The Internalizing Paradox – Youth Anxiety and Depression Symptoms

In this Papers Podcast, Dr. John Weisz discusses his JCPP paper ‘Research Review: The internalizing paradox – youth anxiety and depression symptoms, psychotherapy outcomes, and implications for research and practice’ (https://doi.org/10.1111/jcpp.13820).

There is an overview of the paper, methodology, key findings, and implications for practice.

Discussion points include:

• An explanation of what the internalizing paradox is.
• The five different possible explanations for the internalizing paradox.
  • The differential comorbidities between anxiety disorders and depressive disorders.
  • Insight into ‘variegated nature of polythetic conditions’.
  • A definition of differential progress in the search for mechanisms of change.
  • How differential complexity of evidence-based psychotherapy protocols relate to the internalizing paradox.
  • The clinician’s challenge.
• How the different perspectives suggest different treatment strategies and insight into these strategies.
• The limitations of current research and the possible avenues for future work.
• Implications for clinicians and how this research impacts interventions.
• Messages for parents and carers and the importance of parents/carers partnering with clinicians with regards to interventions.

In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.

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John Weisz’s research involves development and testing of interventions for these disorders and challenges, as well as meta-analyses to characterize and improve the science of youth mental health care. His most recent work involves building and testing, in randomized controlled trials, transdiagnostic approaches to youth psychotherapy that use modular design and empirically supported principles of change. His work integrates evidence-based practices with strategies for personalizing treatment to fit individual youth and family characteristics. His research also includes development and testing of brief digital interventions designed to maximize access by young people, and interventions delivered by lay-providers to adolescents in Africa. Weisz’s books include Psychotherapy for children and adolescents: Evidence-based treatments and case examples (Cambridge University Press), Evidence-based psychotherapies for children and adolescents (Co-edited with Alan Kazdin; Guilford Press), and Principle-guided psychotherapy for children and adolescents: The FIRST treatment program for behavioral and emotional problem (Co-authored with Sarah Kate Bearman; Guilford Press). Weisz’s awards include the Klaus-Grawe Award for the Advancement of Innovative Research in Clinical Psychology and Psychotherapy, from the Klaus-Grawe Foundation; the Sarah Gund Prize for Research and Mentorship in Child Mental Health, from the Scientific Research Council; and the James McKeen Cattell Lifetime Achievement Award from the Association for Psychological Science—described by APS as its highest honor—for work that “has had a profound impact on the field of psychological science over the past quarter century.”

Transcript

[00:00:01.560] Mark Tebbs: Hello, and welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, and I’m a Freelance Consultant. Today, I’m really pleased to be talking to Dr. John Weisz, who’s the lead author for a Research Review entitled, “The Internalizing Paradox – Youth Anxiety and Depression Symptoms, Psychotherapy Outcomes, and the Implication for Research and Practice,” which was recently published in the Journal of Child Psychology and Psychiatry. Welcome, John, it’s lovely to be speaking to you.

[00:00:39.784] Dr. John Weisz: Thank you, Mark, and thank you for the invitation.

[00:00:42.148] Mark Tebbs: Great stuff. So, could you introduce yourself and the people that you worked with on the paper?

[00:00:47.904] Dr. John Weisz: Sure. I’m a Professor in the Harvard Psychology Department and, also, in Harvard Medical School. And my co-authors are, grad students Olivia Fitzpatrick, Katherine Venturo-Conerly and Josh Steinberg, and a Post-Doctoral Fellow in the lab, Ariel Sternberg, and then a lab graduate, Mei Yi Ng, who is now faculty at Florida International University.

[00:01:09.788] Mark Tebbs: Excellent, thank you, and could you tell us a little bit about yourself, sort of, what your research specialty areas are?

[00:01:16.584] Dr. John Weisz: I’ve been studying for many decades, more than I’d like to reveal, interventions for young people who have mental health problems. And our work consists of developing interventions, refining them, testing them, if they work, disseminating them in every way that we can find to do, and then going on to develop other interventions.

And then we also do meta-analyses, which are syntheses of evidence generated by hundreds of Researchers. In fact, the number of randomised controlled clinical trials that we have now in our collection is more than 800 studies. And we use that to understand what’s the state of the field, what kinds of interventions are working well and which ones are not, and what the future should look like, in terms of the next research questions and the approaches that work best to answer those questions.

[00:02:09.348] Mark Tebbs: Let’s turn to the paper. Could you start by explaining what is “The Internalizing Paradox”?

