8 Models of Treatment Acceptability ........................................................................ 8 Acceptability and Outcome……………..…..…….. ............................................... 9 Acceptability as Outcome ..................................................................................... 10 Acceptability and Utilization……………..…..…….. .......................................... 11 Prior Research on the Acceptabili ty of Depression Treatments ........................... 12 Factors That May Influence Judgments of Treatment Acceptability ............................ 15 Perceived Cause of the Disorder ........................................................................... 15 Race/Ethnicity………..…..…….. ......................................................................... 18 Acculturation......................................................................................................... 21

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ii Socioeconomic Status ……………..…..…….. .................................................... 22 Symptom Severity ................................................................................................. 23 Prior Experience with Mental Health Services ..................................................... 23 Other Factors.. ....................................................................................................... 24 Objectives and Specific Aims ........................................................................................... 25 Method ........................................................................................................................ ...... 30 Participants .................................................................................................................. .. 30 Measures ...................................................................................................................... 32 Socioeconomic Status ........................................................................................... 32 Mental Health Service Use ................................................................................... 32 Ethnicity ................................................................................................................ 33 Acculturation......................................................................................................... 33 Perceived Cause(s) of Depression ........................................................................ 34 Depression............................................................................................................. 36 Treatment Acceptability ........................................................................................ 36 Procedure ..................................................................................................................... 37 Recruitment of Participants ................................................................................... 37 Data Collection ..................................................................................................... 39 Development of Study Materials .......................................................................... 41 Results ....................................................................................................................... ........ 43 Missing Data ................................................................................................................. 43 Descriptive Statistics ..................................................................................................... 43 Hollingshead Four Factor Index of Social Status ................................................. 43 Income................................................................................................................... 44 Short Services Assessment for Child ren and Adolescents (modified) ................. 44 Bidimensional Acculturation Scale for Hispanics ................................................ 45 Beliefs About Causes of Child Pr oblems Questionnaire (modified) .................... 46 Reynolds Adolescent Depression Scale ................................................................ 46 Abbreviated Acceptability Rating Profile ............................................................. 48

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iii Preliminary Analyses .................................................................................................... 49 Hypothesis Testing........................................................................................................ 49 Objective I ............................................................................................................. 49 Objective II ........................................................................................................... 51 Discussion .................................................................................................................... ..... 57 Limitations ................................................................................................................... 71 Summary ....................................................................................................................... 74 References .................................................................................................................... ..... 76 Appendices .................................................................................................................... .. 112 Appendix A: Protocol for the Assessme nt of Suicidality and Self-Harm ................. 113 Appendix B: Case Descriptions ................................................................................. 128 Appendix C: Treatment Descriptions ........................................................................ 130

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iv List of Tables Table 1. Participants’ social strata as assessed by Holli ngshead Four Factor Index ........44 Table 2. Frequencies with which mental health services had been utilized by participants ..........................................................................................................45 Table 3. Frequencies with which causal beliefs were endorsed .......................................47 Table 4. Frequencies with which causal fact ors identified as most significant in determining depression .......................................................................................48 Table 5. Acceptability ratings by treatment type ..............................................................50 Table 6. Acceptability ratings by ethnicity .......................................................................52 Table 7. Median treatme nt ranks by ethnicity ..................................................................53 Table 8. Differences in tr eatment ranks by ethnicity ........................................................53 Table 9. Pearson’s r for acceptability and se lf-reported depressive symptomatology .....56

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v List of Figures Figure 1. Witt and Elliot’s (1985) model of treatment acceptability ..................................9 Figure 2. Theoretical model of factors a ssociated with treatme nt acceptability ...............16 Figure 3. Model of variables assessed in relation to treatment acceptability ...................29

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vi The Acceptability of Treatments for Adoles cent Depression to a Multi-Ethnic Sample of Girls Nicole Caporino ABSTRACT An efficacious treatment is diminished in value if clients will not seek it out and adhere to it (Kazdin, 1978). Thus, the acceptabi lity of a treatment to consumers is an important indicator of the quality/effectiveness of the treatment (APA, 2002). The purpose of this study was to examine acceptability of treatments for depression to adolescent females and to explore factors that might be associated with acceptability. Sixty-seven high school stude nts (36 Hispanic and 31 non-Hispanic White) were recruited from communities in New Jersey a nd Florida, and interv iewed by telephone. Participants were presented with a vignette describing a de pressed adolescent and asked to use the Abbreviated Acceptability Rating Pr ofile to indicate their opinion of four single treatments (cognitive-behavioral thera py, interpersonal therapy, family therapy, and pharmacotherapy) for depression and three treatment combinations. Consistent with hypotheses, psychotherapy approaches were generally more acceptable to adolescents than combinations of psychotherapy and pha rmacotherapy. Pharmacotherapy used alone was not acceptable, on average. There was preliminary evidence to support the hypotheses that treatment acceptability is related to ethnicity, acculturation, and perceived causes of depression; however contrary to expectations, treatment acceptability was not associated with symptom severity in this study. Implications for increasing the utilizatio n of mental health services in this population ar e discussed and directions for future research are offered.

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1 Introduction Depression Among Adolescents Unipolar depression refers to Major Depressive Disorder (MDD), Dysthymic Disorder (DD), or “double de pression” (both MDD and DD), and is characterized by feelings of sadness and/or loss of interest or pleasure. Other symp toms include loss of energy, feelings of guilt or worthlessness, dimi nished ability to concentrate, significant changes in weight/appetite, sl eep disturbances, psychomotor ag itation or retardation, and recurrent thoughts of death (D iagnostic and Statistical Ma nual of Mental Disorders— Fourth Edition, 1994). The phenomenology of depression in adolescence differs from that of depression in childhood. For example, depressed adolescents have significantly higher rates of hypersomnia and weight cha nge than depressed children (Kovacs, 1996; Ryan et al., 1987) whereas depressed children are more likely than depressed adolescents to make somatic complaints (Kashani, Rose nberg, & Reid, 1989; Ryan et al., 1987) and show more irritability an d uncooperativeness (Kashani, Holcomb, & Orvaschel, 1986). Depressed adolescents are more likely than depressed children to have impaired functioning (Birmaher et al., 1996). Prevalence. Conclusions on the prevalence of depression among adolescents are difficult to make since studies of this popul ation are limited and have employed various methods (Stark, Boswell Sander, Yancy, Br onik, & Hoke, 2000). Some investigators have reported rates of both MDD and DD wh ereas others have reported only rates of MDD. According to Essau & Dobson (1999) the point prevalence of MDD among is adolescents is 1 in 20 (MDD affects 1 in 20 adol escents at any one time). Earlier studies yielded estimates of point prevalence rangi ng from 4% to 8% (Lewinsohn, Clark, Seeley, & Rohde, 1994; Kashani et al., 1987a, 1987b). Reports of one-year prevalence of MDD

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2 among adolescents reach as high as 8.3% (Gar rison et al., 1997; Anderson & McGee, 1994; Lewinsohn et al., 1994). By 18 years of ag e, approximately 20% of teens will have experienced at least one episode of major depression (Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; Lewinsohn, Rohde, & Seeley, 1998). Consequences of Depression. Unipolar depression in a dolescence is associated with impairments in interpersonal functioning, poor academic performance, arrests, early childbearing, cigarette smoking, and reduced life satisfaction (see Birmaher et al., 1996 for a review; Reinherz, Giaconia, Hauf, Wasserman, & Silverman, 1999). Longitudinal studies consistently show that depressive disorders in ad olescence predict the occurrence of depressive disorders in adulthood and ar e associated with l ong-term psychosocial impairment (Essau, Conradt, & Petermann, 1999). Adolescent depression is also associat ed with suicidality (Shaffer, Gould, & Fisher, 1996; Gould et al., 1998) and is t hus a major public health concern. Approximately 500,000 adolescents in the Unit ed States attempt suicide each year (Shaffer, Gould, & Fisher, 1996; Gould et al., 1998), making suicide the third leading cause of death among adolescents in this country (Kochanek, Murphy, Anderson, Scott, 2004). Almost 2000 adolescents, approximately one half of whom suffer from major depression, die as a result of suicide each ye ar (Shaffer, Gould, & Fisher, 1996; Gould et al., 1998). Adolescents with a mood disorder are 11 to 27 times more likely to die by suicide than adolescents without a mood diso rder (Groholt et al., 1998; Shaffer et al., 1996; Brent et al., 1993; Brent et al., 1988; Shafii et al., 1988; Beautrais, Joyce, & Mulder, 1996). Gender and adolescent depression. Among adolescents, girls are approximately twice as likely to suffer from MDD as boys (Essau & Dobson, 1999; Hankin et al., 1998; Lewinsohn et al., 1994; Lewinsohn et al., 1993). This gender difference in the rate of depression does not emerge until mid-adoles cence; in fact, results from studies of preadolescent children consis tently show that depression is more prevalent among boys than girls (Anderson, Williams, McGee, & Silva, 1987; Angold, Costello, & Worthman, 1998; Nolen-Hoeksema, Girgus, & Selig man, 1991; Nolen-Hoeksema, Girgus, & Seligman, 1992). Possible explanations for females’ increased risk for depression

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3 include early traumatic experiences (e.g., physic al and/or sexual abuse; Cutler & NolenHoeksema, 1991), hormonal changes affecti ng reactions to stress (e.g., Parker & Brotchie, 2004), cognitive styl e, (e.g., Mazure, Bruce, Maciejewski, & Jacobs, 2000), ruminative coping (Nolen-Hoeksema, 1991), body image dissatisfaction (e.g., Marcotte, Fortin, Potvin, & Papillon, 2002), poor se lf-esteem (e.g., Kling, Hyde, Showers, & Buswell, 1999), social roles/cultural norms (e.g., Nolen-Hoeksema, Larson, & Grayson, 1999), and pre-existing anxiety disorder s (e.g., Simonds & Whiffen, 2003). (See Kuehner, 2003 for a comprehensive review.) More female than male adolescents have suicidal ideation and make suicide attempts but more male than female adolescents die by suicide (CDC, 2002; Lewinsohn, Rohde, Seel ey, & Baldwin, 2001; Gould et al., 1998; Lewinsohn et al., 1996; Garris on et al., 1993; Bingham, Bennion, Openshaw, & Adama, 1994; Deykin & Buka, 1994; Rich, Kirpatrick-S mith, Bonner, & Jans, 1992; Anderson, 2002). Ethnicity/culture and adolescent depression. Data from the Centers for Disease Control and Prevention’s (CDC) Youth Risk Behavior Surveillance System (YRBSS) consistently indicate that Hispanic adolescen ts are more likely than African American or non-Hispanic White adolescents to make a su icide plan and to attempt suicide (CDC, 2004, 2002, 2000, 1998, 1996, 1995). Hispanic females, in particular, appear to be most at risk for suicide attempts (Rew, Thomas Horner, Resnick, & Beuhring, 2001; Roberts & Chen, 1997; Roberts, Chen, & Roberts, 1995 ). According to re sults from a study by Rew et al. (2001), adolescent Hispanic fe males have a 19.3% prevalence of suicide attempts, which is significantly higher than that of any other ethnic-gender group. Not surprisingly, some studies have shown that Hispanic adolescents are more likely to be depressed than adolescents of other ethnic groups (Wight Aneshensel, Botticello, & Sepulveda, 2005; Roberts, 2000; Roberts, R oberts, & Chen, 1997; Roberts & Sobhan, 1992; Emslie et al., 1990). Wight et al. (2005) for example, found depression to be more prevalent among Hispanics than non-Hispan ic Whites, Asian Pacific Islanders, and “other” ethnic groups, even afte r controlling for age, sex, fa mily structure, and household income. The number of youths who experien ce a depressive episode by the end of high school is estimated to be more than three times higher for Hispanics than non-Hispanic

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4 Whites (Danziger, Sandefur, & Weinberg, 1994) One explanation fo r the relatively high prevalence rates of depression and suicidalit y among Hispanic youths is that as members of an ethnic minority group, th ey often struggle with accultu rative stress (e .g., prejudice/ discrimination, disruption of social support) which has been found to be related to psychopathology and suicidal behavior (Canino & Roberts, 2001; Vega, Gil, Zimmerman, & Warheit, 1993; Hovey & King, 1996). Treatment of Adolescent Depression A number of treatments have been de veloped for adolesce nt depression, each based on a different etiological theory. These treatments vary in the degree to which their use is supported by empirical findings. Efficacy. Cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) have been identified as evidence-based treatments for adolescent depression (see Kazdin, 2004; Asarnow, Jaycox, & Tomps on, 2001; Cuijpers, 1998; Kaslow & Thompson, 1998 for reviews). There is some evidence for the effectiveness of family therapy in treating adolescent depression (Brent et al., 1997; Diamond, Reis, Diamond, Siqueland, & Isaacs, 2002), alt hough more research is need ed. With the exception of IPT, psychodynamic therapies for adolescent depre ssion have not been tested empirically. Two interventions for adolescents with MDD that have been the source of much controversy are pharmacotherapy and electroconvulsive thera py (ECT). No controlled studies of ECT with adolescents have been published. Rey and Walter (1997) reviewed 60 reports of ECT and concluded that it may be nefit depressed clients 18 years of age or younger but emphasized that most of the report s did not have sufficient outcome data. ECT has been fiercely debated because its a dverse effects are considerable and include impairment of memory and new learning, tard ive seizures, prolonged seizures, and risks associated with general anesthesia (A ACAP, 2004). Baldwin and Oxlad (1996) concluded from a review of 217 child/adolescen t cases that ECT might even exacerbate an existing psychological crisis.

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5 With respect to pharmacotherapy, tric yclic antidepressants are commonly prescribed for adolescents de spite the lack of evidence s upporting their us e with this population (Burns, Hoagwood, & Mrazek, 1999). Se veral randomized controlled trials have shown selective serotonin reuptake inhib itors (SSRIs) to be effective in treating adolescent depression (e.g., Wagner et al ., 2003, 2004; Emslie, Heiligenstein, & Wagner, 2002; Keller et al., 2001; Emslie et al, 1997; Simeon Dinicola, Ferguson, & Copping, 1990). However, results from more recent tria ls and re-examinations of data from earlier trials have suggested that SSRIs are ineffectiv e and are associated wi th double the rate of suicidality and aggression/hostility comp ared to placebo (see Whittington, Kendall, & Pilling, 2005 for a review). These findings ha ve caused regulatory agencies in the United States, the United Kingdom, and Canada to step in and designate certain SSRIs as contraindicated for persons less than 18 y ears of age. (Whittington, Kendall, & Pilling, 2005). The Food and Drug Administration (FDA) has directed all antidepressant drug manufacturers to label their pr oducts with a ‘black-box’ warn ing about the increased risk of suicidality (Food and Drug Administration, 2004). Still, many mental health professionals consider pharmacotherapy for depressed adolescents to be an evidencebased practice (e.g., Asarnow et al., 2005). The most recent data on the use of SSR Is with adolescents comes from the Treatment for Adolescents with Depressi on Study (TADS, 2004). This randomized controlled trial compared fluoxetine, cognitive -behavioral therapy, and their combination. Results suggested that fluoxetine with CBT is superior to both fluoxetine alone and CBT alone and combining the two appeared to reduce the risk of suicidality down to the level of placebo. The cognitive-behavioral inte rvention in this study, however, has been criticized for being over struct ured and devoting too little ti me to cognitive restructuring (Hollon, Garber, & Shelton, 2005). In additi on, the overall treatment was delivered in fewer sessions than the CBT evaluated in prio r studies despite the f act that it included more components (Hollon, Garber, & Shelton, 2005). Before the TADS study, there were no major trials of the combination of psychotherapy and pharmacotherapy in the treatment of adolescent depression. According to Kratochvil, Simons, Vitiello et al. (2005), there are several reasons why

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6 combined treatments may be superior to single treatments. First, two treatments provide a greater “dose” and might thus speed rec overy. Second, two treatments may target different symptoms of a disorder such that their combination is required to maximize outcome. Third, in the case of a partial re sponse, adding a second treatment may improve symptoms targeted by the first treatment. Fourth, combined treatments may be more likely to improve conditions that are comorbid with depression. However, findings from studies comparing single and combined treatm ents for adult depression have been mixed (Keller et al., 2000; Hollon et al., 1992; Murphy et al., 1984). One criticism of treatment-outcome studi es in general is that racial/ethnic minorities, especially Hispanic Americans, are often not adequately represented (Case & Smith, 2003, 2000; Rossello & Bernal, 1999; Mi randa, Azocar, Organista, Munoz, & Lieberman, 1996; Bernal, 1993; Navarro, 1993). The under-incl usion of certain minority groups limits the external validity of re search on psychological interventions, since findings can typically only be generalized to middle class, non-Hispanic Whites (Rossello & Bernal, 1999). Few studies have eval uated treatments developed or adapted specifically for use with a pa rticular minority population. Efficacy with Hispanic adolescents. Only two depression treatment-outcome studies to date have sampled Hispanic a dolescents exclusively. Rossello and Bernal (1999) tested a cognitive-behavioral trea tment and an interpersonal psychotherapy treatment adapted for depressed Puerto Rican adolescents using a framework that considers eight culturally sensitive elem ents of intervention: language, persons, metaphors, content, concepts, goals, methods, and context. Results suggested that the two treatments were superior to a waitlis t control condition in reducing depressive symptoms. 82% of adolescents in the IP T condition and 59% of those in the CBT condition were considered to be functional after treatment. Rossello and Bernal (2005) have repo rted preliminary findings from a second trial, in which they crossed treatment type (CBT versus IPT) with format (group versus individual). Again, both IP T and CBT significantly reduced depression symptoms from pretreatment to posttreatment, this time with CBT showing a definite advantage over IPT. There were no differences in efficacy between the two treatment formats.

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7 Conclusions. In summary, the results of empirical studies have shown several different therapies and combinations of ther apies to be promising in the treatment of adolescent depression. There is a strong evidence base for both CBT and IPT (Kazdin, 2004; Asarnow, Jaycox, & Tompson, 2001; Cuijpers, 1998; Kaslow & Thompson, 1998), with culturally sensitive ad aptations of these treatments receiving some support for use with Hispanic adolescents (R ossello & Bernal, 1999). The results from a couple of randomized controlled trials offer preliminary support for the use of family therapy in treating depressed adolescents (Brent et al., 1997; Diamond, Reis, Diamond, Siqueland, & Isaacs, 2002). Although the use of pharm acological treatments with this population remains controversial, recent research has s uggested that SSRI’s can be used safely and effectively in combination with CBT (TADS, 2004). ECT for the tr eatment of adolescent depression has not been well researched. Client Variables The finding that multiple treatments are potentially effective in the treatment of depression suggests that vari ables such as nonspecific th erapy factors and client characteristics may be as important or even more important than the specific content of the interventions. In fact, results from the Treatment of Depression Collaborative Research Program (TDCRP), a multisite study comparing CBT, IPT, and pharmacotherapy in the treatment of adults with depression, suggest ed that outcome is better predicted by client characteristics than by the effects of particular interventions (Ablon & Jones, 1999; Blatt, Quinlan, P ilkonis, & Shea, 1995; Zuroff et al., 2000). According to Lambert (1992), as much as 40% of client improvement in psychotherapy can be attributed to client variables and extratherapeutic influences. Research has examined pretreatment client variables such as symptom severity, functional impairment, sociodemographic characteristics, expectanci es, motivation for change, and psychological mindedness as they relate to outcomes of psychotherapy (see Clarkin & Levy, 2004 for a review).

