SPECIAL SECTION: COGNITIVE-BEHAVIORAL THERAPY FOR YOUTH DEPRESSION 393 (b) our data showing that duration of UC in participating clinics the best documented requirements for implementing interventions increased by 70% when the PASCET versus UC trial was intro- in new settings not yet included. duced; (c) studies of the natural time course of remission, resem- A closely related point pertains to the marked difference be- bling duration of UC in our study (and markedly longer than the tween therapists in their familiarity and skill with the treatment duration of PASCET); and (d) studies of youth depression treat- procedures used in the two conditions. UC therapists used their ment follow-up suggesting that the main benefit of successful own preferred and familiar treatment procedures, which they them- treatments lies in speed of improvement, not ultimate outcome. selves had selected. By contrast, PASCET therapists used an unfa- However, because our design did not include measurement of miliar approach guided by a manual they had not selected or even depression at common time points for all participants, a definitive seen before. The PASCET therapists’ total exposure to PASCET test of this interpretation awaits further research. prior to starting treatment with study cases consisted of one 6-hr training program. No PASCET therapist had any practice case Interpretation B: PASCET and UC Did Not Differ prior to the first study case, and for 18 of the 24 PASCET in Effectiveness therapists, their first PASCET case was their only study case. Most PASCET therapists did show acceptable fidelity, but fidelity mea- We note an alternative interpretation of our findings: that the sures, including ours, assess only whether the main components absence of posttreatment condition effects on depression symp- and skills of the manual are included in the sessions. Not covered toms or diagnoses means that PASCET and UC did not differ in in such measures is the competence or skill with which therapists effectiveness in the community clinic context of the present study. used the components and skills. This is a study limitation, but we If this were the case, several strands of research would be relevant. are not aware of a relevant measure that has been validated. Previous findings (e.g., Brent, Kolko, Birmaher, Baugher, & Our session videotape reviews suggested a broad range in ther- Bridge, 1998; Hammen, Rudolph, Weisz, Rao, & Burge, 1999; apist skill with PASCET; some therapists introduced treatment Southam-Gerow, Chorpita, Miller, & Gleacher, 2008, 2003; components and skills effectively but many appeared uncomfort- Wright et al., 2007) have suggested that youths referred to com- able and unnatural. Some therapists read portions of the manual to munity clinics through normal community channels are more the youths, some lost track of where they were in the protocol, and likely than those treated in research clinics or traditional efficacy others introduced key points in ways that left youngsters confused trials to show high levels of externalizing comorbidity, poverty, or bored. Therapist lack of skill in the protocol may have under- and family stress; other studies have shown that effects of CBT are mined PASCET effectiveness. In the future, it will be useful to markedly diminished in youths with significant externalizing co- assess the impact of PASCET when delivered by community clinic morbidity (Rohde, Clarke, Mace, Jorgensen, & Seeley, 2004) and therapists who have gained experience and familiarity with the in youths referred from community sources (rather than recruited protocol and can deliver it comfortably and skillfully. through ads; Brent et al., 1998; Weersing, Iyengar, Kolko, Birma- If it were true that PASCET did not outperform UC in reducing her, & Brent, 2006). Our sample was completely community depressive symptoms and disorders, it would be worthwhile to ask referred and had high rates of externalizing comorbidity. The whether approaches other than CBT might be a better fit for the notion that CBT faces challenges with community-referred youths therapists, youths, and settings of community clinic care. This is consistent with findings of Kerfoot et al. (2004; noted in the possibility is suggested by our unexpected finding that clinical introduction) that teaching CBT to practitioners did not improve outcomes in UC were predicted not by therapists’ use of CBT but outcomes for depressed youths referred from and treated in the by their use of psychodynamic methods. Of course, our data on community. frequency of various approaches tell us nothing about the quality If it were true that PASCET did not outperform UC, two other with which the approaches were used; poorly conducted CBT perspectives on our findings would deserve attention. First, Fixsen might well not predict outcomes, whereas skillfully conducted et al. (2005) stressed that when a previously tested intervention is CBT might. Despite these caveats, the finding warrants attention in applied in a new context, null findings may reflect, not a problem future research (see below). with the intervention itself, but rather incomplete implementation in the new context. Fixsen et al. (2005) stressed that information Findings on Therapeutic Alliance, Service Use, and Cost dissemination, and training alone "repeatedly have been shown to be ineffective" (p. 70; see also, Grimshaw et al., 2001) and that and Their Clinical Implications "successful implementation efforts. . .require a longer-term multi- Beyond symptom and diagnostic change, our findings showed a level approach" (Fixsen et al., p. 70). Fixsen et al. noted that the number of condition differences that have clear clinical relevance. implementation approaches supported by evidence include (a) The PASCET group, as compared with the UC condition, used skill-based training, (b) practice-based coaching, (c) practitioner significantly fewer adjunctive services, was lower in total cost, and selection, (d) practitioner performance evaluation, (e) program generated higher parent ratings of therapeutic alliance. Thus, along evaluation, (f) facilitative administrative practices, and (e) systems some significant clinical and practical dimensions, PASCET interventions. Our procedures included only the elements in a and showed advantages over UC that might be of real value to prac- b; some of the best supported approaches-for example, selecting titioners and provider organizations. Using fewer adjunctive ser- the best practitioners to conduct the new intervention-were ruled vices can mean more efficient intervention that does not require out by the need to create a fair experimental test of PASCET complex case management and liaison with other providers. Stron- versus UC (which required random assignment of clinicians). The ger alliance with parents can enhance their participation in the evidence from Fixsen et al. suggests that our approach to exam- treatment process and increase the likelihood of getting their ining PASCET in community clinics is a first step, with some of children to scheduled appointments, and our findings did show Show less