[00:02:15.984] Dr. John Weisz: Sure, Mark. In children and adolescents, depression and anxiety are often lumped together. They’re called “internalizing conditions,” because they involve internal distress. They often occur together in the same children at the same time, same adolescents at the same time, they have overlapping symptoms, and the treatment procedures for the two overlap quite a lot, and yet they diverge markedly in outcomes.

For anxiety, we have perhaps the best treatment outcomes of any mental health condition. For depression, we have the weakest treatment outcomes, and, in fact, there’s some evidence that the effects of treatment for depression in children and adolescents is declining slightly over time in its effectiveness. So, that’s the paradox. The paradox is that two mental health problems that are so similar, in so many ways, can differ so dramatically in treatment outcomes.

[00:03:07.068] Mark Tebbs: So, what were you trying to achieve through the research review?

[00:03:10.560] Dr. John Weisz: We wanted to unearth explanations for the paradox, how could it be? And then we wanted to suggest ways of addressing the paradox, by bringing treatment outcomes closer together, which really, in essence, is boosting depression treatment outcomes for young people.

[00:03:26.628] Mark Tebbs: Thank you. So, let’s dig into that a little bit more. So, I think in the paper you describe five possible different explanations for the internalizing paradox. I think it’d be really good to spend a little bit of time on each of those. So, could you start by telling me a little bit more about the differential comorbidities between anxiety disorders and depressive disorders?

[00:03:48.584] Dr. John Weisz: Anxiety and depression both have comorbidities, meaning they often co-occur with other disorders happening at the same time, or they have co-occurring problems. But the anxiety disorders are especially likely to be comorbid with other anxiety disorders, so a lot of similarity across the comorbidities. Depressive disorders have more diverse comorbidities. They’re often comorbid with disorders and problems that are very different from depression, and that makes treatment for depression more complex.

[00:04:16.948] Mark Tebbs: Thank you. The second explanation, the paper uses the phrase of the, kind of, “variegated nature of polythetic conditions,” so, yeah, if you could explain that one, that’d be great.

[00:04:28.504] Dr. John Weisz: Sure. Polythetic conditions are conditions that have some, but not all, features in common. Well, for anxiety disorders, there are a lot of features in common. In fact, the core of anxiety is similar across all the different anxiety – virtually all the different anxiety disorders. Depressive disorders come in many, many different forms, and that’s true in part because of our diagnostic system. In the most commonly used diagnostic system in the United States, and I think in parts of Europe, major depressive disorder is diagnosed from having five of nine possible symptoms. If you do the math, there are 227 possible combinations of symptoms for a diagnosis of major depressive disorder. That makes it very, very different from one depressed person to another.

So, if you are a Clinician and you treat 20 different kids with major depressive disorder in a year, you’re probably treating 20 very, very different types of young people, very different combinations of symptoms, that require different ways of conceptualising and understanding and even treating the kids, makes it very complex, compared to treating anxiety disorders.

[00:05:38.908] Mark Tebbs: And there’s discussion around the “differential progress in the search for the mechanism of change,” could you also explain that for us?

[00:05:47.224] Dr. John Weisz: There’s a lot of interest in understanding how treatments work by understanding what’s the mechanism? What’s the, sort of, flip switch that you flip to produce actual change in the disorder? And we have a pretty good idea what that switch looks like for anxiety. It centres around exposure, getting kids to do the things that they fear, repeatedly, and the fear declines. So, this can work either through a process called habituation, or it might work through inhibitory learning. Kids learn through repeated exposures that the things that they were afraid might happen are not happening. But both of these processes involve reduced anxiety with increased exposure to what the kids fear. It’s almost a magic bullet in the treatment of anxiety conditions in kids.

For depression, the situation is very different. We do not really know what leads to recovery from depression. Could be changing thoughts, making unhelpful thoughts more helpful; it could be strengthening social connections; it could be helping kids learn to do healthy activities, could be calming negative emotions. These, and other skills, are parts of treatments, and differentially emphasised in different treatments. And we really don’t know from the evidence so far which mechanism works best for young people, and it’s quite possible that different mechanisms work for different depressed kids, given the many different forms depression can take, as we were discussing earlier.

So, if you’re a Clinician treating an anxious adolescent and you’re following the evidence on what works, you probably know pretty much what to do. If you’re treating a depressed adolescent, not so much.

[00:07:22.628] Mark Tebbs: And, likewise, there’s the differential explanation around the “complexity of evidence-based psychotherapy protocols.” Again, if you could tell us how those, kind of, different explanations relate to the internalizing paradox.