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8 Treatment Acceptability Given the variety of models for depr ession (Beckham & Leber, 1995) as well as the availability of different public information about the treatment for this disorder, it is perhaps surprising that the perceived acceptabil ity of alternative treatments for depression has received relatively little research attenti on as a client variable that could potentially influence outcome (Hamilton & Dobson, 2002). Treatment acceptability refers to judgments about treatment procedures made by nonprofessionals, la ypersons, clients, and other potential consumers of treatment. They are based on an evaluation of whether the treatment is appropriate for the problem, fa ir, reasonable, intrusive, and whether it concurs with popular notions about what tr eatment should be (Kazdin, 1980). Two or more treatments can be effective and yet diffe r in the extent to which those who receive them consider them to be acceptable (Kazdin, 1980, 2000). For example, both stimulant medication and behavioral pare nt training are well establishe d as empirically supported treatments for ADHD in youth; however, behavior al parent training ha s been found to be more acceptable to parents (Gage & Wilson, 2000). Kazdin (1980) suggested that acceptable treatments are more likely to be s ought out and adhered to once treatment has begun, resulting in fewer dropouts, greater client compliance and motivation, more positive behavioral changes, and greater satisfaction with treatment. Models of treatment acceptability. Several models of treatment acceptability have been proposed in the school psychology liter ature. Witt and Elliot (1985) hypothesized that teachers’ initial judgments about acceptabil ity guide their selecti on of treatments and affect the extent to which they implemen t the procedures as intended (treatment integrity), ultimately playing a role in determ ining the effectiveness of a treatment. It was further hypothesized that if teachers deem the treatment to be effective once it has been implemented, their initial judgments a bout acceptability will be enhanced. Thus, Witt and Elliot’s (1985) model can be illustrated as consisting of reciprocal relationships between four treatment variables: acceptab ility, use, integrity, and effectiveness (see Figure 1). Reimers, Wacker, and Koe ppl (1987) expanded this model, adding knowledge/ understanding of a treat ment as a prerequisite for making judgments about its

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9 acceptability. From these models, one can hypothesize that consumer judgments of treatment acceptability ultimately influence treatment outcomes. Effectiveness of treatment Acceptability of treatment Use of treatment Integrity of treatment Figure 1. Witt and Elliot’s (1985) mode l of treatment acceptability. Acceptability and outcome. Researchers appear to agree that treatment acceptability is likely related to treatmen t outcomes (see Cross Calvert & Johnston, 1990 for a review); however, this relationship has ra rely been tested empirically. Tarnowski, Simonian, Bekeny, and Park (1992) offer ethical and practical considerations to explain this lack of empirical scrutiny. They asse rt that one cannot reas onably ask clients to provide acceptability ratings pr ior to the start of treatment and then provide a treatment that is judged to be relatively unacceptable. Asking clients for acceptability ratings after treatment is completed would also be probl ematic since acceptability ratings may be confounded with the outcome of the treatment. Despite the ethical concerns raised by Tarnowski et al. (1992), Reimers, Wacker, Cooper, & DeRaad (1992a) conducted a study that provided direct empirical support for the relationship between treatment acceptabili ty and treatment outcome. Parents of children seen in a pediatric behavior mana gement outpatient clinic were recommended positive reinforcement procedures. Ratings of acceptability were obtained at the initial clinic visit and one, three, and six months later. Parents also rated their child’s behavior during the last three assessments. Acceptabili ty ratings were highly consistent over time and were strongly and positively associated with change in child behavior problems. One criticism of this study, however, is that treat ment acceptability and child behavior were

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10 both assessed using parent-report, intr oducing a method variance confound (Foster & Mash, 1999; Sterling-Turner & Watson, 2002). Using a data set expanded from that reported on in Reimers et al. (1992a), Reimers et al. (1992b) showed that treatme nt acceptability is also related to adherence/compliance, which has been found in numerous studies to be related to outcome (e.g., Addis & Jacobson, 2000; Burn s & Spangler, 2000; Bryant, Simons, & Thase, 1999; Taft, Murphy, King, Musser, & DeDeyn, 2003; Leung & Heimberg, 1996; Charach, Ickowicz, & Schachar, 2004; Rittmannsberger, Pachinger, Keppelmuller, & Wancata, 2004). They reported that pare nts who rated the treatments as highly acceptable were more likely to be complia nt at each of the follow-up points. More support for the theorized acceptability -outcome relation comes from studies that show that giving clients a choice of tr eatments improves outcomes. Lin et al. (2005) found that among depressed adults seen in a primary care setting, clients who were matched with their preferred treatment (c ounseling, medication, or both) demonstrated more rapid symptom reduction th an unmatched clients. Asar now et al. (2005) found that depressed adolescents who were given a choi ce of treatment modalities as part of a quality improvement intervention evaluated in primary care clinics re ported significantly fewer depressive symptoms and greater qualit y of life at follow-up than adolescents who received usual care. Acceptability as outcome. It can be argued that treatm ent acceptability is worthy of study irrespective of its relationship to a dherence and outcome. Researchers should be concerned not only with clini cal outcomes thought to be im portant by professionals but also with aspects of tr eatment identified as important by co nsumers. In other words, the acceptability of a treatment to consumers s hould be an outcome variable in treatment effectiveness research in and of itself (Kazdi n, 1978). Indeed, client perceptions of care (e.g., satisfaction) have received greater attention in recent years by provider accreditation agencies such as the Joint Comm ission on the Accreditation of Healthcare Organizations (JCAHO, 2005) and the Na tional Committee on Quality Assurance (NCQA, 2001), reflecting global trends towa rd increasing consumer involvement in healthcare. The Criteria for Evaluating Treat ment Guidelines, published by the American

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11 Psychological Association (APA, 2002), includes acceptability to the patient as one of the 21 criteria for evaluating the effectiveness of a treatment approach. According to Whitstock (2003), attending to the acceptability of a proposed treatment to an individual client could improve the “uptake” of research evidence, narrowing the gap between best available evidence and current practice. In addition, there is some evidence that the acceptability of an intervention is predictive of attributions of blame and the propensity to litigate (Meller, Mart ens, & Hurwitz, 1990). Acceptability and utilization. The possibility that treatment acceptability is associated with treatment usage (Kazdin, 1980) has received some support in the youth treatment literature (e.g., Bannon & McKay, 2005; Chavira, Stein, Bailey, & Stein, 2003; Kazdin, 2000) and is yet another reason w hy treatment acceptability deserves more research attention. Understanding what makes a treatment acceptable to potential consumers may lead to improvements in rate s of service utilization, which are notably poor among youth (Satcher, 2000; Le af et al., 1996). Approxima tely 70% of children and adolescents in need of treatment in the United States do not receive mental health services (Report on the Surgeon General’ s Conference on Children’s Mental Health, 2000). Among children and adolescents who enter therapy, 40-60% terminate prematurely (Kazdin, 1996; Wier zbicki & Pekarki, 1993). Service underutilization by Hispanic youths a nd families in the United States is of particular concern given that they have lower rates of specialty mental health service utilization than nonHispanic Whites (Hough et al., 2002; Roberts, 2000; Leaf et al., 1996). Hough et al. (2002) sample d adolescents receiving services in at least one of five public sectors of care and reported that nonHispanic White youths with one or more mental health diagnoses and moderate impair ment were 2.2 times as likely as their Latino counterparts to receive specialty outpatient me ntal health services. In addition, Latino youths reported entering specialty mental hea lth services at a later age and making fewer visits than non-Hispanic White youths. A ccording to Zwillich (2000), 80% of Hispanic adolescents with mental health issues do not receive care, a nd Hispanic youth have even higher rates of premature termination of therapy than non-Hispanic White youth (Takeuchi, Bui, & Kim, 1993; Sue, Fujino, Hu, & Takeuchi, 1991).

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12 Unmet need may be greater for depressed adolescents than for adolescents with other disorders. Ping et al (1999) examined the relations hip between mental health diagnoses and patterns of serv ice utilization in a community sample of 1, 285 children and adolescents controlling for potential conf ounding variables such as perceived need. They reported that while disrup tive behavior disorders were si gnificantly associated with the use of mental health serv ices, depression was not. This finding is consistent with the results of earlier studies (Koot & Ver hulst, 1992; Cohen, Kasen, Brook, & Struening, 1991). Keller et al. (1991) s uggested that up to 80% of a dolescents with depression do not receive any treatment. Results from the National Household Survey on Drug Abuse (NHSDA; Substance Abuse and Mental Health Services Administration, 2003) indicated that only 32 percent of Hispanic females aged 12 to 17 found to be at risk for suicide over the course of one-year received mental health treatment during the same period. One possible explanation for unmet need among depr essed youth is that service providers are not sufficiently attentive to the acceptabil ity of available depression treatments to potential consumers. Prior research on the acceptabili ty of depression treatments. Studies of acceptability have generally focused on trea tments for attention-deficit/hyperactivity disorder (ADHD) and disruptive behavi or (e.g., Kazdin, 2000), especially among developmentally delayed or mentally re tarded children (e.g., Bihm, Sigelman, & Westbrook, 1997). Treatment acceptability in relation to school-based consultation practices has received considerable attenti on in the research literature (e.g., Elliott & Busse, 1993; Gresham & Lopez, 1996). Many studies have used undergraduate participants, although parents, teachers, ment al health professionals, and occasionally children have been sampled. Only a handful of studies have examined the acceptability of various treatments for depression and of th ese, only one has sampled parents of youth. Banken and Wilson (1992) presented 174 college undergraduates with case illustrations for major depression and dysthymia and asked them to rate the acceptability of four different ther apies (behavioral, c ognitive, interpersonal, and pharmacotherapy) using the Treatment Evaluation Inventor y (TEI; Kazdin, 1980) and the Semantic Differential (SD; Osgood, Suci, & Tannenbaum, 1957). Participants also completed the

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13 Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Consistent with the authors’ primary hypothesis, the treatments were rated differentially, with psychotherapies rated as significan tly more acceptable than pharmacotherapy. Behavioral therapy and cognitive therapy were rated as equally acceptable and interpersonal therapy was rated as the mo st acceptable treatment. There was some evidence that participants who scored above 10 on the BDI evaluated treatment options differently from participants who scored a 10 or below, suggesting th at symptom severity may affect treatment acceptability. Finall y, the authors noted an inverse relationship between ratings of acceptability and treatment-s pecific attrition in a study by the National Institute of Mental Health (NIMH) publis hed a few years prior (Elkin et al., 1989). More recently, Hall and Robertson (1998) i nvestigated the acce ptability of single and combined treatment approaches for adult depression. Seventy-six college undergraduates read the case hi story of a student with majo r depression and used the TEI and the Credibility Rating Scale (CRS, Fox & Wollersheim, 1984) to evaluate the acceptability of the following interventions: CBT, IPT, pharmacotherapy with CBT, pharmacotherapy with IPT, and pharmacoth erapy with support group therapy. No significant effects were found on the CRS. Data from the TEI, however, showed that treatments consisting of psychotherapy alone consistently fell toward the higher end of the acceptability continuu m while the combination of pharmacotherapy and support group therapy consistently fell toward th e lower end. Because combinations of individual psychotherapy and medication tended to fall between these two extremes, the authors concluded that the acceptability of pharmacotherapy is raised when combined with psychotherapy (or the acceptability of psychotherapy is lowered when combined with pharmacotherapy). Tarnowski et al. (1992a) examined the acceptability of five interventions for childhood depression: attribution retraini ng, cognitive therapy, social skills training, contingency management, and pharmacothera py. Sixty mothers whose children were seen for routine pediatric outpatient visits at a hospital were rando mly assigned to read one of two case illustrations of an 11-year-old child with depressive symptomatology. The two cases represented differe nt levels of symptom severit y. Results were consistent

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14 across all levels of symptom severity desc ribed and indicated that pharmacotherapy was judged to be least acceptable. Of note, however, was that the acceptability of psychosocial treatments varied as a function of the participant’s ra ce, with contingency management treatment rated as significan tly less acceptable by African American mothers. More recently, Cooper et al. (2003) inve stigated the acceptability of treatments for depression among African American, Hisp anic, and non-Hispanic White patients in primary care settings across the United States Their sample consisted of 829 adults who acknowledged having one week or more during the prior month when they felt sad, empty, depressed, or lost inte resting things they normally enjoyed, and who met criteria for a major depressive episode in the year prior, as determined using the Composite International Diagnostic Inte rview (CIDI; Robins et al 1988). Participants were administered a telephone survey, part of whic h asked them to use a four-point Likert scale to rate the acceptability of two options for helping themselves to feel better: taking antidepressant medications and going for individual counse ling from a mental health professional. The survey also assessed attitudes towards medication and counseling. Hispanics and African Americans were more likely than non-Hispanic Whites to find antidepressant medication unacceptable and to believe that antidepressant medications are addictive. Hispanics, but not African Americans, were more likely than NonHispanic Whites to find counseling acceptable. Given that studies have revealed consid erable differences in the acceptability of various treatments for depression, it is importa nt to identify the factors that influence judgments of treatment acceptability. Potent ial factors include ch aracteristics of the individual judging the acceptab ility of the treatment (e.g., race/ethnicity, SES, prior mental health service use), characteristics of the individual receiv ing the treatment (e.g., symptom severity, age), and/or characteristics of the treatme nt itself (e.g., effectiveness, side effects).

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15 Factors That May Influence Judgmen ts of Treatment Acceptability A theoretical model of factors associated with treatment acceptability is presented in Figure 2. The model suggests that ethnic ity is related to ju dgments of treatment acceptability and that this relationship is mediated by several factors, including the perceived cause of the disorder for which treatme nt is sought. Further, this relationship is thought to be moderated by one’s acculturation st atus. A number of factors in addition to ethnicity are suggested to in fluence judgments of treatm ent acceptability. Included among these are symptom severity and pr ior experience with mental health services/satisfaction. These factors are discussed below. Perceived cause of the disorder. According to Kazdin (1980), judgments of treatment acceptability are based, in part, on an evaluation of whether the treatment is appropriate; that is, whether it is the best possible match to the client’s needs (Salzer, Nixon, Schut, Karver, & Bickman, 19 97). It is possible that the perceived cause of the disorder targeted by an intervention affects judgments of whether or not the intervention is appropriate to the problem. A treatment that maps onto the perceived cause would be more likely to be deemed appropriate and thus, acceptable. Support for this hypothesis comes from a study by Iselin and Addis (2003) in which mental health clients and undergraduates rated seven depression treatmen ts first presented alone and then with six different etiological vignettes. All particip ants considered the treatments more helpful when the cause and treatment focus were congruent. In another study, Addis and Carpenter ( 1999) found significant relationships between reasons adults use to explain depr ession and their reactions to activationoriented or insight-oriented trea tment rationales. Individuals who attributed depression to past experiences in childhood or to stable asp ects of the self responded more favorably to insight-oriented treatment rationales and less favorably to activation-oriented treatment rationales than individuals who did no t endorse these reasons for depression. Consistent with the possibility that causal beliefs are associated with judgments of treatment acceptability is evidence that client s show better adherence to treatments that

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16 Treatment Acceptability Ethnicity Compliance Symptom Improvement Perceived Helpfulness of Treatment Likelihood of Dropping Ou t Decision to Seek Services Perceived Stigma of Treatment Knowledge of Treatment Perceived Cause of Disorde r Beliefs about Children Symptom Severity Perceived Burden of Treat m ent SES Side Effects of Treatment Perceived Credibility of Professional Acculturation Generational Status Prior Experience with Treatment Role in Intervention Figure 2. Theoretical Model of Factors Associated with Treatment Acceptability.

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17 are congruent with their own causal beliefs (Elkin et al., 1999) and those of their caregivers (Sher, McGinn, Sirey, & Meyers, 2005) Also, data from at least one study has suggested that clients have better outcomes with therap eutic approaches that match their causal explanations fo r depression. Addis and Jacobson (1996) found support for their prediction that clients who attributed depression to existential causes (e.g., being stuck in the same place in life) would res pond better to cognitive therapy and worse to behavioral activation than w ould clients who did not attrib ute depression to existential causes. They also found that endorsing rela tionship-oriented reas ons for depression was negatively related to cognitive therapy outcomes. While several studies have examined parents’ causal beliefs about child behavioral and/or emotional problems in general (e.g., Yeh, Forness, Ho, McCabe, & Hough, 2004; Yeh et al., 2004; Yeh, McCa be, Hough, Lau, Fakhry, & Garland, 2005), there have not been any studi es that have looked at beli efs specific to depression in children or adolescents. A nu mber of studies, however, ha ve reported on adults’ beliefs about the causes of depressi on in adults (Thwaites et al ., 2004; Srinivasan, Cohen, & Parikh, 2003; Lauber, Falcato, Nordt, & Rossl er, 2003; Kirk et al., 1999; Jorm et al., 1997; Kuyken et al., 1992; Addis & Jacobs on, 1996; Furnham & Kuyken, 1991). It is difficult to draw conclusions from the resu lts of these studies because they sampled populations from different countries (e.g., Aust ralia, Canada) in diffe rent settings (e.g., outpatient clinic, community) using different measures of causal beliefs (e.g., Reasons for Depression Questionnaire; semi-structured inte rview). Causes that were most highly endorsed include achievement-related concer ns (Twaites et al., 2004) or unfulfilled desires, hopes, and ambitions (Kuyken et al ., 1992), stress and nega tive life experiences (Srinivasan, Cohen, & Parikh, 2003), cogniti ve causes (Furnham & Kuyken, 1991) biological causes (Kirk et al., 1999), difficultie s within the family or partnership (Lauber et al., 2003), day-to-day probl ems (Jorm et al., 1997), response to life events/traumatic experiences (Kuyken et al., 1992), and existe ntial concerns that reflect a stable disillusionment with life (Addi s & Jacobson, 1996). Studies va ried with respect to the causes that were included among response op tions. For example, only a few studies assessed participants’ agreem ent with a cognitive cause (Srinivasan, Cohen, & Parikh,

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18 2003; Kirk et al., 1999; Furnham & Kuyken, 1991) and only one study included a cause that was specifically familial (Lauber et al., 2003). Several studies have reported ethnic/cultu ral differences in the perceived cause(s) of depression (Furnham & Malik, 1994; Lawr ence et al., 2006; Karasz, 2005) and/or other mental disorders (Yeh, Hough, McCabe, Lau, & Garland, 2004; Sheikh & Furnham, 2000; Milsten, Guarnaccia, & Mi dlarsky, 1995; Schnittker, Freese, & Powell, 2000; Furnham & Chan, 2004; Furnham & Murao, 2000; Edman & Koon, 2000; Narikiyo & Kameoka, 1992). If perceptions of the causes of depression are indeed related to treatment acceptability, then one could deduce from these findings that there might be ethnic differences in acceptability judgments. Race/ethnicity1. There are several other reasons w hy race/ethnicity in general and Hispanic ethnicity in particular might in fluence the acceptability of treatments for adolescent depression. First, the symptoms identified by the DSM-IV as constituting a major depressive episode may not represent a coherent syndrome in other cultures. The DSM-IV is based on research that was conducted largely with majority culture populations and has been criticized for be ing culturally invali d (Lewis-Fernandez & Kleinman, 1994; Fabrega, 1995). If Hisp anics have a different experience or understanding of the symptoms associated with depression as it is experienced by members of the majority culture, they will likely make different judgments of the appropriateness of various treatments for thos e symptoms. More specifically, Hispanics would be expected make less favorable judgmen ts of available treatments for depression (as it is defined by the DSM-IV) than w ould non-Hispanic Whites. Second, Hispanics might generally view treatments for depressed adolescents as less acceptable than nonHispanic Whites view them because Hispan ics tend to believe that conventionally defined symptoms of psychopathology refl ect temperament when exhibited by youth rather than mental illness, which is thought to be an adult experience (Arcia, Castillo, & Fernandez, 2004). Finally, values that have been identified as fundamental to Hispanic culture may translate into preferences for some treatments over others. These values include 1 Many researchers distinguish between “race” and “ethnicity .” The focus of this section is on the Hispanic ethnic group; however, re levant studies of cultural groups defi ned by their race are also cited.

