Evidence-Based Practice in Family Therapy: Adolescent Depression as an Example
Denton, Wayne H., Walsh, Stephanie R., Daniel, Stephanie S., Journal of Marital and Family Therapy
The article "Taking a stand: An adolescent girl's resistance to medication" (Sparks, this issue) raises two issues of considerable importance to family therapists. The first is how to ameliorate the suffering of adolescents who feel seriously depressed. The second is how family therapists should, more generally, make decisions about intervening clinically with their clients. Our goal here is to respond to some of the issues raised in "Taking a stand" and to use a discussion of the treatment of adolescent depression as an example of clinical decision making that family therapists may find useful in approaching other clinical conditions.
In focusing on depression in adolescents, the author of "Taking a stand" has selected a problem that is serious and relatively common among adolescents. The prevalence of major depressive disorder has been found to be between 4% and 8% among adolescents with a female-to-male ratio of 2:1 (Fleming & Offord, 1990; Kashani et al., 1987a,b; Lewinsohn, Clarke, Seeley & Rohde, 1994). ). By age 18 approximately 20% of people in community samples will have met the criteria for major depressive disorder (Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993).
Although there is much speculation, there is little evidence to explain the gender difference in depression that emerges during adolescence (Nolen-Hoeksema & Girgus, 1994). The author of "Taking a stand" expresses concern that antidepressants are more commonly prescribed to adolescent females than they are to males. The gender difference in the occurrence of major depressive disorder in the community would be consistent with a gender difference in the application of a treatment for that condition.
Depression in adolescents can be associated with many adverse outcomes of which the most serious is suicide. Suicide has been reported to be especially problematic among persons between the ages of 15 and 24. According to the most recent data from the Centers for Disease Control (Centers for Disease Control [CDC], 1991), suicide is the third leading cause of death among persons between the ages of 15 and 24 and the fourth leading cause of death among persons between the ages of 10 and 14. Epidemiologic data from community samples, as well as surveys of high school students, suggest that the incidence of suicide attempts among older adolescents is between 7% and 9% (Andrews & Lewinsohn, 1992; CDC, 1991; Friedman, Asnis, Boeck, & DiFiore, 1987; Lewinsohn, Rohde, & Seeley, 1996; Smith & Crawford, 1986).
Ultimately, for the clinician, the question to be addressed is how to intervene most effectively to relieve the suffering of depressed adolescents and their families. This is a question, of course, that applies to all clinical problems that clients present to family therapists.
Evidence-based practice is becoming increasingly prominent in health care and has led to a movement variously referred to as empirically validated treatment, empirically supported treatment, empirically evaluated treatment (e.g., Kendall, 1998) or evidence-based treatment (e.g., Evidence-based medicine working group, 1992). Evidence-based practice can be described as the selection of treatments for which there is some evidence of efficacy. Implementing evidence-based practice "requires efficient literature searching and the application of formal rules of evidence evaluating the clinical literature" (Evidence-based medicine working group, 1992, p. 2420). Finally, the use of "treatments shown to be efficacious in controlled research with a delineated population" (Chambless & Hollon, 1998, p. 7) further characterizes evidence-based practice.
We have argued elsewhere that the profession of marriage and family therapy (MFT) has an ethical obligation to begin to move towards a standard of evidence-based practice to best advance the welfare of individuals, couples, and families (Denton & Walsh, 2001). …