[00:07:37.904] Dr. John Weisz: Depression treatment protocols are generally way more complicated than anxiety protocols, and probably largely because depression is so complicated, as a condition, and so diverse in its forms. So, for anxiety, treatment, if you follow the evidence closely, treatment is often various ways to get kids to do exposure. Like, persuade them to try to do the things that they’re afraid of more and more until they’re not so afraid of them anymore. For depression, oh, way more complicated, because we don’t really know what’s going to work well for kids. We don’t know the mechanism of change. The protocols for depression are – very often involve five to ten different skills, teaching the kids these skills, hoping that one or two of them will work.

So, you know, it could be cognitive restructuring, could be behavioural activation, social skills training, relaxation and calming skills, etc., etc., and that makes treatment difficult for the Therapist. And also, it can make treatment difficult for the kids, because, you know, they’ve learned five, six, seven, eight skills, and now they’re out of the Therapist’s office, they’re in real life, and which of those skills should they use when? So, I think the complexity cuts both ways, both for the Clinician and the kids.

[00:08:55.028] Mark Tebbs: You mention in the paper about “the Clinician’s challenge,” if you could tell us a little bit more about that.

[00:09:00.944] Dr. John Weisz: Well, when I think – one difference between anxious and depressed kids, this is generalising, and, certainly, there’s a broad range of styles of kids, but, in general, my experience has been that anxious kids tend to be relatively quick to engage, they’re eager to learn and to master skills, they want to do well. Depressed kids may want those same things, but because depression saps energy and motivation, those kids may find it harder to connect with the Therapist, harder to find the energy to practice new skills, harder to find the energy or schedule the time to do their therapy homework. So, the very symptoms of depression can make depression harder to treat.

[00:09:42.148] Mark Tebbs: So, these different perspectives suggest different treatment strategies, could you say a little bit more for our listeners?

[00:09:49.700] Dr. John Weisz: Sure. The – in the paper, we offer six ideas about strategies, I’ll – I won’t cover them all now, but there are some that might be worth mentioning. One that we think is important – and, by the way, most of the suggestions are in the service of trying to boost treatment effectiveness for depressed young people, to bring it up to the level that we’re seeing commonly for anxious kids. So, one approach that we have participated in developing and, with colleagues, have pioneered is addressing comorbidity and co-occurring symptoms using transdiagnostic modular treatment.

So, this is basically creating a menu of treatment options that could cover a range of different styles that the children may bring in a range of treatment needs, and then providing guidance to Clinicians in how to select from that menu the combination of treatment elements that seems to be the best fit for a particular young person. We, and our colleagues, have done half a dozen trials of approaches to treatment like that.

Another thing that we think is important is engaging family members in treatment, in richer ways that may have been done traditionally. So, teaching the parents the same skills that the kids are learning, skills in stress reduction, problem solving, behavioural activation, cognitive restructuring, all those skills can be learned readily by parents, as well as kids. And then the parents can be natural allies with the Therapist in working with their child, and when the therapy ends, they can extend therapy beyond the time of the official work with the Clinician, by reinforcing and encouraging and praising the use of those skills with their children.

Another approach we think is very important in this era is capitalising on technological advances. It’s possible now to draw on the appeal and potency with young people of teletherapy, gamification, there are approaches to treatment that are very much like video games, using virtual reality in treatment, ecological momentary assessment to track through text messaging how the kids are doing, how they’re responding to stressful situations. And then there are adaptive interventions. There’s a lot of potential to capitalise on technology and technology of a kind that the kids really enjoy using.

The last approach that we’ve recommended is shortening and digitising treatments. We’ve developed a suite of digital interventions that take about a half hour for kids to complete. We, and our colleagues, have tested those and shown surprisingly beneficial effects of treatments that are very, very brief, that don’t require a professional Therapist, at all. All they require is a link for kids to click, and then they go through a self-directed, self-generated set of exercises guided online.

And there are lots of advantages of this approach, as a complement to traditional kinds of therapy. They’re highly scalable. They’re totally accessible on personal devices. They can also be administered in classrooms. A 30 minute segment of one class in one school year is nothing in terms of the burden on the school. And from the evidence thus far, could be extremely helpful to kids in coping with mental health challenges.

Another big advantage is they can be produced quickly, covering a diverse range of problems and a diverse range of skills, so that kids can select the specific, brief digital interventions that fit their needs. And that may provide better personalising than having a Therapist judge which one is going to be most helpful for a young person.

[00:13:39.668] Mark Tebbs: And you end the paper with a discussion of caveats and questions for future studies. So, what are the, kind of, limitations of the current research? And what are potential avenues for the future work?