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19 familismo and personalismo Familismo has been defined as “a strong identification with and attachment to their nuclear and extende d families, and strong feelings of loyalty, reciprocity, and solidarity among members of the same family” (Marin & Marin, 1991; p.13). Based on this value, Hispanic American s, more than Non-Hispanic Whites, might prefer family therapy to i ndividual psychotherapies. Personalismo involves an emphasis on close interpersonal relationships (Flores, 2000; Flores, 1994; Levi ne & Padilla, 1980) and might thus influence Hispanics to see more value in IPT than treatments that do not have a relational emphasis (e.g., CBT). In addition to the core values of familismo and personalismo, Hispanic Americans have been found to be more collectivist th an European American s (Oyserman, Coon, and Kemmelmeier, 2002). In collectivist cultures, the group takes priority over the individual and the concept of the self is enmeshed in the social context (Fiske, 2004). Thus, the finding that Hispanic Americans are more likely to endorse a collectivist value orientation supports the hypothesi s that they would be more likely than members of the majority culture to favor family therapy and IPT relative to alternative treatments. It could also be argued that these values mi ght lead Hispanics to consider available treatments for depression less acceptable across the board than Non-Hispanic Whites consider them. Furnham and Malik (1994) sugg est that in cultures in which the interest of the family takes preceden ce over individual interests, there is less tolerance for cognitions regarding the self and depression is often percei ved as self-indulgent. If depression is not perceived as a bona fide illness, then any treatment developed within the context of a medical mode l of depression is not likely to be perceived as highly acceptable. Another worldview/value orientation associ ated with Hispanic culture that might serve to make treatments for de pression generally unappealing is fatalismo or the idea that individuals have minimal cont rol over their environment (Kouyoumdjian, Zamboanga, & Hansen, 2003). Hispanics who a ccept fatalismo might see events as the result of luck or divine will (Kouyoumd jian, Zamboanga, & Hansen, 2003) and might not expect there to exist any treatm ent that would ameliorate sympto ms of mental disorders.

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20 Few studies have examined the relationshi p between race/ethnicity and treatment acceptability or treatment preferences. As mentioned earlier, C ooper et al. (2003) found that Hispanic adults were more likely than non-Hispanic White adults to find counseling acceptable and to find antidepressant medicati on unacceptable. Tarnowski et al. (1992a) found a relationship between race (Caucasian or African American) and mothers’ ratings of the acceptability of various psychosoci al treatments for childhood depression. In a separate study, Tarnowski et al. (1992b) found that mothers’ ratings of the acceptability of treatments for child externalizing behavi or did not vary as a function of race (NonHispanic White or African American). This finding was consistent with that of Heffer and Kelley (1987), who sampled the same population. Findings from studies on treatment credibi lity and preferences are consistent with the possibility that treatment acceptability is associated with race/ethnicity.2 Using a sample of Asian American college student s, Wong, Kim, Zane, Kim, & Huang (2003) found that cultural identity moderated ratings of the credibility of cognitive therapy and time-limited dynamic psychotherapy. Dwight -Johnson, Sherbourne, Liao, and Wells (2000) reported that African American adults seen in primary care clinics were more likely than non-Hispanic Whites to prefer c ounseling over medication in the treatment of depression. It should be noted, however, that factors othe r than treatment acceptability might influence preferences; for example, whether or not insurance will cover the treatment. Data from focus groups conducte d by Cooper-Patrick et al. (1997) suggest that non-Hispanic Whites are more likely than African Americans to be concerned with attributes of specific treatments for depres sion, raising the possibi lity that treatment acceptability plays a greater role in non-Hi spanic Whites’ preferences than it does in African Americans’ preferences. The impact of race/ethnicity on percepti ons of treatment accep tability is worth exploring given that service utilization patterns differ by ethnic group. Data from the U.S. National Ambulatory Medical Care Su rvey (NAMCS) for th e years 1992 through 1996 indicated that the rate of encounters documenting the use of antidepressants, a 2 Treatment credibility has been defined as the extent to which clients feel that a treatment is appropriate, logical, and helpful and is one that could be recommended to a friend (Borkovec & Nau, 1972). The literature on treatment credibility is relatively small and items that have been used to measure this construct appear to sample the content of items used to measure treatment acceptability.

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21 diagnosis of depressive illne ss, or both were comparable for African Americans and Hispanics yet less than half the rates obser ved in Non-Hispanic Whites (Skaer, Sclar, Robison, & Galin, 2000). While data specific to the treatment of depression in youth are unavailable, there have been several studies of service utilization specific to ADHD (e.g., Zito, Safer, dosReis, Magder, & Riddle, 1997) Stevens, Harman, and Kelleher (2004) reported that an ADHD diagnosis and/or the pr escription of stimulants was less likely to be given to Hispanic youths relative to non-Hispanic White youths during primary care visits from between 1995 and 2000. Bauermeist er et al. (2003) repor ted that only 7% of Hispanic children with ADHD received stim ulant medication during the year prior to when they were interviewed and only 3.6% were still taking the medication at the time of the interview. Consistent with these findi ngs are qualitative data collected by Arcia, Fernandez, and Jauqez (2004) which suggest that Hispanic moth ers of young children with behavior problems overwhelmingly pr efer treatments other than stimulant medication because they believe medicati on to be addictive, dulling of cognitive processes, and inappropriate for behavior pr oblems. Interestingly, 5% of the 62 mothers sampled spontaneously mentioned that they delayed help seeking because they thought that the physician might prescribe medicati on and an additional 14.5% of the mothers identified possibility of bei ng prescribed medication as a ba rrier to help seeking when presented with a list of 15 possible barriers. Data on utilization rates of specific types of psychotherapy are generally not reported on in the peer-reviewed literature. Acculturation. It may not be ethnicity per se that is related to treatment acceptability but rather, the degree to which one shares the lifestyle, beliefs, and values associated with the majority culture. Ev idence of a relationship between acculturation and treatment acceptability would support this hypothesis. Although numerous definitions of acculturation have been proposed in the literature, the classic, most frequently cited definition of acculturati on was put forth by Redfield, Linton, and Herskovits (1936): “Acculturation comprehe nds those phenomena which result when groups of individuals having different cultur es come into first-hand contact, with subsequent changes in the original cultural patterns of either or both groups” (p.149).

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22 Berry and his colleagues proposed a widely accepted framework of individual-level acculturation based on the negotiation of two issu es: the retention of or immersion in an ethnic society other than the dominant societ y, and the adoption of or immersion in the dominant society (Berry, 1980; Berry & Kim, 1988; Berry & Sam, 1996). This negotiation results in four positions or m odes of acculturation: assimilation, which involves moving away from one’s ethnic society and immersing fully in the dominant society; integration, which is immersing in both ethnic and dominant societies; separation, which involves withdrawal from the dominant society and complete immersion in the ethnic society; and marg inalization, which is a complete lack of meaningful immersion in either the ethnic or dominant society. Acculturation has been found to be associated with a number of f actors thought to be related to treatment acceptability, including familism (Sabogal, Marin, Otero-Sabogal, & Marin, 1987), collectivism (Gomez, 2003), il lness concepts (Glovsky & Haslam, 2003), perceived causation of symptoms/etiology beliefs (M allinckrodt, Shigeoka, & Suzuki, 2005), mental health status (e.g. Miranda & Umhoefer, 1998; see Rogler, Cortes, & Malgady, 1991), mental health service utilizati on (Wells, Golding, Hough, Burnam, & Karno, 1989), attitudes toward seeking professiona l psychological help (Zhang & Dixon, 2003; Tata & Leong, 1994), and locus of control, which has been linked conceptually to fatalismo (Guinn, 1998). Socioeconomic status. In order to draw conclusions about the impact of race/ethnicity on judgments of treatment acc eptability, it is necessary to examine socioeconomic status (SES) as a potential confound. Compared to non-Hispanic Whites in the United States, Hispanic Americans ha ve lower levels of income, education, and occupational status (Kouyoumdjian, Zamboanga & Hansen, 2003; U.S. Census Bureau, 2001; Sue, Zane, & Young, 1994). Approximately one in three Hispan ics live in poverty (Rosenthal, 2000) and one in four Hispanics do not have health insurance (Brown, Ojeda, Wyn, & Levan, 2000). In the year 2000, 27.8% of Hispanics dropped out of high school compared to 6.9% of non-Hispanic Whites (N ational Center for Education Statistics, 2002). Given these statistics, any study of Hispanic ethnic ity in relation to treatment acceptability should consider SES as a covariate.

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23 Symptom severity. Symptom severity refers here to the degree to which symptoms impair functioning and/or cause distress. The severity of depression experienced by an adolescent may affect his/ her judgments of trea tment acceptability. For example, an adolescent who is unable to get out of bed in the morning to go to school may be more willing to tolerate the side effects of an antid epressant than an adolescent who makes it to school but feels some what sluggish throughout the day. Treatment acceptability studies have ge nerally manipulated symptom severity using case illustrations (e.g., Elliot & Fuqua 2002; Sturmey, 1992; Kazdin, 1980). Some studies have measured the severity of symptoms experienced by respondents (e.g., Banken & Wilson, 1992) or their children (e .g., Chavira et al., 2003; Reimers et al., 1992). Two studies of the acceptability of treatments for depression have looked at symptom severity. As noted above, Banken and Wilson (1992) reported some evidence that respondents who scored high on self-report measure of depressive symptoms rated the acceptability of treatments differently than respondents who scored low. Tarnowski et al. (1992a) found that part icipants who were randomly assigned to read a vignette representing a severe case of depression rated treatments as more acceptable than participants who read a vigne tte describing a mild case; however, this effect was not significant. Prior experience with ment al health services. A history of mental health service use might influence judgments of treatment acceptability positively or negatively depending on the outcome of the interven tion(s) delivered. If there is symptom improvement, the treatment is mo re likely to be perceived as helpful and thus, acceptable. This possibility is accounted for in Witt a nd Elliot’s (1985) model by the bi-directional relationship between treatment acceptability and treatment effe ctiveness. Mental health service use might also influence judgments of treatment acceptabi lity by changing the consumer’s understanding of the disorder tr eated (through education about its etiology, for example), his/her appreciation of the time and effort involved in treatment (perceived burden), and/or his/her judgment of side effects. Three studies of the acceptability of treatments for depression have measured pa rticipants’ service use histories (Banken & Wilson, 1992; Hall & Robertson, 1998; Cooper et al., 2003). Two of these studies did

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24 not analyze for the effects of this variable presumably because the large majority of participants reported no treatment histor y (Banken & Wilson, 1992; Hall & Robertson, 1998). The third study, conducted by Cooper et al. (2003), sampled adults who reported one week or more of depressed mood or loss of interest within th e past month and who met criteria for Major Depressive Episode in the past year. Results indicated that both participants who found antidepressant me dications acceptable and those who found counseling acceptable were more likely than participants who did not find these treatments acceptable to have had previous tr eatment for depression at specialty mental health settings and to have discussed an em otional problem during a primary care visit. Participants who found antidepressant medica tion acceptable were also more likely to have been treated for depression in a general medical setting. The authors did not offer an explanation for these findings. Although it’s possible that previ ous treatments were effective (at least in the short-term) and therefore enhanced subsequent acceptability judgments, it’s also possible that a third variable such as symptom severity was responsible for the relationship between prior service use and acceptability. Other factors. Other factors that have been rese arched in relation to treatment acceptability are knowledge regarding the tr eatment (e.g., Corkum, Rimer, & Schachar, 1999), information about the treatment’s eff ectiveness (e.g., Clark & Elliot, 1988), side effects of the treatment (Kazdin, 1981), the rationale provided for the treatment (e.g., Cavell, Frentz, & Kelley, 1986), the treatment setting (e.g., primary care, specialty clinic; Van Voorhees et al., 2003), and the location of the intervention (in publ ic, in private, at home, or self-administered; Turco & Ellio tt, 1986). Factors that have not been researched include characteristics of the professional describing or recommending the treatment, stigma attached to the treatment, media portrayal of the treatment, perceptions of how commonly others have undergone the tr eatment, cultural beliefs about children, and geographic region.

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25 Objectives and Specific Aims This study examined treatment acceptability with respect to seven therapies for depression: CBT, IPT, family therapy, pharmacotherapy, CBT with pharmacotherapy, IPT with pharmacotherapy, and family therapy with pharmacotherapy. There were two primary objectives. The fi rst objective was to ascertain up-to-date information from adolescents on the acceptabil ity of various treatments for adolescent depression. No treatment acceptability study to date has focused specifically on the use of treatments for depression with adolescents In addition, the study by Tarnowski et al. (1992a) described earlier is th e only one that has focused on treatments for depressed youth. Major shifts in public opinion regarding the treatmen t of depression and mental health treatment in general are likely to have occurred since that study was conducted. Consistent with this possibil ity are data indicating that there were enormous increases throughout the 1990s in the use of psychotro pic medications among youth (Najjar et al., 2004) and that the medicati ons that are currently mo st commonly prescribed by outpatient child psychiatrists are stimulants and antidepressan ts (Staller, Wade, & Baker, 2005). Changes in the layperson’s attitudes toward psychotropic medications could be both a cause and a consequence of these recent trends in thei r use. Now especially, in light of the recent controversy surroundi ng SSRIs, it is important to understand the consumer perspective on the risks and benefits of various treatments for depression, at the very least because their effectiveness is limited by treatment adherence/compliance. By eliciting adolescents’ judgments of the acceptability of treatments, this study will help to fill a gap in the literature. Adolescents are a unique population in that they may have the cognitive capacity to unders tand the rationale behind a treatment and to evaluate its risks/benefits and yet, unlike a dults, their rights regarding treatment are not protected by legal consent procedures. Als o, adolescents are often referred by adults who may have a different agenda for treatment (DiGuiseppe, Linscott, & Jilton, 1996). They are notoriously difficult to engage in th erapy (A. Freud, 1946; Meeks, 1971), perhaps because the developmental press toward in creasing autonomy discourages them from relying on adults, including ther apists, for guidance (Shirk & Karver, in press).

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26 The specific aim that corresponds to this first objective is: 1. To assess the perceived acceptability of seven single and combined treatments for adolescent depression using a multi-ethni c community sample of adolescent females. These treatments are: CBT, IPT, family therapy, pharmacotherapy, CBT with pharmacotherapy, IPT with pharmacotherapy, and family therapy with pharmacotherapy. Based on past research, it was hypothesi zed that in general, psychotherapy approaches (CBT, IPT, family therapy) w ould be judged as more acceptable than pharmacotherapy, with combined treatme nts (CBT with pharmacotherapy, IPT with pharmacotherapy, and family ther apy with pharmacotherapy) falling somewhere in between. The second objective of this study was to add to the literature on the predictors of treatment acceptability. Information about th e client characteristics associated with reduced treatment acceptability can alert practitioners to the need to more thoroughly address concerns that are common to particul ar populations and help them match clients to the treatments to which they are most likel y to adhere. Also, data on predictors of treatment acceptability can help inform the deve lopment of treatments that are tailored to specific populations and can be easily transpor ted into real-world se ttings. Treatments tailored to minority groups, in particular, are sorely needed (Rossello & Bernal, 1999). Specific aims that correspond to the second objective are: 2. a. To test for differences between non-Hispanic Whites’ and Hispanics’ perceptions of the acceptability of se ven single and combined treatments for adolescent depression. It was hypothesized that Hispanics would judge acceptability of treatments for adolescent depression less fa vorably overall than would non-Hispanic Whites. It was also hypothesized that there would be ethnic differences in the acceptability

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27 of treatments relative to each other. Specifically, Hispan ics would be more likely than non-Hispanic Whites to judge IPT and family therapy as relatively more acceptable than other treatments for adolescent depression. b. To examine the relationship between tr eatment acceptability and acculturation among Hispanics. It was hypothesized that Hispanics who are immersed predominantly in U.S. culture would judge the acceptability of treat ments more favorably than would Hispanics who are immersed predominantl y in their culture of origin (but not Hispanics who are highly immersed in both cultures, or bicultural). 3. To evaluate the influence of different perc eptions of causes of depression on ratings of the acceptability of various treatments. a. For each causal factor-treatment pair listed below, it was hypothesized that participants who endorse th e causal factor as an explan ation for depression would judge the acceptability of the corresponding treatment more favorably than participants who do not endorse th e causal factor. The pairs are: i. physical causes – pharmacotherapy ii. relational causes – IPT iii. family issues – family therapy iv. cognitive causes CBT b. It was further hypothesized that participan ts who identify the causal factor as being most significant in determining de pression would judge th e acceptability of the corresponding treatment more fa vorably than they would judge the acceptability of alternative singl e treatments for depression. 4. To evaluate the relationship between symptom severity and treatment acceptability. It was hypothesized that all treatments, esp ecially medication, w ould be viewed as more acceptable in the case of a severely depressed adolescent than in the case of

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28 a mildly depressed adolescent. Furthe r, it was hypothesized that medication would be considered more acceptable rela tive to other treatments when depression symptoms are severe than when they are mild. 5. To examine the relationship between adolescent self-reported depressive symptomatology and treatment acceptability. It was hypothesized that there would be a positive associa tion between selfreported depressive symptomatology and the acceptability of treatments for depression, especially medication. Figure 3 illustrates th e constructs and relationships of interest in this study.

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29 Treatment Acceptability Ethnicity Acculturation Symptom Severity Prior Experience with Treatment Perceived Cause of Disorde r SES Predictor/Independent Variable Assessed as Potential Covariate Dependent Variable Relationship Examined Relationship Not Examined Figure 3. Model of Variables Assessed in Relation to Treatment Acceptability.

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30 Method Participants Sixty-seven female high school students (grades 9 through 12) were included in this study. Approximately 36% of the sample ( n =24) was recruited from one of six public high schools, two in New Jersey (E merson, Union Hill) and four in Florida (Alonso, Hillsborough, Leto, South County).3 The remainder of the participants responded to flyers posted around the commun ity in Tampa and in two counties in northern New Jersey (Bergen and Hudson). There were no significant differences by state on any of the dependent variable s in the analyses reported below ( p values ranged from .33 to .99). It is estimated that 650 females at Un ion Hill and 400 females at Emerson were contacted about partic ipation in the study.4 Based on the demographic profile of these two schools, it is assumed that almost all of the female students cont acted about the study were either Hispanic or non-Hispanic White and thus, would have met criteria for inclusion in the study. The participation rate for each of these two high schools was approximately 2%. Approximately 20 fe males at Alonso, 100 females at Hillsborough, and 30 females at South County were informed about the study. Estimated participation rates for these schools were 10%, 1%, and 7%, re spectively. It could not be determined how many females contacted at Alonso and H illsborough were eligible for participation in the study; however, all of the females from South County who were informed about 3 15 additional high schools in Hillsborough County Florida were identified as potential sites for recruitment based on their demographic profiles. However, the principals of these schools did not agree to assist with the study by allowing access to their student population. Superi ntendents and/or pr incipals of 14 additional high schools in northern New Jersey also declined participation. 4Given the demographic profile of these two schools, it is assumed that the majority of female students contacted about the study were eligib le to participate. However, becau se multiple methods of recruitment were used at these two sites, it could not be determined how many repeat contacts were made. The number of adolescents from each school who were contacted about the st udy is a rough estimate.

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31 the study were Hispanic and thus eligible to participate. The number of students from Leto who were informed a bout the study is not known5; however, only one student from this high school participate d. Approximately 75 adolescents responded to flyers made available in the community; 56% of thes e adolescents participated in the study. Thirty-six participants self-identified as Hispanic and 31 participants selfidentified as non-Hispanic White. Slightly more than one third of the Hispanic participants ( n = 13) were born in a Latin American nation. Of the 23 Hispanic participants born in the Unite d States, 18 indicated that on e or both biological parents were born in a predominantly Spanish-speak ing nation. The remaining 5 participants reported that at least one of their grandparents was born in a Spanish-speaking nation. Participants had parents a nd/or grandparents from the following Spanish-speaking nations: Argentina ( n =1), Chile ( n = 1), Colombia ( n = 2), Cuba ( n = 9), Dominican Republic ( n = 9), Ecuador ( n = 2), El Salvador ( n = 3), Guatemala ( n =1), Honduras ( n =1), Mexico ( n =2), Paraguay ( n = 1), Peru ( n =1), and Puerto Rico ( n =12), and Spain ( n =3). Participants ranged in age from 14 years to 18 years ( M = 16.5, SD = 1.23). Approximately 9 percent of participants were in grade 9 at the time of data collection, 30% were in grade 10, 18% were in gr ade 11, and 40% were in grade 12. The overrepresentation of 12th graders is likely due to the abil ity of 18 year olds to provide sufficient consent to participa tion without parental consent. Approximately 31% of participants ( n = 21) endorsed symptoms of depression at a level associated with clinical severity in the restandardization sa mple (Reynolds, 2002). About 43% of the sample ( n = 29) had utilized mental h ealth services, which included services provided by a school counselor ( n = 12). The same rate of lifetime service utilization was reported for youth ages 9 to 17 years in the Methods for the Epidemiology of Child and Adolescent Mental Disorder s (MECA) Study (Dulcan, 1996; Lahey, Flagg, Bird, & Schwab-Stone, 1996; Wu et al., 1999). 5 The procedure for recruiting participants relied on teachers to announce the opportunity to learn more about participation in the study. Administrators did not provide information about the number of students to whom this announcement was made.

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32 Measures Socioeconomic Status. SES was measured using the Hollingshead Four Factor Index of Social Status (Ho llingshead, 1975), which was admini stered in the form of a pencil-and-paper questionnaire. This index uses educati on, occupation, sex, and marital status to determine a family’s composite soci al status. Each family’s composite score was computed by multiplying the Occupation scale value by a weight of 5 and the Education scale value by 3 and summing th e products. Hollingshead Education scores range from 1 (less than seventh grade) to 7 (graduate professional training) and Hollingshead Occupation codes range from 1 (f arm laborers/menial service workers) to 9 (higher executives, proprieto rs of large businesses, and major professionals). Hollingshead Four Factor Index raw scores range from 8 to 66, with higher scores reflecting higher SES. In homes with two employed parent figures, the scores were averaged to obtain one scor e per family. In addition to using the Hollingshead classification scheme, data on income was collected using a single item. Cirino et al. (2002) reported on the inte rrater reliability of the Hollingshead system for use with families of varying cons titutions. Kappa coefficients ranged from .31 (for one-female-wage-earner families) to .82 (for two-wage-earner families), with a kappa of .68 for the total sample of 140 fa milies. Convergent validity with two other measures of SES was also assessed. Co rrelation coefficients ranged from .42 to .92, with the majority above .80. Mental health service use. Mental health service use was measured using a modified version of the Short Services A ssessment for Children and Adolescents (Short SACA, Horwitz et al., 2001). The SACA is an interview that examines where children/adolescents and/or their parent s have received assi stance for emotional behavioral problems, the types of care receiv ed, and satisfaction with care. The SACA was developed based on four survey instru ments used in multi-site federally funded studies (e.g., National Institute of Me ntal Health-sponsored Methods for the Epidemiology of Child and Adolescent Disorder s, MECA). The short form was modified for use in this study by eliminating items that refer to early childhood services that are not likely related to attitudes about depression treatments (e.g., play therapy). The modified

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33 Short SACA was administered to adolescen ts to assess lifetime service use and the adolescent’s perception of the helpfulness of any services th at the adolescent received. Responses to items on the SACA were collapsed into four categories in order to simplify analyses: services received and considered helpful; services re ceived and considered somewhat helpful; services received but not co nsidered helpful; services never received. For adolescents who endorsed the use of more th an one mental health service, helpfulness ratings were averaged. The original English-langua ge SACA has been shown to have excellent test-retest reliability for lifetime service use when ad ministered to parent and good to excellent reliability when administered to children ag ed 11 and older (Horwitz et al., 2001). The Spanish-Language SACA exhibited good test-re test reliability when administered to adolescents and when administered to thei r parents (Bean, Rotheram-Borus, Leibowitz, Horwitz, & Weidmer, 2003). The concordance between parent reports using the Englishlanguage SACA and medical and administrativ e service records were assessed in one study. Kappas ranged from .48 to 1.00 for inpati ent services, outpatient services, and school services, with a kappa of .76 for a gl obal “any use” service va riable (Hoagwood et al., 2000). In another study, The Englishlanguage SACA adultyouth correspondence for lifetime use of any services, inpatient services, outpatient services, and school services ranged from fair to excellent (k = .43 to .85 with most at .61 or greater; Stiffman et al., 2000). Kappas for the Spanish-language SACA have been reported to range from .30 to .89 (Bean et al., 2003). Ethnicity. Participants were asked to self-ide ntify as “Hispanic or Latino”, “nonHispanic White”, or “Other.” “Hispanic or Latino” was defined for participants using the official criteria developed by the United States Office of Management and Budget (OMB): “A person of Mexican, Puerto Ri can, Cuban, Central or South American or other Spanish culture or or igin, regardless of race” ( Federal Register 1978, p.19269; Federal Register 1997, p.58783). Participants were al so asked to indicate their birthplace and that of thei r parents and grandparents. Acculturation. Hispanics’ level of accultura tion was measured using the Bidimensional Acculturation Scale for Hi spanics (BAS; Marin & Gamba, 1996). The

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34 BAS was chosen over commonly used unidi mensional scales such as the Short Acculturation Scale for Hispanics (SASH; Marin, Sabogal, VanOss Marin, OteroSabogal, & Perez-Stable, 1987) b ecause it is rooted in the th eoretical perspective that acculturation involves two indepe ndent dimensions: maintenance of the culture of origin and adherence to the dominant or host cu lture (Berry, 1997, 1998; Berry & Sam, 1996, Cuellar, Arnold, & Maldonado, 1995; Marin & Gamba, 1996). Thus, the BAS provides two scores: for the Hispanic domain and one for the non-Hispanic domain. Each domain consists of 12 items rated on a 4-point Likert-t ype scale. Ratings are averaged to produce cultural domain scores that ra nge from 1 to 4. Respondents who score 2.5 or higher in a particular domain are considered to be immersed in the culture it represents. Respondents who score a 2.5 or higher in both doma ins are considered to be bicultural. Items on the BAS were chosen to reflect the experiences of all Hispanics rather than just one subgroup and the measure has be en found to be equally reliable and valid with Mexican Americans and Central Amer icans (Marin & Gamba, 1996). The BAS has been used with adolescents with very good in ternal consistency reported for each domain (Guinn, 1998) and has been recommended above other acculturation measures for use with this population (Zayas, Lester, Cabassa & Fortuna, 2005). In the current sample, Cronbach’s alpha coefficients for the Hisp anic domain and the non-Hispanic domain were 0.92 and 0.90, respectively. Sample items include “How often do you watch television programs in English?” and “How often do you speak in Spanish with your friends?” The BAS is available in both English and Spanish. Perceived cause(s) of depression. Beliefs about the cause of depression were measured using a modified version of the Beliefs About the Causes of Child Problems questionnaire (Yeh & Hough, 1997). This questionnaire was developed based on a literature review, expert consul tation, and prior qualitative and quantitative research. It is administered as a semi-structured interview and measures etiological beliefs in eleven separate categories: Physical Causes, Pers onality, Relational Issues, Familial Issues, Trauma, Friends, American Culture, Prejudi ce, Economic Problems, Spiritual Causes, and Nature Disharmony. One additional category, Cognitive Causes, was added for this study. This category was chosen based on a re view of studies of causal beliefs about

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35 depression and other mental health pr oblems (Srinivasan, Cohen, & Parikh, 2003; Thwaites, Dagnan, Huey, & Addis, 2004; Kirk, Brody, Solomon, & Haaga, 1999; Kuyken, Brewin, Power, & Furnham, 1992; La ndrine & Klonoff, 1994; Sonuga-Barke & Balding, 1993; Schnittker, Freese, & Powe ll, 2000; Sheikh & Furnham, 2000; Addis & Jacobson, 1996; Jorm et al., 1997; Sher, Mc Ginn, Sirey, & Meyers, 2005; Matschinger & Angermeyer, 1996; Whittle, 1996; Furnham & Malik, 1994; Armstrong & Swartzman, 1999; Atkinson, Worthington, Dana, & Good, 1991; Jo rm, 2000). For each of the twelve categories, participants were asked to respond yes/no to whether or not they believe that any emotional/behavioral problem the youth desc ribed in the vignette has “is likely due, at least in part,” to issues described by a global item pe rtaining to that category. Endorsement of the global item prompted mo re specific questions within that category, with the exception of the Prejudice category (w hich consists only of a global item). Dichotomous variables were created for each category, reflecting the endorsement of one or more specific items within that category. For the purposes of this study, participants were also asked to choose a sing le causal category that they be lieve is most significant in determining depression. There are both parent and adolescent vers ions of the Beliefs about the Causes of Child Problems questionnaire, each of which are available in English and Spanish. Psychometric information has been reported for the parent version onl y. Test-retest data was collected from 23 parents with an average time of 8.23 days between administrations. According to guidelines by Ro sner (1995), reliability estimates for 7 of the 11 scales suggest “excellent reproducibi lity” (or greater than 85% agreement between administrations). Kappas for two of th e four remaining scales suggest “good reproducibility” while kappas for the other two scales (Personality and Friends) suggest “marginal reproducibility.” Construct validi ty of the questionnaire is supported by previously hypothesized raci al/ethnic differences in responses to items about biopsychosocial causes (Yeh et al., 2004). Fi nally, results from a confirmatory factor analysis (CFA) of the 11 etiologic categories showed an adequate fit for an a priori 3factor model (biopsychosocial vs. sociologi cal vs. spiritual/nature disharmony) that

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36 reflects the broader domains hypothesized to be differentially relate d to mental health service use. Depression. Depression was measured us ing the Reynolds Adolescent Depression Scale—2nd Edition (RADS-2; Reynolds, 2000). The RADS-2 is a 30 item self-report measure of the seve rity of depressive symptoms in adolescents in grades 7 through 12. Items are rated on a 4-point scale. Estimates of the inte rnal consistency of the RADS range from .91 to .96 with ethnica lly diverse samples of normal and depressed adolescents ranging in size from 62 to 2,120 (Reynolds & Mazza, 1998). Cronbach’s alpha coefficient for the current sample was .85. Test-retest reliability estimates range from .79 for a 12-week interval (Reynolds 1987) and .93 for a 1-4 week interval (Reynolds & Mazza, 1998). Concurrent va lidity has been shown using the Beck Depression Inventory (BDI), the Center fo r Epidemiological Studies—Depression Scale (CES-D), the Children’s Depression Inve ntory (CDI) among other measures (see Reynolds & Mazza for a review). Criterion-re lated validity has been demonstrated using diagnostic and semistructured clinical inte rviews of depression (King et al., 1997; Reinecke & Shultz, 1995). The RADS-2 was c hosen over other measures of depression symptomatology because it has been develope d and validated with large and diverse samples of adolescents in the community/schools. Treatment Acceptability. Treatment acceptability was measured using the Abbreviated Acceptability Rating Profile (AARP; Tarnowski & Simonian, 1992). The AARP consists of 8 items that load on a unitary factor accoun ting for 84.9% of the variance in responses. The AARP yields a total score that ranges from 8-48 and has been shown to statistically distinguish be tween pharmacological and nonpharmacological treatments as well as among different types of nonpharmacological treatments (Tarnowski et al., 1992a). Reliability was asse ssed using a culturally diverse sample with limited educational background. P ublished split-half and Cronbach alpha coefficients for the measure are .95 and .97, respectively. In the current sample, Cronbach’s alpha coefficients ranged from .93 for IPT to .95 both for Family Therapy and for CBT + Pharmacotherapy. The AARP takes approxima tely 10 minutes to complete and has a readability index of 5.0 according to the Harris-Jacobson Wide Range Readability

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37 Formula. The AARP was chosen over meas ures such as the Treatment Evaluation Inventory (TEI; Kazdin, 1980) a nd the Intervention Rating Profile-20 (IRP-20) because it is shorter and easier to unde rstand. Sample items include “I like the treatment” and “Overall, the treatment would help the child.” Procedure Recruitment of participants. Adolescents were recruited from public high schools in New Jersey and Florida, and from the co mmunity. At five of the six high schools, a brief presentation about the study was made to students in grades 9-12 in their English classes (or some equivalent). A letter e xplaining the study was di stributed along with forms to indicate parental consent and student assent to participation. A sociodemographic questionnaire to be completed by parents who consented to participation was included with these materials. Students were informed verbally that if they had difficulty reading th e letter and/or consent forms, they could approach their teacher privately. When this occurred, the te acher informed the research staff so that individual telephone calls to review the letter and consent form could be arranged. The research staff included Spanish-speaking indi viduals who were available to communicate with parents/guardians who do not use English as their first language. The consent/assent forms distributed to students provided information about the purpose of the study, the type of information collected, and the risk s and benefits of participating. They also explained confiden tiality and its limits (reports of danger to self, danger to others, abuse) and included a toll-free telephone number that potential participants could use to cont act project staff if they have any questions. The letter distributed along with the consent/assent form s indicated that students may or may not be contacted for data collection de pending on whether or not they meet criteria for inclusion in the study. Students were asked to revi ew the forms at home w ith their parents and discuss whether or not they w ould like to participat e in the study. Parents were asked to indicate their decision by checking off “I freel y give my permission for my child to take part in this study” or “I do not give my permission for my child to take part in this study”

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38 and to provide their signatures. They were also asked to indi cate their decision to participate or not to participate themselves in a similar manner. Students were asked to indicate their decision by checking off “I have thought about this and agree to take part in this study” or “I do not ” want to take part in this study” and to provide th eir signatures. The letter asked that students and parents who consent to participation complete and return a separate form that asked them to identify their ethnicity and to indicate their home address, their home telephone number, times at which they are likely to be available for an interview, and the language in which they prefer to be interviewed. Students were asked to return the forms to th eir homeroom teachers (or some equivalent). Parents were given the option of return ing the sociodemographic questionnaires simultaneously with the consent/assent forms, or separately by mail. Teachers were instructed to maintain consent forms in a lo cked file cabinet until a research assistant collected them in person. At Emerson High School, the principal inve stigator addressed students during an assembly in addition to visiting classrooms to recruit participants. At Union Hill High School (New Jersey), parents were addressed directly at “Parents’ Night.” They were informed of the study (according to th e procedures outlined above) and given consent/assent forms to review with their da ughters. Also, administ rators at Union Hill High School agreed to disclose directory information (in accordance with the Family Educational Rights and Privacy Ac t) and research assistants c ontacted parents directly via phone to describe the study and ascertai n whether or not they would consider participating along with their children. Research assistants mailed the forms described above to parents who expresse d interest in the study a nd gave them the option of returning the forms by mail or having their children return the forms at school. At Leto High School, teachers were notifie d of the study by a memo distributed to their mailboxes. The memo requested that th ey read a paragraph a bout the study to their classes and have students who are interested in learning more about the opportunity to participate provide their name s and phone numbers. This procedure was also used for classes at Emerson High School in which the majority of students did not speak English

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39 comfortably. Bilingual research assistants then contacted par ticipants by phone to provide more information about the study. Adolescents who self-identified as eith er Non-Hispanic White or Hispanic American were contacted for further data collection. Individuals who met criteria for inclusion and actually partic ipated in the study were compensated with a $10.00 money order. Data collection. Once informed consent had been obtained from parents and assent from adolescents, all research mate rials (including treatmen t descriptions, case descriptions, and questionnaires) were mailed to their places of residence. Materials were provided in the language that they indicated to be their preference either on the phone or on the form that participants re turned along with the consent/a ssent forms. Participants who lost these materials were mailed a sec ond set. Approximately one week after research materials were mailed out, bilingual research assistants attempted to contact participants by phone to conduc t interviews. (All partic ipants were interviewed individually.) Participants for whom it is not a convenient time to complete the interview were offered the opportunity to re-schedule. Adolescents younger than 18 years of age were only interviewed at times during which at least one parent/legal guardian was present in the home (in case she endorsed a cri tical item on the RADS). Eight of the 67 interviews were conducted in Spanish. Research assistants6 followed a protocol for each interview and recorded participants’ responses using paper copies of the measures. They began by reminding participants that they are free to withdraw from the study at any time. Participants were also reminded of the exceptions to confidentia lity and asked to confirm that at least one parent/guardian would be at home for the durat ion of the interview. Participants were then asked to make sure that they have access to the packet of study materials that was sent in the mail, as some of the interview que stions would require th em to read and refer to information provided in that packet. Participants were asked again to identify their ethnicity and indicate their country of origin. Hispanic participants were admi nistered the BAS verbally and were able to 6 59 interviews were con ducted by the Principal Investigator and 8 interviews were conducted by one of two bilingual research assistants.