[00:13:53.664] Dr. John Weisz: Well, I think the biggest challenge that’s relevant to this particular paper is that there’s been a lot of lumping of internalizing disorders and problems into one big category. They’re so often studied together that much of the research doesn’t distinguish between anxiety and depression. And that inhibits what we can learn about the characteristics of anxious kids and depressed kids, and about what treatments will work best for those two different conditions. Our analysis suggests that anxiety and depression in young people is so different in so many ways that we need more work that distinguishes between them, so we’re encouraging more splitting, less lumping.

[00:14:34.868] Mark Tebbs: So, I’m interested, from a clinical perspective, if I was a frontline Clinician, what should I be taking from this research? You know, how’s it impacting on interventions?

[00:14:45.744] Dr. John Weisz: Well, I think so much of our paper focuses on the challenge of treating depression in young people, and how different it is from treating anxiety. So I think one message for Clinicians, and this won’t surprise people who’ve been Clinicians for many years, I’m sure, is that if you’re going to be treating depressed young people, you’re going to need a big bag of tricks. You’ll need lots of skills to teach kids, and a willingness to keep trying until you find one or two skills that really help. And you’ll need strong skills yourself in engaging and motivating kids, whose depression makes it hard for them to find energy, to learn new skills and practice them.

[00:15:24.228] Mark Tebbs: And I’m also curious about messages to parents and carers, you know, particularly if someone who’s listening, they have a young person who’s suffering from depression, and they’re not having the desired treatment outcomes. Are there any messages to parents and carers?

[00:15:43.151] Dr. John Weisz: I do, I have a suggestion, and I think it’s for – this is relevant to me and many other parents. There’s a tendency, I think, at least if we approach psychotherapy from the perspective of a medical model to, kind of, go in, turn our child over to the expert, and then let go. And I actually think it’s very important for parents to recognise that they know their child much better than any Clinician ever will. That you, as a parent, will know what motivates your child to engage with an adult, or to engage in learning a new skill, to try new things, you know what kinds of experiences are actually mood-boosting for your child. If you can partner with your child’s Clinician and share your deep knowledge of your child, that they can never acquire, you’re going to enhance prospects for good treatment outcomes, and make treatment much more gratifying to your child, as well, I expect.

And I would also add, if you don’t mind, that – going back to something I said earlier, that if parents can learn the skills that their kids are learning in therapy, that gives them an opportunity to reinforce and encourage and praise the use of those skills at home by their kids. And that can happen while therapy is ongoing, it can also happen after therapy ends, so I think that’s another reason for parents to get very engaged in the process and learn what their kids are learning.

[00:17:14.508] Mark Tebbs: Are you planning any follow-up research, or is there anything in the pipeline that you’d like to share with us?

[00:17:20.504] Dr. John Weisz: Oh yeah, thanks for asking. We’re doing a lot of things that I find very exciting. So, one of the themes of our work I’ve already talked about, transdiagnostic modular therapies, building a menu of procedures and guidance to Clinicians, in how to select the procedures that are going to work best with which – with the young person that they’re treating. How to personalise treatment to fit.

Related to that, simplifying therapy by identifying, partly through our meta-analyses, five core principles of change that appear apparently for much of the benefit of therapy with young people, and we built a protocol that – called ‘FIRST’, that embodies those five principles of change. We’ve tested it in three open trials, and now we have a randomised control, or clinical trial, funded by the National Institute of Mental Health, that we’re about halfway through. So, we think that this is a promising approach, because of its streamlined nature.

We also use, and have tried a number of ways to improve use of measurement-based care. This is regular feedback on each young person’s response, week-by-week, to the treatment that they’re receiving. And we think is essential to, sort of, know whether you’re on the right track, whether what you’re doing is leading to reduced symptoms, or not, and whether it’s time to change your treatment strategies.

And, finally, as I mentioned previously, we’re – we have a suite of brief digital interventions, teaching very specific skills, that we believe are helpful for – and we have evidence are helpful for depression and for anxiety, that teaches kids to calm themselves when they feel distressed – distressing emotions, another teaches them problem solving skills for dealing with everyday problems and stresses. Another one teaches cognitive restructuring to get away from unhelpful thinking, and another one teaches kids to identify the positive opposite of something they would like to change, and then work on practicing that positive opposite. We have a lot of things going on, in addition to our meta-analyses, which are ongoing, so I love going to work every day.

[00:19:34.668] Mark Tebbs: Thank you so much for such an interesting conversation. For more details on Dr. John Weisz, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.