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40 read along in their packet if they so desired. All adolescent particip ants were interviewed about their history of mental health service utilization using the SACA. Participants were then presented with a case description of a 15-year-old who meets DSM-IV criteria for MDD. The case de scription represented one of two levels of symptom severity (mild and severe), which was determined by random assignment. Research assistants read the case descriptions out loud as participants followed along. Participants were then administered the Beliefs About the Causes of Child Problems interview. The items that make up this interview were modified such that participants were asked to think about the problems e xperienced by the prot agonist in the case description (rather than their own problems). In addition, participants were asked at the end of the interview to choose among the “globa l” causes that which they believe is most significant in determining depression. Following the interview, participants were instructed to follow along as the research as sistants read descriptions of four single treatments (CBT, IPT, family therapy, pharm acotherapy) presented in random order. Participants were then asked to review th e treatment descriptions and use the AARP to rate the acceptability of each of those treatm ents for use with the adolescent featured in the case description. They were also prompted to rate the a cceptability of three treatment combinations (CBT + pharmacotherapy, IPT + pharmacotherapy, family therapy + pharmacotherapy) in random order. They were told that there are no right or wrong answers to items on the AARP and asked to in dicate their true opi nions. Participants were encouraged to refer back to both the cas e description and treatment descriptions as necessary. They were given the option to hear the questions read out loud and indicate their responses, or record their own respons es and read them off to the interviewer. Participants were then administered the RADS. In the event that an adolescent endorsed the critical item that reads, “I feel like hurti ng myself” by responding hardly ever, sometimes, or most of the time, the research assistant followed a suicide risk assessment protocol (Appendix A), which involved asking follow-up questions to determine if a more thorough risk assessment by a Ph.D. level psychologist is needed. Four clinical psychologists (Dr. Marc Ka rver, Dr. Vicky Phares, Maria dePerczel Goodwin, Dr. Christine Totura) agreed to serve as suicid e consultants and designated

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41 times at which they could be reached by telephone/cellular phone. Interviews were only conducted at times during which one or more suicide consultants were available. Consultants were also provided with a protoc ol for assessing and responding to risk, and to assist in determining whether or not pare nts of adolescents who endorsed the critical item should be notified and given contact in formation for local service providers. Each interview took approximately 35-50 minutes. Research assistants thanked participants for their time and reminded them that they would rece ive a $10 money order by mail. The study was carried out in accordan ce with professional and legal standards of ethical conduct for resear ch involving human subjects. The University of South Florida Institutional Review Board appr oved all recruitment and data collection procedures. Development of study materials. Two case descriptions of approximately 130 words each were developed in English base d on DSM-IV criteria for MDD, and then translated into Spanish (Appendix B). While both feature the same nine symptoms of MDD, the frequency or severity of each of these symptoms is varied across the two descriptions in order to reflect the different severity levels of the cases (see Appendix B). The number of symptoms incl uded in the case descripti ons was chosen based on the recommendations of social judgment researcher s, who maintain that most judges are able to mentally track and utilize eight to te n cue values (Cooksey, 1996). The symptoms featured in the case descriptions were selected based on published reports of the prevalence rates of various depressive symptoms among Hispanic and non-Hispanic White adolescents (Roberts, Chen, & Solovitz 1995) and adolescent females in particular (Bennett et al., 2005; Kovacs, Obrosky, & Sher rill, 2003). The order in which physical and psychological symptoms are presented in the descriptions was randomized. Pilot testing with clinical psychology doctoral ca ndidates demonstrated that reliable MDD diagnoses and judgments of symptom seve rity could be made based on the case descriptions. Treatment descriptions (Appendix C) were developed based on empirically supported treatment manuals specific to adol escent depression (Mufson, Dorta, Moreau, & Weissman, 2004; Clarke, Lewinsohn, & Hops, 1990; Diamond, Siqueland, &

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42 Diamond, 2003; Brent et al., 1997) as well as treatment descrip tions used in prior studies of the credibility and percei ved helpfulness of depression treatments (Iselin & Addis, 2003; Rokke, Carter, Rehm, & Veltum, 1990). Each description was approximately 95100 words long (in English) and included the goals and methods of the treatment, the time commitment involved, and any potential side effects. Tr eatment descriptions were generally equivalent with respect to Flesch-Kincaid grade level. All research materials excluding those standa rdized measures that are available in Spanish were translated and b ack-translated by two bilingual rese arch assistants. That is, one research assistant translated the origin al version of a measur e into Spanish and a second research assistant inde pendently translated it back into English. The original version and the back-translated English ve rsion were compared. The two research assistants were consulted to identify the reas ons for any inconsistencies that were found and were asked to come to a consen sus regarding the best alternative.

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43 Results Missing Data Thirty-one parent-adolescent dyads did not complete and return questionnaires used to assess SES. These 31 cases were excluded from all preliminary analyses involving either annual househol d income or the Hollingshead Four Factor Index. 4 of the remaining 36 cases were also excluded fr om preliminary analys es involving income either because the item was not completed or because it appeared that the income reported was not annual. For the measures administered by telephone, there were few missing data. One observation (out of 864) was missing for the BAS, which was scored by averaging responses across the items that make up each domain. Helpfulness ratings were missing for 3 of the 29 adolescents who ha d utilized mental health services. These three cases were excluded from analyses i nvolving helpfulness ratings but were included in all other analyses. Finally, 1 (out of 2010) observations was missing for the RADS-2. The total depression score in this case was calculated according to the procedure outlined in the RADS-2 Professional Manual (Reynolds, 2002) for prorating incomplete protocols. Descriptive Statistics Hollingshead Four Factor Index. Thirty-six participants in this study returned the questionnaires7 with items required to calculate the Hollingshead Four Factor Index. The range of scores was 24 to 66. The median score was 48, which falls into the second highest social stratum outlined by Hollingshead (1975): medium business, minor professional, technical workers. The breakdow n is provided in Table 1. It is suspected that the true SES breakdown of the sample is much lower than these data reflect, as the majority of participants from whom questi onnaires were not colle cted were recruited 7 15 adolescents and 21 parents reported SES.

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44 from Union City, which is among the districts in New Jersey with the lowest reported SES. Also, the method of data collection assume d that parents of partic ipants are literate. Table 1. Participants’ Social Strata as Assessed by Hollingshead Four Factor Index Stratum Range of Scores Households ( n = 36) Major business and professional 65-55 27.78% Medium business, minor professional, 54-40 44.44 technical Skilled craftsmen, clerical, sales 39-30 11.11 workers Machine operators, semiskilled 29-20 16.67 workers Unnskilled laborers, menial service 19-8 0 Workers Income. Household income was reported for abou t half of the sample. The range was $5,000 to $170,000 annually. The median income was $80,000. 1 participant reported household income less than $8,000; 5 participants reported between $8,000 and $32,000; 6 participants reported between $32,000 and $78,000; 19 participants reported between $78,000 and $164,000; and 2 partic ipants reported between $164,000 and $357,000. Although the median household income for this sample was substantially higher than the national median ($48, 201; Ce nsus Bureau, 2006), it was comparable to the median household income in Bergen County ($71,394; U.S. Census Bureau, 2005), where the majority of participan ts who reported income reside. Short Services Assessment for Chil dren and Adolescents (modified). The modified Short SACA used in this study c onsisted of 13 items assessing participants’ mental health service utilization history. The items were scored dichotomously. Frequencies with which participants endor sed each item are presented in Table 2.

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45 Participants were asked to rate the helpfuln ess of each service util ized (1 = helpful; 2 = somewhat helpful; 3 = not helpful). In cases where more than one service had been utilized, helpfulness ratings were averag ed. The mean helpfulness rating across participants was 1.75 ( SD = 0.78). Table 2. Frequencies with which Mental Health Serv ices had been Utilized by Participants Service Adolescents ( N = 67) Community mental health center, child guidance clinic, 4.4% or outpatient mental health clinic Professional in private office (e.g., ps ychologist, 23.5 psychiatrist, social worker, counselor) In-home provider, therapist, family preservation 5.9 worker or counselor Pediatrician or family doctor 4.4 Nurse practitioner 1.5 Healer, shaman, spiritualist 4.4 (for emotional/behavioral problems) Acupuncturist, chiropractor, nutritionist 4.4 (for emotional/behavioral problems) Psychiatric or medical unit in general hospital (overnight) 2.9 Residential treatment center 2.9 Group Home 1.5 Foster Home 1.5 Other (all reported school counselor ) 32.4 Bidimensional Acculturation Scale for Hispanics. Hispanic participants were assigned to one of four categ ories based on their Hispanic domain and non-Hispanic

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46 domain scores on the BAS: immersed in Hispanic culture, immersed in non-Hispanic culture, immersed in both cultures (bicultural), and immersed in neither culture. The cutoff score recommended by the developers of the BAS (2.5 for each Hispanic domain and non-Hispanic domain) was used to determ ine the latter two categories. 38.9% of the Hispanic sub-sample (n=13) were identifie d as immersed in non-Hispanic culture and 61.1% were identified as bicultur al (n=22). None of the participants were identified as immersed predominantly in Hispanic culture. This characteristic of the sample is not unusual among school-based studies conducted in the United States/English-speaking classrooms (e.g., Christenson et al., 2006) b ecause the measure relies on the frequency with which Spanish is spoken as an indicator of immersion in Hispanic culture. Scores on the BAS were normally distributed, for bot h the Hispanic domain (skewness = -0.12, standard error = 0.39; kurtosis = -1.0, st andard error = 0.77) and the non-Hispanic domain (skewness = -0.78, standard error = 0.39; kurtosis = -0.76, sta ndard error = 0.77). The mean for the Hispanic domain was 2.7 ( SD = 0.69) and the mean for the nonHispanic domain was 3.54 ( SD = 0.49). Beliefs About Causes of Child Problems Questionnaire (modified). Dichotomous variables were created to represent the global items that assessed causal beliefs about depression. The frequencies with which each causal factor was endorsed are reported in Table 3. There appeared to be less variab ility in global item responses than Yeh and colleagues found in their research using th e measure (Yeh, et al., 2004a; Yeh et al., 2004b; Yeh et al., 2005). For example, 4 of the 12 causal factors were endorsed by more than 80% of the sample. Participants were also asked to indicate wh ich causal factor was most significant/played the biggest part in determining the prob lems of the adolescent in the case description. This item is not part of the semi-structured in terview that was used in previous studies. The fre quencies with which participants selected the various causal factors are presented in Table 4. Reynolds Adolescent Depression Scale. The range of possibl e total scores on the RADS-2 is 30 to 120; the range of total RADS-2 scores in th is sample was 44 to 94. This range is somewhat smaller than that repor ted in a validation study with young adolescents (Reynolds & Mazza, 1998): 33 to 100. Scores on the RADS-2 were normally distributed

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47 in the current study (skewness = 0.23, standa rd error = 0.29; kurto sis = -0.22, standard error 0.58). The mean score was 69.93 ( SD = 10.30), which is significantly higher than the mean score reported for females in the restandardization sample ( t = 6.45, p < .01): 61.81 (Reynolds, 2002). According to the R ADS-2 Professional Manual (Reynolds, 2002), the mean found in the vast major ity of samples is 60 2 points. Table 3. Frequencies with which Causal Beliefs were Endorsed Cause Adolescents ( N = 67) Physical Causes 43.3% Personality 94.0 Relational Issues 85.1 Familial Issues 80.6 Trauma 76.1 Friends 68.7 American Culture 25.4 Prejudice 29.9 Economic Problems 41.8 Spiritual Causes 14.9 Nature Disharmony 10.4 Cognitions 94.0

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48 Table 4. Frequencies of Causal Factors Identified as Most Significant in Determining Depression Cause Adolescents ( N = 67) Physical Causes 1.5% Personality 22.1 Relational Issues 13.2 Familial Issues 5.9 Trauma 14.7 Friends 4.4 American Culture 0.0 Prejudice 0.0 Economic Problems 0.0 Spiritual Causes 0.0 Nature Disharmony 0.0 Cognitions 32.4 Approximately 31% of participants ( n = 21) in the current study endorsed symptoms of depression at a level associated with clinical severity in the restandardization sample. The standard deviation for this sample wa s 10.30, which was smaller than that published for females in the restandardization sample: 15.23. Abbreviated Acceptability Rating Profile. One variable was created for AARP scores (regardless of treatment type) in order to examine the distribution. Although kurtosis was acceptable (kurtosis = -0.40, sta ndard error = 0.23), the distribution was negatively skewed (skewness = -0.54, standard error = 0.11). Values were reflected and a square root transformation was applied. Skewness and kurtosis both fell within

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49 acceptable ranges (skewness = -0.16, standard error = 0.11; kurtosis = -0.60, standard error = 0.23). The range of raw scores was 8 to 48. The mean was 32.45 ( SD = 10.20) and was comparable to the mean of AARP scores across various treatments in studies that sampled college students (Elliott & Fuqua 2002), parents (Tarnowski et al., 1992a; Krain, Kendall, & Power 2005), a nd direct care professionals (Miltenberger & Lumley, 1997). Preliminary Analyses Prior to hypothesis testing, potential c onfounding variables, namely SES and the perceived helpfulness of mental health serv ices utilized, were assessed in relation to treatment acceptability using bivariate tests. Correlations between income and the dependent measures (AARP scores for each individual treatment/treatment combination and the sum of AARP scores across treatme nts) ranged from -.32 to .11 and were not significant at an alpha level of .05. Neither were correlations between Hollingshead Four Factor Index scores and the dependent meas ures, which ranged from -.02 to .19. There were no significant differences in dependent measures based on whether or not mental health services had been u tilized by participants; p-valu es ranged from .31 to .92. Among participants who had utilized mental heal th services, ratings of the helpfulness of these services were not significantly rela ted to acceptability scores; Pearson’s r ranged from -.36 to .19. Hypothesis Testing Hypothesis testing was carried out using raw scores on the AARP and then again using transformed scores; findings did not differ. In the interest of clarity, results of analyses performed using ra w data are reported. Objective I. The perceived acceptability of single and combined treatments for adolescent depression was assessed (Aim 1) It was hypothesized that in general, psychotherapy approaches (CBT, IPT, fam ily therapy) would be judged as more acceptable than pharmacotherapy, with combined treatments (CBT with

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50 pharmacotherapy, IPT with pharmacotherapy, and family therapy with pharmacotherapy) falling somewhere in between. Table 5 pr esents mean AARP scores (and standard deviations) for each treatment/treatment combin ation. The rank order of the treatments from most acceptable to least acceptable is as follows: CBT, IPT, Family Therapy, CBT + Pharmacotherapy, Family Therapy + Pharmacotherapy IPT + Pharmacotherapy, Pharmacotherapy. Acceptability scores for CBT were significantly higher than acceptability scores for each of the other treatments, with the exception of IPT. Acceptability scores for pharmacotherapy we re significantly lower than acceptability scores for each of the other treatments. Analyses were repeated excluding the fifth item of the AARP, which asks participants to indicate how much they ag ree/disagree with the statement that the treatment in question would not have ba d side effects. The mean score for pharmacotherapy, the description of which expl icitly mentioned side effects, was still significantly lower than the mean score for each of the other treatments. P-values were all less than .01. Table 5. Acceptability Ratings by Treatment Type (N = 67) Treatment Type M SD CBT 39.15a 8.08 IPT 38.07a 7.70 Family Therapy 33.85b 10.02 CBT + Pharmacotherapy 33.27b 9.50 Family Therapy + Pharmacotherapy 29.18c 9.29 IPT + Pharmacotherapy 29.07c 7.68 Pharmacotherapy 24.54d 10.52 Note. The range of possible scores is 8 to 48. Means with di fferent subscripts differ significantly at p < .05.

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51 Objective II. It was hypothesized that Hispanics would judge the acceptability of treatments for adolescent de pression less favorably overall than would non-Hispanic Whites. To test for ethnic differences in accep tability judgments (Aim 2a), a 2 (ethnicity) x 7 (treatment type) mixed-model repeated measures ANOVA was executed with ethnicity as a between-subjects va riable, treatment type as a within-subjects variable, and total scores on the AARP as the dependent vari able. Consistent w ith hypotheses, there was a significant main effect of treatment type, F (1, 65) = 22.86, p <.01 but not ethnicity, F (1, 65) = 2.83, p = .10. There was a small to medi um effect of ethnicity on total acceptability ratings, which were calculat ed by summing scores on the AARP across treatments ( d = 0.42); however, it was not in the predic ted direction. That is, Hispanics judged the acceptability of treatments more favorably overall than did non-Hispanic Whites. Due to the small sample size, this effect may not be reliable. Means and standard deviations of AARP scores by ethnicity are reported in Table 6. It was also hypothesized that there would be ethnic differences in the acceptability of treatments relative to each ot her. Specifically, Hispanics would be more likely than non-Hispanic Whites to judge IPT and family th erapy as relatively more acceptable than other treatments for adolescen t depression. To examine this hypothesis, the ranks of the seven treatments were calculated fo r each participant and Mann-Whitney U tests were carried out with ethnicity as the grouping variable. There we re no significant findings. Thus, the hypothesis was not supported. Median treatment ranks are presented in Table 7. U values for each treatment type are presented in Table 8.

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52 Table 6. Acceptability Ratings by Ethnicity Hispanic ( n = 36) NHW ( n = 31) Treatment Type M SD M SD CBT 39.03 8.46 39.29 7.75 IPT 39.36 7.26 36.58 8.04 Family Therapy 35.61 9.63 31.81 10.25 Pharmacotherapy 24.53 10.96 24.55 10.18 CBT + Pharmacotherapy 34.17 11.00 32.23 7.44 IPT + Pharmacotherapy 30.28 8.34 27.68 6.70 Fam + Pharmacotherapy 31.53 8.99 26.45 9.29 Note. The range of possible scores is 8 to 48. NHW = non-Hispanic White; Fam = Family Therapy.

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53 Table 7. Median Treatment Ranks by Ethnicity Treatment Type Total sample ( N = 67) Hispanic ( n = 36) NHW ( n = 31) CBT 2.00 2.00 1.50 IPT 2.50 2.00 3.00 Family 3.00 3.00 4.00 Pharm 6.50 6.75 6.50 CBT + Pharm 3.00 3.25 3.00 IPT + Pharm 5.00 5.00 5.00 Family + Pharm 5.00 5.00 5.00 Note. Higher ranks correspond to more favorable judgments. Family = Family Therapy; Pharm = Pharmcotherapy. Table 8. Differences in Treatment Ranks by Ethnicity Treatment Type Mann-Whitney U p -value CBT 409.00 .05 IPT 500.00 .46 Family Therapy 536.50 .79 Pharmacotherapy 512.00 .54 CBT + Pharmacotherapy 552.00 .94 IPT + Pharmacotherapy 527.50 .70 Family Therapy + Pharmacotherapy 515.00 .59

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54 The relationship between treatment acceptability and acculturation among Hispanics was examined (Aim 2b). A series of independent sample s t-tests was carried out with acculturation status (b icultural, predominantly non-H ispanic) as the independent variable and mean scores on the AARP for each treatment type as the dependent variable. There were significant differences in ra tings made by predominantly non-Hispanic participants and bicultural participants on the CBT, t (34) = -2.48, p = .02 and Family Therapy + Pharmacotherapy, t (34) = -3.434, p = .002. Also, composite acceptability ratings differed significan tly by acculturation status, t (34) = -2.83, p = .008. To evaluate the hypothesis that particip ants who endorse part icular causes of depression would make more favorable j udgments of corresponding treatments than participants who do not endorse such cause s (Aim 3a), a series of four one-way ANOVA’s were performed with AARP scores for the treatment in question as the dependent variable. As hypothesized, partic ipants who endorsed relational causes as a probable cause of depression rate d IPT significantly higher th an did participants who did not endorse relational causes, F (1, 65) = 10.38, p < .01. Also, participants who endorsed familial issues rated family therapy signifi cantly higher than participants who did not endorse familial issues, F (1,65) = 4.79, p <.03. The hypothesis that participants who endorsed physical causes of depression would rate pharmacotherapy significantly higher than participants who did not endor se physical causes was not supported, F (1,65) = 0.00, p = .93). Neither was there support for the hypothesized relationship between endorsement of cognitive causes and ratings of cognitive therapy, F (1, 65) = 0.37, p = .54. It was hypothesized that there would be a relationship betwee n the causal factor that participants identify as most significant in determini ng depression and judgments of the corresponding treatment relative to j udgments of other treatments (Aim 3b). However, these relationships were not examined due to the small number of participants who identified each cause of interest: physical causes, ( n = 1, 1.5%), relational causes ( n = 9, 13.2%), familial causes ( n = 4, 5.9%), and cognitive causes ( n = 22, 32.4%). It was hypothesized that all treatments, es pecially medication, would be viewed as more acceptable in the case of a severely de pressed adolescent than in the case of a

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55 mildly depressed adolescent. In order to evaluate the relationship between symptom severity (of the adolescent in the case descri ption) and treatment acceptability (Aim 4), a 2 (symptom severity) x 7 (treatment type ) mixed-model repeated measures ANOVA was performed with symptom severity as a between -subjects variable and treatment type as a within-subjects variable. The effect of symp tom severity on ratings of acceptability was negligible, F (1, 65) = 0.008, p = .93, as was the interaction between symptom severity and treatment type, F (1, 65) = 0.30, p = .94). It was also hypothesized that medicati on would be considered more acceptable relative to other treatments when depression symptoms were severe than when they were mild. To examine this hypothesis, Mann-Whitney U tests were carried out on ranks with symptom severity (of the adolescent in the ca se description) as th e grouping variable. Participants who were presented with th e mild case did not rank pharmacotherapy significantly different from pa rticipants who were presen ted with the severe case ( U = 555.5, p = .94). Finally, correlations were used to eval uate the hypothesis that there would be a positive association between self-reporte d depressive symptomatology and the acceptability of treatments for depression, espe cially medication (Aim 5). Using total scores on the RADS-2, there were no signifi cant findings. All correlation coefficients showed little to no association. Pearson’s r coefficients are displayed in Table 9 The possibility that more depressed pa rticipants did not discriminate among treatments was examined by calculating for each participant the standard deviation for AARP scores (across treatments) and conducting a correlational analysis to evaluate the relationship between standard deviations and total RADS-2 scores. The correlation coefficient indicated a weak, nonsignificant association ( r = .10, p = .44).

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56 Table 9. Pearson’s r for Acceptability and SelfReported Depressive Symptomatology ( N = 67) AARP Total Score RADS-2 Total Score CBT .03 IPT -.02 Family Therapy -.09 Pharmacotherapy -.23 CBT + Pharmacotherapy .01 IPT + Pharmacotherapy -.08 Family Therapy + Pharmacotherapy -.20 Total Acceptability -.14

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57 Discussion The primary objective of this study was to ascertain information from adolescents on the acceptability of various single and combined treatments for depression. Despite the prevalence of depression among adolescents, the challenge of engaging this population in treatment, and recent media attent ion to the increased risks of psychotropic medications when administered to adoles cents, there have not been any published quantitative studies of the accep tability of treatments fo r depression to adolescents themselves. Another objective of this st udy was to add to literature on variables associated with treatment acceptability in orde r to alert practitioners to concerns common to particular populations, to assist with matc hing clients to treatments that will maximize adherence, and inform the development of treatments that are tailored to specific populations and can be easily tr ansported into real-world se ttings. It was hypothesized that adolescents would judge psychothera py approaches as more acceptable than pharmacotherapy, with combined treatments falling in between; and that treatment acceptability would be related to perceived causes of depression, ethnicity, acculturation, and symptom severity. As expected, psychotherapy approaches without a pharmacological component were generally more acceptable to adoles cents than those with a pharmacological component, which were considerably more acceptable than pharmacotherapy alone. These findings are consistent with previous re search that showed th at adolescents prefer non-medical interventions in general (e.g., Offer, Howard, Schonert, & Ostrov, 1991). Psychotherapy approaches were rated acceptable, on average, although mean scores suggest that adolescents’ views of these tr eatments could be improved. Pharmacotherapy in the absence of psychotherapy was rated unacceptable, on average.

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58 Among the psychotherapy approaches, CBT was favored by the sample, on average, and was followed closely by IPT. Also, CBT and pharmacotherapy used together was rated significantly higher, on aver age, than each of the other psychotherapy approaches in combination with pharmacother apy. The finding that adolescents in this sample tended to rate CBT as most acceptabl e is consistent with results of another vignette study that examined adolescent girls’ beliefs about treatment for bulimia nervosa (Mond et al., 2007). Participants in that st udy expressed a preferen ce for CBT over other types of psychotherapy/counseling, medica tion, and non-professional interventions. There are several possible reasons w hy adolescents preferred CBT. First, adolescents may have been responding to the content of the interv ention, which included “teaching the teen to replace negative thoughts a bout herself, others, and the world with more realistic thoughts that make her feel better.” Consistent with this possi bility is the finding that 94% of the sample endorsed cogni tions as a likely cause of depression. Second, adolescents may have favored CBT because its description did not identify parent/family involvement as a key component of the treatment. The description of IPT, the mean of which was ranked second highest, indicated that parents may or may not play a part in treatment. Parent involvement, wh ich is integral to family therapy, may be viewed unfavorably by adolescen ts, whose primary developmen tal task is to establish autonomy (Logan & King, 2001). Third, the description of CBT, unlike IPT and family therapy, included mention of homework assignm ents in order for adolescents to practice skills in between sessions. Homework is us ed in therapy to transfer learning to the client’s everyday life (Spiegler & Guevrem ont, 1998). The implication that specific skills acquired in session could be applied outs ide of therapy may have led adolescents to form an impression of CBT as more concrete an d/or more relevant than other approaches. Also, the mention of practice c ould be appealing to adolescent s because it suggests that in CBT, they have some control over improving th eir condition. According to Corey (2001) homework helps clients to assume active ro les in the change process. Although it has been suggested that using the term “homework” in CBT with youth could lead to noncompliance (Hudson & Kendall, 2000), the imp act of using this term has not been investigated empirically. Given that all of the adolescents who participated in this study

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59 had attended school and less than half of them had ever utilized ment al health services, it’s possible that the mention of homework in this context made adolescents feel more oriented to the format of CBT and thus, mo re comfortable with it. Finally, CBT was described as consisting of many different components (e.g., cognitive restructuring; relaxation; problem solving) that could each be considered to produce a distinct outcome (e.g., positive thinking; reduced anxiety; rem oval of stressors), increasing the likelihood that adolescents would find the treatment helpfu l in at least one respect. The description of IPT, on the other hand, emphasized one focus only (i.e., improvi ng relationships) and discussed variations of this focus (e.g., resolving disagreeme nts with parents or conflicts with peers). The description of family therapy also emphasized one focus (i.e. changing the way family members get along), to wh ich each of the components mentioned (e.g., communication; problem solvi ng) were clearly linked. In contrast to CBT, pharmacotherapy was rated as low on acceptability by most adolescents, even when analyses were repe ated excluding the item that addressed side effects. More than half of the sample j udged pharmacotherapy as l east acceptable of all of the treatments. Several possible explanati ons for these findings are considered. First, it might be difficult for adolescents who have not experienced the benefits of pharmacotherapy first hand to believe that it is effective for emotional and behavioral problems; without knowledge of neurotransmitte rs, it is not obvious how antidepressants bring about change in symptoms. A study in the adult literature show ed that only 40% of clients who had already been prescribed an tidepressants could explain how they work (Bultman & Svarstad, 2000). It might be easie r for adolescents to appreciate the potential for psychotherapy to be effective given that they’ve probably experienced at some point a change in mood after talking about problems with a friend or family member, if not a professional. Rates of informal help s eeking from friends and family are high among adolescents (e.g., Boldero & Fallon, 1995; Schone rt-Reichl & Muller, 1996), especially females (Rickwood, Deane, W ilson, & Ciarrochi, 2005) a nd Hispanics (McMiller & Weisz, 1996; Rew, Resnick, & Blum, 1997), and st udies have shown that help from these sources is frequently perceived as benefi cial (e.g., Offer et al., 1991). Second, adolescents might view pharmacotherapy as a cover up rather than a solution to one’s

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60 problems. Loewenthal and Cinnirella (1999) reported that the prevalent view of antidepressant medication in their multicultu ral sample of women was that it is a superficial form of help. Third, in line with one of the primary criticisms of the medical model (e.g., Engel, 1977), adolescents might perceive pharmacotherapy as pathologizing the individual rather than locating the sour ce of problems in the environment. As a result, pharmacotherapy might be more stigma tized than psychotherapy. Moreover, the impact of stigma is likely heightened dur ing adolescence, when capacities for selfreflection and social perspec tive-taking develop, and indivi duals become sensitive to potentially negative evaluations made by ot hers (Elkind & Bowen, 1979; Harter, 1990). Disturbances in self-concept are also more common during adolescence (Rosenberg, 1985). The thought of taking medication, which implies being “sick,” might be especially threatening to an a dolescent’s sense of self. Furt her, the relatively passive role that adolescents have in pharmacotherapy co mpared to psychotherapy might make them feel weak, unempowered, or ineffective in th eir environment. Finally, adolescents might believe that addiction to antidepressants is likely and fear being reliant on them to function. A qualitative study by Wisdom, Clar ke, and Green (2006) provides support for some of these ideas. Adolescents who were interviewed individually and as part of a focus group tended to view taking antidepressant medication as inconsistent with their views of themselves as autonomous, independe nt, healthy and normal; and struggled with the decision to take medication even when they recognized their depres sion as abnormal. Future studies should explore whether adolescents’ unfavorab le attitudes are based on factual information (e.g., about risk s and side effects), misconceptions (e.g., about the potential for addicti on), or other variables (e.g., stig ma). To the extent that views of pharmacotherapy and related treatm ent approaches as relatively unacceptable can be attributed to the latte r two possibilities, school-based programs to increase mental health awareness (Battaglia Coverdale, & Bushong, 1990; Esters, Cooker, & Ittenbach, 1998; Pinfold et al., 2003) or “mental heal th literacy” (knowledge and beliefs about mental disorders which aid their recognition, management, and prevention; Jorm et al.,

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61 1997a) may prove effective in increasing acceptability and in turn, utilization.8 Such programs could address stigma by providing fact ual information to counter stereotypes of people who take antidepressants. Given that adolescents resist seeking treatment because they expect their provider just to “medi cate” them (e.g., Wisdom, Clarke, & Green, 2006) and that in primary care settings, at least, adolescents who present with depressive symptoms are likely to be prescribed antidepre ssants (DeBar, Clarke, O’Connor, & Nichols, 2001; Park & Goodyer, 2000), these programs might benefit from incorporating information on adolescents rights as consumers of mental health serv ices and training in how to communicate with mental health provide rs about available tr eatment options. In addition to addressing the acceptabi lity of treatments to adol escents prior to entry into treatment (e.g., at school), role induction and other pretreatment strategies that have been found to be successful with adults (see Walitzer, Dermen, & Connors, 1999 for a review) should be explored with adoles cents in clinic settings. Pretreatment interventions to in crease acceptability might include psychoeducation about causes of depression, as results of th is study partially supported the hypothesized relationship between the per ceived causes of depression and treatment acceptability. Adolescents who endorsed relatio nal issues as a likely cause of depression rated IPT as more acceptable than adolescents who did not endorse relational issues. Also, adolescents who endorsed familial causes rated family therapy as more acceptable than adolescents who did not endorse familial causes. The data did not support the hypothesis that the perception of cognitions as a cause of depression would be related to the acceptability of CBT. However, it is likely that a ceiling effect prevented a relationship from being detected given that 94% of particip ants endorsed cognitions as a likely cause of depression and CBT was rate d acceptable by most participants. Finally, there was no relationship between perceptions of physical causes of depression and the acceptability of pharmacotherapy, suggesting a ge neral aversion to this treatment that is 8 These recommendations should be proceeded upon cautiously, with consideration of whether or not the acceptability of antidepressants to adolescents should be increased. Although re sults of a recent metaanalysis support the safety and efficacy of SSRI’s in the treatment of yout h depression (Bridge et al., 2007), concerns have been raised about selective publication of positive findings (Mamdani, 2008) and the lack of research on the long-term effects of antidepressants on the developing central nervous system (Leckman & King, 2007). Ongoing attention to emerging evidence from large scale research efforts (e.g., Child and Adolescent Psychiatry Trials Networ k; March et al., 2007) is critical.

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62 independent of the causes of depression. Da ta on causal factors identified by adolescents as most significant in determining depressi on could not be analyzed in relation to acceptability ratings due to the limited sample size. The finding that at least some causal belie fs were related to the acceptability of congruent treatments is consistent with the results of a study by Meyer and GarciaRoberts (2007). They found th at, in general, ad ult clients’ reported reasons for their depression that were systematically associated with their motivation to engage in corresponding interventions. These findings do not necessarily imply that matching clients to treatments that target their pe rceived reasons for depression would improve outcomes. After reviewing the work of Hayes and colleagues, who developed Acceptance and Commitment Therapy (Hayes Luoma, Bong, Masuda, & Lillis, 2006; Hayes, Strosahl, & Wilson, 1999), Meyer and Garcia-Roberts (2007) suggest that the reasons that people offer for behavior may not be related to the contingencies that actually control their behavior. However, at the least, fi ndings from the current study underscore the need for clinicians to assess c lients’ beliefs about th e causes of depression and discuss any concerns th at clients may have about whether or not the proposed treatment would address the causes of their dist ress. It may be important to introduce the distinction between original causes and maintaining causes (Iselin and Addis, 2003). According to Addis and Carpenter (2000), a common concern among clients is that treatment involves a superficial focus on symptoms without co rrecting the “real underlying” problem. Future research shoul d focus on identifying the most effective ways for clinicians to communicate with cl ients about the causes of depression and incorporate their beliefs into the rationale for treatment. Results may have been influenced by modifications made to the measure of causal beliefs. Respondents in this study were instruct ed to indicate whether or not they believe that the problems experienced by the depre ssed adolescent in the vignette “were likely due, in part, to” the cause represented by each global item. The version of the measure that has been validated asks respondents to reflect on causes of emo tional or behavioral problems, which may include but are not limited to depression. Also, the original version of the measure asks respondents to reflect on pr oblems that they have experienced (in the

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63 adolescent version) or their children have experienced (in the parent version). Thus, there was more personally contextualized in formation available to them to help in narrowing down the causes to which they attri bute emotional and behavioral problems. Limiting the information available to participan ts in this study by asking them to consider a hypothetical scenario might have resulted in responding that was overly-inclusive. Numerous participants were reluctant to rule out a cause of depression because they felt it could be possible given the lack of information. A related limitation is that because participants in this study we re instructed to think about another depressed individual, their responses may have been influenced by the fundamental attrib ution error, or the tendency for people to overemphasize disposi tional explanations for behaviors observed in others (e.g., personality) while undere mphasizing situational explanations (e.g., economic problems). To the extent that belief s about the causes of depression are related to treatment acceptability, a de-emphasis on situational explanations may have contributed to the finding that family ther apy was less acceptable than CBT and IPT. Thus, the findings from this study should be replicated using a sample of depressed adolescents. Alternative measures (e.g., Illness Perceptions Qu estionnaire-Revised; Moss-Morris et al., 2002) as well as qualitative indices might be useful for assessing beliefs about the causes of depression in fu ture studies. The semi-structured interview used in this study did not di stinguish between distal and proximal causes of depressive symptoms. At least some adolescents voluntee red verbal descriptions of a sequence of events which they believed had led to the ons et of depression, or ways in which several causal factors likely interacted to produce depression. The dichotomous items that make up the interview did not capture such comple xity of thought. Finally, in addition to assessing beliefs about the causes of depr ession, future research could assess other attributions in relation to treatment acceptability; for exam ple, identity, consequence, duration, and controllability/cure (Leventhal et al., 1980; Weinmann, Petrie, MossMorris, & Horne, 1996). Based on previous findings that Hispan ics are less likely than non-Hispanic Whites to utilize services and more likely to believe that conventionally defined symptoms of psychopathology reflect temperam ent (rather than mental illness), it was

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64 hypothesized that Hispanic adolescents would judge the acceptability of treatments for adolescent depression less favor ably overall than would non-Hi spanic White adolescents. This hypothesis was not supported. In fact, there was a small to moderate effect in the opposite direction, indicating that Hispanic adolescents overall rated treatments more favorably than did non-Hispanic White ad olescents. An examination of mean acceptability scores, however, showed that this pattern was not consistent across treatment types. Findings from this sample are somewhat consistent with results of studies in the adult literatu re. Cooper et al. (2003) f ound that counseling was more acceptable and antidepressant medication was le ss acceptable to Hispanic adults than to non-Hispanic White adults. A more r ecent study of older adults’ acceptance of depression treatments reported that Hispanics attitudes across all treatments were as favorable as those of their non-Hispanic White peers (Choi & Morrow-Howell, 2007). One potential explanation for the finding that treatment acceptability did not differ by ethnicity in this study is that Hi spanics’ response style differed from the response style of non-Hispanic Whites such th at Hispanics were more likely to choose extreme response options. This cross-cultur al difference in response style has been documented in the literature (Marin, Gamba, & Marin, 1992; Clarke, 2000). Consistent with this explanation, the m ean score for pharmacotherapy, which was clearly rated least acceptable by both ethnic groups, was lower fo r Hispanics than non-Hispanic whites. Further, an examination of the frequency with which each response option was selected across treatment types showed that 35.71% of responses made by Hispanics were extreme (either 1 or 6 on a 6-point scal e) versus 22.75% of responses made by nonHispanic Whites. Finally, the largest diffe rences between ethnic groups were found for the means of combined treatments. It makes se nse that treatments falling in the middle of the overall rank order of means would be most affected by differences in response style. Although some response styles are consider ed problematic (e.g., acquiescent) because they contaminate results, extreme responding does not necessarily indicate inaccurate reporting. Extreme responses may reflect extr eme opinions. To confirm the finding that Hispanics tend to have strong opinions about treatments for depression, future studies should incorporate multiple re sponse formats and include qualitative components.

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65 The finding that treatments for depression are at least as accept able to Hispanic adolescents as they are to non-Hispanic White adolescents su ggests that negative treatment expectations, which have been wr itten about as a barrier to treatment (e.g., Lahey et al., 1996), do not account for ethnic differences in unmet need for services. Addressing service underu tilization in Hispanic adolescents might require more attention to other barriers to treatment id entified in the literature (e.g., Lahey et al., 1996), such as system barriers (e.g., inability to get an appointment), fina ncial barriers (e.g., lack of health insurance), and stigma (e.g., concern ove r what others are thi nking). Research on stigma, in particular, is l acking, although qualitative studies have established its impact on adolescents’ attitudes toward seeking profes sional help for mental disorders in general (e.g., Chandra & Minkovitz, 2007) and for depr ession specifically (e.g., Wisdom, Clarke, & Green, 2006). A study in the adult literatu re showed that Hispanic women were more likely than non-Hispanic White and African American women to anticipate stigmarelated barriers to treatment (Alvidrez & Azocar, 1999). Futu re research should explore stigma as a factor contributing to ethnic disparities in serv ice utilization among adolescents. Although the acceptability of treatments to adolescents does not appear to account for ethnic differences in unmet need in this population, future studies should examine the acceptability of treatments to parents, who cons ent to adolescents’ treatment and facilitate treatment progress; for example, by scheduling appointments and providing transportation. Parents’ judgments of treatm ent acceptability may differ from those of their adolescent children because they ha ve different perceptions of the need for treatment, for example, or because they woul d have different roles in the interventions. Ethnic group differences in acceptability may be more pronounced among parents, who are often likely to be less acculturated than their adolescent children due to differences in generational distance from the tim e of immigration or in the age of arrival in the United States (Marin et al., 1987). There has been only one published study of the acceptability of treatments for child problems to Hispan ic parents (Borrego, Ibanez, Spendlove, & Pemberton, 2007). Although the study did not sample non-Hispanic White parents, precluding direct ethn ic group comparisons, results cont radicted findings of previous

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66 studies that were conducted with predom inantly non-Hispanic samples (e.g., Jones, Eyberg, Adams, & Boggs, 1998). Specificall y, punishment-based behavior management interventions were preferred in the Hisp anic sample whereas reinforcement-based interventions were preferred in predominantly non-Hispanic White samples. Thus, it appears that ethnicity might be related to the acceptability of treatments to parents. This question has yet to be examined with respect to depression in particular. In addition to the hypothesis that Hi spanic adolescents would judge the acceptability of treatments for adolescent depression less favorably overall than would non-Hispanic White adolescents, it was hypot hesized that there would be ethnic differences in the acceptability of treatments relative to each other. That is, values and worldviews that have been described as characteristic of Hi spanic culture (e.g., familismo, personalismo, fatalismo collectivism) but not Angl o culture would translate into different treatment preferences across the two groups. Specifically, Hispanics would be more likely than non-Hispanic Whites to j udge IPT and family therapy as relatively more acceptable than other treatments (e.g., CBT) for adolescent depression. Because these analyses relied on ranks for each partic ipant, the influence of response style was decreased. While the median rank of each of these treatments was higher for Hispanics than non-Hispanic Whites, results were not si gnificant. This finding should be replicated with a larger sample. If it’s tr ue that ethnicity is not related to the relative acceptability of treatments for adolescent depression, efforts to improve the cultural sensitivity of mental health services delivered to adolescents might focus less on the content of interventions and more on extratherapeutic fa ctors or therapy process factors, such as the alliance. In a study with Puerto Rican adults, the alliance was found to explain 45% of the variance in the effectiveness of psychotherapy (Bernal, Bonilla, Padilla-Cotto, & Perez-Prado, 1998). Research on the alliance with Hi spanic adolescents is needed. In interpreting the finding that relative acceptability did not differ by ethnicity, the demographic characteristics of the non-Hispan ic White sub-sample should be considered, as it might not have sufficiently represente d the larger Anglo p opulation. Specifically, the majority of non-Hispanic White partic ipants were recruited from northern New Jersey, where there is a con centrated population of Italian Americans. Approximately

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67 one-third of the non-Hispanic White sample reported that at least one parent or grandparent was born in Italy. Italian culture, like Hispan ic culture, also places an emphasis on relationships with family (Giordano, McGoldrick, & Klages, 2005; Yaccarino, 1993). Thus, to the extent that non -Hispanic White participants are immersed in Italian culture, effects of et hnicity would be attenuated. Finally, it is worth mentioning that the median rank of CBT was equal to the median rank of IPT in the Hispanic sub-samp le and the ratings of these two treatments indicated that they were both acceptable to Hispanics, on average. This finding lends support to the argument that integrating CBT and IPT by focusing on interpersonal schemas might be particularly effective with this populati on (Perez, 1999). Alternatively, individual differences in the acceptability of these treatments to Hispanics could inform prescriptive matching (e.g., Beutler & Harw ood, 1995); that is, the use of different therapies or techniques for diffe rent kinds of clients. It w ould be interesting to explore whether or not types of depression that ar e proposed to respond differentially to CBT versus IPT (e.g., dependent versus self-cri tical; Blatt & Marouda s, 1992) correspond to differences in the acceptability of each of these treatments to indi viduals suffering from depression. The hypothesis that Hispanics who are immers ed predominantly in their culture of origin would judge treatments as less accepta ble than would Hispanics who are immersed predominantly in U.S. culture could not be evaluated because the range of acculturation in this sample was restricted such that none of the Hispanic participants could be considered highly immersed in th eir culture of origin but not bicultural. It’s possible that this restricted range was a result of lim itations in the measurement of acculturation (Unger et al., 2007; Cabassa, 2003). Accord ing to Unger et al. (2007), acculturation measures are only modestly correlated, and conclusions of a study may differ based on which scale is selected. Although the BAS has rela tively strong psychometric properties, it only measures surface level acculturation; that is, items primarily assess language use. Many of the adolescents in th is study were recruited from classrooms in which English is spoken; the potential for these adolescents to score highly on the Hispanic domain scale was limited. Measuring other aspects of acculturation, such as

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68 awareness and appreciation of cultural material (e.g., history, art, music, foods, holidays) and preferences for relationships (e.g., fr iendships, romantic relationships) with individuals from one or both cultures (Cue llar et al., 1995; Orozco, Thompson, Kapes, & Montgomery, 1993; Padilla, 1980) might have produced a greater range of acculturation scores. Unexpectedly, overall acceptability wa s significantly higher for bicultural adolescents than Hispanic adolescents immers ed predominantly in non-Hispanic culture. It’s possible that bicultur al adolescents were more likely than predominantly nonHispanic adolescents to find multiple treatmen ts appealing because they were able to consider how a given treatment might be effect ive within the context of Hispanic culture or non-Hispanic culture. According to cult ural frame switching theory (Hong, Morris, Chiu, & Benet-Martinez, 2000), bicultural indi viduals shift between two culturally based interpretive lenses in response to contextual cues that make different cultural identifies salient. Cues may be subtle or implicit; for example, roles, ex pectations, and goals embedded in a particular context (Benet -Martinez, Lee, & Leu, 2006). In a study by Verkuyten and Pouliasi (2002), bicultural ch ildren showed differences in attributions (external versus internal), self-identification (social versus personal), and attitudes toward family integrity and obedience depending on cultur al identity salience. It’s possible that in the current study, characteristics of the vari ous treatments activated different cultural frames, allowing bicultural individuals to appraise treatments hypothesized to be appealing in collectivist cultures (e.g. family therapy) as accept able in addition to treatments that place more emphasis on the in dividual (e.g., CBT). Another possibility is that treatment descriptions di d not activate different cultur al identities but bicultural individuals, as a result of frequently switching cultural frames, are more cognitively flexible and thus able to evaluate multiple treatment approaches as acceptable. In addition to rating treatments overall as more acceptable, bicultural participants assigned higher acceptability ratings to CBT and to family therapy and pharmacotherapy combined than did Hispanic participants immersed predominantly in non-Hispanic culture. According to Sue and Sue (1990), Hi spanics expect treatments to be problemsolving oriented and directive, and to have immediate effects. Th ese characteristics are

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69 all consistent with the description of CBT. In the case of family therapy and pharmacotherapy combined, bicultural adolescents might have been more likely than their highly acculturated counterparts to valu e the family component because they are more vulnerable to conflict with parents due to generational gaps with regard to assimilating to U.S. culture (Organista, 2000) They might perceive pharmacotherapy as a solution that provides some immediate reli ef, especially if they experience somatic symptoms, but disapprove of it in the absence of psychotherapy either because they appreciate family conflict as a root caus e of depression or because they have the expectation common among Hispanics that a treatment provides desahogo (Martinez Pincay & Guarnaccia, 2007), which is simila r to “getting things off one’s chest.” Future research should capitalize on advances in the operationalization and assessment of acculturation. One measure that could be considered for use in future studies is the Acculturation, Ha bits, and Interests Multicult ural Scale for Adolescents (AHIMSA; Unger et al, 2002; 2007). This scale represents an improvement over measures of acculturation that have been used previously because it is intended specifically for adolescents, it can be used with a multi-ethnic sample, and it measures aspects of acculturation other than language use. In this study, the AHIMSA might have detected varying levels of acculturation within the non-Hispanic White sample, which was partly Italian American, allowing for a more accurate assessment of the relationship between ethnicity/acculturation and treatment acceptability. Also, the items on the AHIMSA appear to tap into respondent’s lifes tyle, which is likely more relevant to treatment acceptability than language use. For the purpose of this study, however, it would have been most valuable to know the extent to which beliefs and values of Anglo culture have been adopted and the extent to which beliefs and values of Hispanic culture have been retained. A need for the devel opment of acculturation measures that tap into beliefs and values has been acknowledged repeated ly in the literature (e.g., Cuellar et al., 1995; Cabassa, 2003). Finally, it was hypothesi zed that treatment acceptabi lity would be related to symptom severity. The design of the study allowed this hypothesis to be addressed in a couple of ways. First, the severity of sy mptoms experienced by the adolescent in the

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70 vignette was manipulated and betw een subjects analyses were carried out. Results failed to support the hypothesized relationship. Th e finding that symptom severity was not significantly related to treatment acceptability is consistent with studies in the adult literature in which vignettes were used to manipulate severity (Banken & Wilson, 1992; Landreville et al., 2001). On e interpretation of these findi ngs is that judgments of acceptability are not influenced by the sever ity of symptoms or the level of distress experienced by the individual for whom the tr eatments are intended. Alternatively, it may be the case that in all of these studies, participants were not able to differentiate the levels of symptom severity represented in th e vignettes. The two vignettes used in this study were identical in terms of how many and which symptoms were included. The primary difference was the frequency or seve rity of each individua l symptom, which was communicated through modifying adverbs (e.g., “somewhat” versus “extremely”). Even if adolescents attended to the modifying adve rbs, they might not have been strong enough to affect impressions of severity. An alte rnative approach would be to construct two vignettes with different symp tom constellations utilizing da ta on the extent to which individual symptoms of depres sion signal distress to adolesce nts (Burns & Rapee, 2006). However, varying the symptoms across vigne ttes would have not allowed for causal beliefs to be analyzed in the sample as a w hole. Thus, it would have been necessary to obtain a sample considerably larger than that which was feasible to obtain with this population in order to have adequate power to address all of the specific aims. In addition to manipulating severity of symptoms experienced by the adolescent in the vignette, the level of depressive symptomatology experienced by adolescent respondents was measured. Correlations with acceptability scores did not yield support for the hypothesized relationship. Thus, it appears that adoles cents’ judgments of treatment acceptability have li ttle to do with the extent to which they experience symptoms of depression. This finding that severity of depressive symptoms was not related to treatment acceptability is consiste nt with results from the adult literature (Landreville et al., 2001). It’s possible, however, that the RADS-2 as it was administered in this study was not an accurate measure of se verity of depression in respondents. First, as would be expected of a ny study conducted with minors, ad olescents were informed at

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71 the start of the study and again before the R ADS-2 was administered that there existed the possibility that the research assistant w ould break confidentiality should adolescents provide information indicating the risk of self-harm. This procedure might have increased the likelihood that at least some adolescents would underreport ideation or other symptoms perceived to be associated with risk of self-harm. Consistent with this possibility, only 3% of participants ( n = 2) in the current samp le endorsed the critical item that assesses for thoughts of self-har m. The prevalence of ideation in other community samples of adolescents has been substantially greater, with some reports exceeding 20% (e.g., Reinherz et al., 2006). Furt her, a one-sample t-test using as the test value the mean score obtained for this item in the RADS-2 school-based standardization sample of females was significant, t (66) = 21.97, p < .01 in the direction expected. Second, the RADS-2 was administered orally, which may have made participants feel less anonymous, increasing the likelihood that some of them would “fake good.” However, both of these possibi lities of underreporting are un likely given that the mean total score for the sample was higher than the mean score for the RADS-2 restandardization sample and as many as fi ve items can be omitted without invalidating the RADS-2 score. Finally, a lthough it appeared that there wa s some range restriction in total depression scores, it was likely not substa ntial enough to have in fluenced results. Limitations In addition to previously mentioned caveats, such as limited variability in causal beliefs, the overrepresentation of Italian Americans in the non-Hispanic White sample, the use of a language-based measure of accultura tion, and slight restriction in the range of depression scores, this study has several other limitations that should be considered. Due to a poor response rate, there was inadequate power to detect moderate effects. For example, results did not show a significant relationship between ethnicity and overall acceptability; however, measures of association suggest that th is relationship may exist in the population and could emerge as significant with a larger sample. Moreover, because the sample was self-selected and there is no information available about adolescents who

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72 did not participate, the possibility that pa rticipants differed systematically from nonparticipants cannot be ruled out. The poor response in this st udy is attributed to several factors. First, the target popul ation was one that underutilizes me ntal health services. It’s possible that some of the same characteristi cs that prevent individuals from seeking mental health services (e.g., stigma; time constraints) also prevent them from participating in research on mental health services. Second, policies imposed by the Institutional Review Board (IRB) at the University of Sout h Florida presented obstacles for recruitment. For example, the IRB required consent from at least one biological parent. In Union City, where many familie s immigrated only recently, a substantial percentage of high school students are in the care of another adult, such as an extended family member. Exclusion of these families not only reduced the response rate but also introduced threats to the gene ralizability of the sample by reducing the likelihood that participants who would score low on measures of acculturation were included. Another IRB policy that likely affected the respons e rate was the requirement that parental consent and youth assent be documented on se parate forms. School administrators volunteered the feedback that there were t oo many consent/assent forms (which were provided both in Spanish and in English) and that the consent forms were too long, alienating parents who are relatively unedu cated and/or whose time is limited (because they work multiple jobs, for example). Several adolescents also provided feedback about the recruitment and consent process, indicating that th e study was far less burdensome than the impression that had been created by the amount of information that the IRB required the investigators to provide beforehand. Third, adol escents who were interested in the study were relied on to complete multiple steps in order for participation to occur (e.g., bring consent forms home to parents, re turn consent forms at school, answer the phone during scheduled interview times). Follow-through was thus less likely than would have been the case if data were co llected at school, for example, using passive consent procedures. Previous school-based rese arch has shown that participation is poor when adolescents are given some responsibil ity for obtaining parental consent but that passive consent procedures re sult in very high response rate s in this population (Tarquini et al., 2007). Exploring diffe rent formats for recruitment and data collection might

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73 facilitate the attainment of a larger sample by improving the response rate. For example, data could be collected via th e internet rather than by tele phone, allowing adolescents to complete the study at their convenience. Also, given that there was minimal risk involved in this study, a waiver of informed consent documentation could be requested in the future, citing the poor response rates in th is study as evidence that the study could not practicably be carried out wit hout the waiver. Replicating the study with a larger sample would increase statistical power to detect differences across subgroups of adolescents and allow for findings to be confirmed us ing more conservative analyses. Due to limitations of power, analyses were conducted on Hispanics as a group regardless of nation of origin. This is a limita tion of the study insofar as there is much cultural heterogeneity among Hispanics (Marin & Marin, 1991, pp. 31-41; Sweeney, Robins, Ruberu, & Jones, 2005). As Malg ady (1994) pointed out though, it would be difficult to specify narrower subgroup differences that are cultural in nature and that are likely to be of consequence in the delivery of mental health servic es. Even if such differences were identified, the resources that would be needed to act in response to them are not likely to be forthcoming in the field of mental health. Thus it would be wiser to search for and develop appropriate course s of action for deali ng with the cultural commonalities among Hispanic nationalities, no t their cultural diversities. A major strength of this study is that it is among the first to look at the relationship between ethnicity (Hispanic or non-Hispanic White) a nd the acceptability of treatments for youths. In addition, it is notable that this study sampled the population for whom the treatments of interest are intended: adolescents. This strength sets it apart fr om other studies in the treatment acceptability literature, which have typically used university undergraduates (Finn & Sladeczek, 2001). Direct evidence th at the use of undergraduates can limit external validity comes from a study by Fore hand and McMahon (1981), in which there were significant differences between mother s and university students on ratings of the acceptability and usefulness of a progra m for managing child noncompliance. Another limitation of this st udy is its analog nature. Tr eatment descriptions were presented in written format, potentially limiti ng the extent to which results would apply in real-world settings, where clients have th e opportunity to ask th eir providers questions

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74 about treatments and providers have the opportuni ty to address their clients’ concerns. There is some evidence to suggest, however that analog and natu ralistic ratings of acceptability are positively associated (Rei mers et al., 1992b) and that beliefs and attitudes concerning treatments for depressi on are related to uti lization (Jorm et al., 2000). Moreover, the analog approach to in vestigating treatment acceptability allowed for comparative judgments to be made, providi ng more information than ratings solicited in a real-world setting, where it is unlikely that clients would have the luxury of choosing from among seven different treatments. In addition to the use of written tr eatment descriptions, another potential limitation was the use of written vignettes to represent depressed individuals. The advantage of using written vignettes, however, was that they allowed for greater control of the information conveyed and attended to by participants. Thus, participants were less likely to use information that is irrelevant to the research questions in forming judgments (McLaughlin, Bell, & Stringer, 2004). Furt hermore, there is evidence that “paper people” studies produce results that are equi valent to those produced by behavioral observation studies or at wors t, the effect sizes in pape r people studies are greater (Cleveland, 1991; Murphy et al., 1986). For example, Bech, Haaber, and Joyce (1986) found that psychiatrists’ judgments of the se verity of illness in confederates enacting depressed clients were in agreement with judgm ents of severity made using paper profiles of the clients. At least two studies fr om the medical literature found agreement ( r > .90) between doctors’ judgments of real patient s and corresponding paper patients (Kirwan, Bellamy, Condon, Buchanan, & Barnes, 1983; Kirwan, Chaput de Saintonge, Joyce, & Currey, 1983). Summary Despite the aforementioned limitations, this study showed adolescents clearly discriminate among treatments in formulating impressions of acceptability; that is, whether a treatment is appropria te to the problem, fair, reas onable, intrusive, and whether it concurs with popular notions about what treatment should be (Kazdin, 1980). The

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75 results of this study support Kazdin’s (1980, 2000) claim that two or more treatments can be effective and yet differ in the extent to which those who receive them consider them acceptable. Some treatments (e.g., pharmacoth erapy) were rated low on acceptability, on average. Given the relationships between tr eatment acceptability and utilization (Bannon & McKay, 2005; Chavira et al., 2003; Kazdi n, 2000), adherence/compliance (Reimers et al., 1992b), and even outcome (Reimers et al., 1992a), these findings underscore the need to address adolescents’ perceptions of accep tability before entry into treatment and throughout treatment in order to achieve successful outcomes. These findings also support the notion that treatment utilizati on in this underserved population could be improved by providing adolescents with access to multiple interventions and considering their preferences (Asarn ow et al., 2005). Future studies should examine the acceptability of treatments to adolescents in clinic settings. According to Finney ( 1991), treatment acceptability is potentially interactive, with prac titioners and consumers influencing the acceptability of treatment to each other. Studies in clinic settings would allow for a more in-depth investigation of the treatment acceptability that in corporates this conceptualiz ation. Future studies should also investigate which aspect s of the interventions (e.g., content; role of parents) adolescents consider most when forming an impression of a treatment as acceptable or unacceptable. Qualitative designs (e.g., Pemb erton & Borrego, 2005) may be helpful in identifying treatment characteristics a ppropriate for quantitative study. Finally, continued research on participant/client variab les that might influence acceptability is recommended. This study provided some evid ence that ethnicity, acculturation status, and perceived causes of depression are re lated to treatment acceptability. Other participant variables that coul d be explored in relation to treatment acceptability include previously acquired knowledge about treatme nt, perceived stigma associated with depression and its treatment, and the perceived credibility of the professional providing information about treatment. Information that would be gained from such research could inform the development of pretreatment interv entions, delivered in schools and clinics, to increase acceptability.

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76 References Ablon, J.S. & Jones, E.E. (1999). Psychothera py process in the National Institute of Mental Health Treatment of De pression Collaborativ e Research Program, Journal of Consulting and Clinical Psychology, 67 (1), 64-75. Addis, M.E. & Carpenter, K.M. (1999). R eason-giving and rumination as predictors of response to activationand in sight-oriented treatment rationales. Journal of Clinical Psychology, 55 881-894. Addis, M.E. & Carpenter, K. (2000). The tr eatment rationale in cognitive behavioral therapy: Psychological m echanisms and clinical guidelines. Cognitive and Behavioral Practice, 7 (2), 147-156. Addis, M.E. & Jacobson, N.S. (1996). Reas ons for depression and the process and outcome of cognitive-behavioral psychotherapies. Journal of Consulting and Clinical Psychology, 64 (6), 1417-1424. Addis, M.E. & Jacobson, N.S. (2000). A cl oser look at the treatment rationale and homework compliance in cogni tive-behavior therapy for depression. Cognitive Therapy and Research, 24 (3), 313-326. Alvidrez, J. & Azocar, F. (1999). Distressed women’s clinic patients: Preferences for mental health treatm ents and perceived obstacles. General Hospital Psychiatry, 21 (5), 340-347. American Academy of Child and Adolescent Ps ychiatry (2004). Practice parameter for use of electroconvulsive therapy with adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 43 (12), 1521-1539. American Psychiatric Associati on (1994). Diagnostic and sta tistical manual of mental disorders (4th ed.). Washington, DC: Author.

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112 Appendices

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113 Appendix A: Protocol for the Assess ment of Suicidality and Self-Harm *** Protocol for the Assessment of Suicidality and Self-harm *** Say to the participant : I want to talk to you a bit more about what you said about trying to kill/harm yourself. Just to be sure, let me ask… 1a. Have you ever tried to kill or harm yourself? YES Record response and complete questions 1b-1e. NO Record response a nd skip to question 2a. Youth Response: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 1b. What happened? (i.e., method of suic ide / self-injury) Youth Response: __________________________________________________________________ _________________________________________________________________ __________________________________________________________________ 1c. Where did this take place? Youth Response: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 1d. What lead up to this? (i.e., why did the participant attempt suicide or self-harm) Youth Response: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 1e. When did this occur? Youth Response: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

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114 Appendix A: (Continued) 2a. I really appreciate your sharing this in formation with me. Have you thought about killing or harming yours elf in the past two weeks? YES Record response and complete question 2b. NO Record response. END PROTOCOL. FOLLOW SCRIPT FOR NON-MANDATORY REPORTING. Youth Response: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2b. Are you currently considering killing or harming yourself? YES Record response and co ntinue to question 3a. NO Record response and skip to question 3b. Youth Response: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 3a. Do you have a plan for killing or harming yourself? YES Record response and skip to question 3c. NO Record response and skip to item 4. Youth Response: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 3b. When you were considering killing or harming yourself within the past two weeks, did you have a plan of how to do it? YES Record response and proceed to 3c. NO Record response and skip to item 4. Youth Response: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

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115 Appendix A: (Continued) 3c. What was/is your plan? (i.e., how, when, and where th e youth planned/plans to kill or harm themselves). Youth Response: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 4. FOLLOW SCRIPT FOR M ANDATORY REPORTING.

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116 Appendix A: (Continued) Script for Mandatory Reporting Say to youth: Your thoughts about killing/harming yourself concern me. It sounds like something to take seriously. Remember -when we first talked to you about the study, we told you that the law requires us to break confidentiality if we are concerned about your safety. I want to be sure -do you understand confidentiality? If necessary, clarify any misunderstanding on confidentiality. I need to let your parents know that you have thought about hurting yourself, so that they can help keep you safe. I must tell them b ecause I am legally responsible for watching out for your safety. After I tell them, I’ll also n eed to follow up with one of the doctors that work with us so they can also make su re you are safe. One of the doctors may call you back to talk with you and your parents. How do you think your parents will react? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ If youth refuses to let you speak with the parent, say: I will have to call one of the doctors that I work with and they will be required to try and contact your parents. If they are unable to contact your parents, they will be required to call 911 and have a law enforcement offi cer come to your house to ensure your safety. Will you please reconsider letting me talk to your parents now? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Then, talk to the parents on th e phone, and say something like… Some of the information your daughter provide d in the interview suggested that she is thinking about harming herself. I am legally required to report this information to you and I feel that it is important for me to make su re you are aware of this. One of our clinicians may be calling to follow up with you. Considering that your daughter is currently thinking about harming herself, I recommend that you closely supervise her and that you take her as soon as possible to a mental health professional Would you like for me to give you contact information for some mental health professionals in your area? Provide parent with contact inform ation from list of providers.

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117 It is important that I stress to you that wh at I have done is not a full psychological evaluation. It is just one interview, but it is important for you to have a more complete follow-up to determine if your daughter need s some sort of in tervention targeting suicidality immediately.

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118 Appendix A: (Continued) Script for Non-Mandatory Reporting Say to youth: From what you’ve told me, it seems like you have been feeling __________________ (e.g., sad a lot lately) Many teens feel this way when they are going through tough times. Letting people, like your parents, know how you’re feeling, rather than keeping it to yourself, is important. Other teens have these feelings and there are trained people who understand teens and can help them deal with these fee lings. I would like to let your parents know how you’ve been feeling so they can help you decide if you’d like to see a trained person to help you feel better. If youth says YES, say to parents: It seems like your daughter has been feeling _______________ (e.g., sad for some time). She gave me permission to let you know how she is feeling. I did not do a formal assessment, but I recommend that you speak to a trained mental health professional for follow-up. I have some information about places you can contact to get help for her. Offer the parent contact information for service providers in his/her area. If youth says NO, say to youth: I hope that you will consider talking with your parents or perhaps a mental health professional about how you’re feeling. Talking to a professional can be very helpful.

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119 Appendix A: (Continued) PROTOCOL FOR SUICIDE CONSULTANTS Step 1: Consult with the RA The research assistant (RA) will contact a suic ide consultant after every interview with an adolescent in which the RA had to consider breaking confidentiality for suicidality /deliberate self-harm. Additionally, RAs may encounter a situation in which the participant herself is not at risk but she is concerned about a friend, and may contact you for guidance. Complete the following Case Information form as you gather information from the RA on the situation. Case Information Consultant Name: _______________________________________________________ Research Assistant Name: ________________________________________________ Participant Name & Number: ______________________________________________ Date & Time of Consultant Contact: __________________________ Date & Time of Consultant Follow-Up Call: ____________________ Was confidentiality broken to the parents? Yes No Document what the RA said to the parents a nd youth and the RA’s report of the parent’s and youth's reactions in the space provided below.

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120 Appendix A: (Continued) Step 2: Consultant Assessment After gathering preliminary information from th e RA, consider whether it is necessary to evaluate the situation further, for example: 1) If it is ambiguous how suicidal the adolescen t is and the parents have not yet been informed 2) If the parents have been informed but the situation is ambi guous and the parents may benefit from having more information 3) If the parents were informed but do not a ppear to be taking the situation seriously and thus should have the added weight of talking to a consultant/doctor When in doubt, contact another consultant: Dr. Totura Dr. Goodwin Dr. Karver Dr. Phares Home (xxx) xxx-xxxx (xxx) xxx-x xxx (xxx) xxx-xxxx (xxx) xxx-xxxx Cell (xxx) xxx-xxxx (xxx) xxx-x xxx (xxx) xxx-xxxx (xxx) xxx-xxxx Office (xxx) xxx-xxxx (xxx) xxx-x xxx (xxx) xxx-xxxx (xxx) xxx-xxxx Consultant Assessment Recommendations: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Did you contact another consultant? Yes No If yes, who was contacted? Christine Totura Maria dePerczel Goodwin Marc Karver Vicky Phares Document your discussion with the consultant: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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121 Appendix A: (Continued) Step 3: Follow up with Adolescent, Paren ts, and Authorities (if necessary) and Document If appropriate after careful consideration of the informa tion provided by the RA and in consultation with other suicide consultants, you will call the adoles cent and follow the attached protocol. Document all c onsultations and conversations conducted.

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122 Appendix A: (Continued) SUICIDE RISK With the Adolescent Clarify the nature/exten t of risk by saying: “In talking with the research assistant, you had mentioned… please tell me more about that.” Obtain information regarding specific thoughts, duration of thoughts, and recency of thoughts. Record the adolescent’s response in the space below. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Planning (e.g. having a specific plan notes, giving away belongings) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Previous attempt(s) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Recent exposure to death/suicide ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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123 Appendix A: (Continued) Current stressors (family, peer, school) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Current mood state ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Availability of means to follow through with act ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Social supports ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Assess overall mental status (oriented – who, when, where, not confused, coherent, adequate judgment) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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124 Appendix A: (Continued) Problem-solve alternatives to hurting self. He lp participant to gene rate coping strategies to deal with suicide-pr ovoking situations in the interim. For example: distracting activities doing something for others avoiding stressful situations distract with pleasant sens ations (any of 5 senses) positive imagery prayer any relaxation strategies known Indicate strategies discussed and adol escent’s attitude toward each below. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Ask subject to contract for safety over next 24 hours if there is more than minimal risk. Place a check mark in the appropriate box and, if possible, record a ny details about each task in the spaces below. If she can agree to contract for safety: With adolescent: Help them develop a concrete plan in case of crisis (e.g., identify social supports to contact, keep emergency telephone numbers by phone). _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ If she is in treatment: Contract with them to talk with the therapist directly as soon as possible (i.e. the next morning). _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________

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125 Appendix A: (Continued) If she is not in treatment: Tell them parents will be encouraged to set up an emergency appointment by the following day. _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ With the Parent: Review crisis plan (including emergency telephone numbers). _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Review limiting access to means (e.g., pills, firearms). _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Review treatment plan (i.e., contacting therapist or scheduling and going to an emergency appointment). _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________

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126 Appendix A: (Continued) If she can’t contract for safety : Attempt to speak with parents Review crisis plan (including emergency telephone numbers). _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Review limiting access to means (e.g., pills, firearms) _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Tell parent to supervise the adolescent and to make an appointment with the therapist (if in treatment already) or for an emergency assessment as soon as possible. _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ If at any point during the in terview, the adolescent seems disoriented, hangs up or refuses to put the parents on the pho ne, immediately contact rescue at 911. Applicable Not Applicable ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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127 Appendix A: (Continued) If the parents refuse to talk or follow th rough with a crisis plan, they should be warned that this would trigger a duty to report call to New Jersey’s Division of Youth and Family Services (DYFS). If they continue to refuse, call DYFS and report this as a “medical neglect” situation. 1-877-NJ ABUSE (652-2873) http://www.state.nj.u s/dcf/abuse/how/ Applicable Not Applicable ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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128 Appendix B: Case Descriptions Mild Depression Maria is a high school student. Lately, she has been feeling somewhat sad or depressed. She feels more tired than usual, like she has little en ergy, and she is not as interested in activities that used to interest her very much. She just doesn’t enjoy them as much as she once did. Maria has been some what irritable and s hort-tempered too, and has had some difficulty concentrating. She ha s been having a bit of trouble falling asleep and sometimes wakes up in the middle of the night. Every now and then, Maria doesn’t really feel like eating. Sometimes she blames herself for things that most people would not feel guilty about. Maria has had brief thoughts about death or dying but has no plan to kill herself. Severe Depression Maria is a high school student. Lately, she has been feeling extremely sad or depressed. She feels a lot more tired than usual, like she hardly has any energy, and she has lost almost all interest in activities that interested her before. She just doesn’t enjoy them anymore. Maria has been extremely i rritable and short-tempered too, and has had a lot of difficulty concentrating. She has been having a lot of trouble falling asleep and often wakes up in the middle of the night. Als o, Maria doesn’t ever really feel like eating anymore. Oftentimes she blames herself for things that most people would not feel guilty about. Maria thinks about death and dyi ng a lot and has even thought about how she could kill herself if she really wanted to.

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129 Appendix B: (Continued) DSM-IV Symptoms as Described in the Mild and Severe Case Descriptions. Symptom Mild Depression Severe Depression depressed mood somewhat sad or depressed extremely sad or depressed fatigue more tired than usual, like she has little energy a lot more tired than usual, like she hardly has any energy anhedonia not as interested in activities that used to interest her very much; doesn’t enjoy them as much as she once did has lost almost all interest in activities that interested her before; doesn’t enjoy them anymore irritability somewhat irritable and shorttempered extremely irritable and shorttempered difficulty concentrating has had some difficulty concentrating has had a lot of difficulty concentrating insomnia has been having a bit of trouble falling asleep and sometimes wakes up in the middle of the night has been having a lot of trouble falling asleep and often wakes up in the middle of the night loss of appetite every now and then, Maria doesn’t really feel like eating Maria doesn’t ever really feel like eating anymore guilt sometimes she blames herself for things that most people would not feel guilty about oftentimes she blames herself for things that most people would not feel guilty about suicidal ideation has had brief thoughts about death or dying but has no plan to kill herself thinks about death and dying a lot and has even thought about how she could kill herself if she really wanted to

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130 Appendix C: Treatment Descriptions Cognitive-Behavioral Therapy With this therapy, the teen m eets individually with a therapist on a regular basis. The therapy has several parts. The therapist help s the teen to plan pleasant activities. The therapist teaches the teen to replace negative thoughts about herself, others, and the world with more realistic thoughts that make her f eel better. The therap ist teaches the teen skills for making friends, communicating, and so lving problems. The therapist teaches the teen to relax by being aware of tensi on in her body and releasing the tension. The teen is given homework so that she ca n practice what she learns in therapy. Interpersonal Therapy With this therapy, the teen m eets with a therapist on a regular basis. Parents may play a part in treatment but don’t ha ve to. Therapy focuses on th e teen’s relationships with important people in her life. The teen and her therapist choose one or two relationship problems to work on. For example, disagreement s with parents, conflicts with peers, the loss of a meaningful relationship, problems with communication, or coping with changes in the family. The therapist helps the teen to express her own feelings The therapist also teaches her new ways of coping with her relationships. Family Therapy With this therapy, the whole family meets with a therapist on a regular basis. All family members are thought to play a role in the teen’s problems. They all work towards changing the problem. The focus of family therapy is on the way that family members get along with each other. Relationships that lead to conflict are changed. The therapist teaches the family skills for communicating better and for working together to solve problems. Family members learn to talk about problems that keep the teen from trusting her parents and using them for emotional support. Pharmacotherapy With this therapy, the teen goe s to see a doctor to get a prescription for medication. This therapy focuses on the chemicals in the brain th at affect a person’s feelings as well as her sleeping and eating. It involves using medication(s) to chan ge those chemicals. The teen usually checks in with that doctor to let the doctor know how the medication is working. A doctor might start the person on a small amou nt of medication and then increase the dosage. The doctor might also choose different medications if neede d. Medications have different side effects fo r different people.