Review: Comprehensive treatments for youth comorbidity – evidence‐guided approaches to a complicated problem

Abstract

Background: Evidence-based treatments (EBTs) with a single-disorder focus have improved the potential for youth mental health care, yet may be an imperfect fit to clinical care settings where diagnostic comorbidity and co-occurring problems are commonplace. Most EBTs were developed to treat one diagnosis or problem (or a small homogenous cluster), but most clinically referred youths present with multiple disorders and problems. Findings: Three emerging approaches may help address the comorbidity that is so common in treated youths. Conceptually unified treatments target presumed causal and maintaining factors that are shared among more than one disorder or problem area; preliminary open trials and case studies show promising results. Modular protocols combine the 'practice elements' that commonly appear in separate single-disorder EBTs and repackage them into coordinated delivery systems; one modular protocol, MATCH, has produced positive findings in a randomized effectiveness trial. Monitoring and Feedback Systems (MFSs) provide real-time data on client progress to inform clinical decision-making, encompassing comorbid and co-occurring problems; one study shows beneficial effects in everyday practice with diverse youth problems. Conclusions: All three approaches -conceptually unified, modular, and MFS -can be strengthened by increased research attention to treatment integrity, clinician user-appeal, design simplicity, and the infrastructure necessary for successful implementation. Key Practitioner Message• Most evidence-based treatments (EBTs) for youths were developed to treat a single target disorder or problem domain, or a homogenous cluster, but most clinically referred youths present with multiple disorders and problems.• When client comorbidity is not directly addressed by EBTs, clinicians may be left without evidence-based guidance. To address this gap, three approaches warrant attention.• Unified manuals that address presumed causal and maintaining factors of more than one disorder may be of value, particularly for problems with shared theoretical and empirical literatures.• Modular approaches to EBTs may be an effective way for clinicians to treat multi-problem and comorbid youths, even those with conceptually distinct conditions, and one approach, MATCH, has been found to be effective in a randomized trial.• Monitoring and feedback systems provide real-time case-specific evidence that can guide the clinical decision-making required in treating comorbid clients, regardless of the treatment approach employed.

A randomized controlled trial of a six-session cognitive behavioral treatment of emotional disorders in adolescents 14–17 years old in child and adolescent mental health services (CAMHS)

“…According to the previously mentioned multilevel meta-analysis [20], treatments of concurrent multiple problems, as opposed to any single targeted problem, showed an effect that was not significantly different from zero at post-treatment or follow-up [20]. Some argue that this could suggest that efforts made to concurrently treat multiple problems have been less effective than focusing more narrowly [30], suggesting new ways to address comorbidity in youths [31][32][33]. In an earlier review of trials of 461 youth psychotherapies, spanning from the 1960-ies and 50 years onward, Weisz and colleagues [20] found that the interventions were usually delivered in settings outside regular clinical practice, i.e.…”

Feasibility randomized controlled trial of a one-day CBT workshop (‘DISCOVER’) for 15- to 18-year-olds with anxiety and/or depression in clinic settings

“…This is often related to a perceived lack of fit between empirically tested (usually disorder-specific) structured treatments and the vagaries of routine practice (Southam-Gerow et al, 2012). 'Transdiagnostic' protocols have been heralded as a way of addressing this implementation gap, offering a more parsimonious and flexible approach to dealing with real-world challenges of comorbidity and case complexity (Bearman and Weisz, 2015). Transdiagnostic interventions for anxiety and depression have been designed to target common mechanisms of emotion regulation implicated in both syndromes (Newby et al, 2015).…”

Innovations in Practice: Using clinician‐rated outcomes to support improved service decision making in a Child and Adolescent Mental Health Service

“…The need for an outcomes based approach to helping children and young people with mental health needs is now widely accepted (Bearman & Weisz, ; Wolpert, Ford, et al., ; Wolpert, Fugard, Deighton, & Gorzig, ) including its role in improving outcomes (Bickman, ). Evidence‐based practice has demonstrated that, even with the most effective interventions such as CBT for anxiety (Reynolds, Wilson, Austin, & Hooper, ), a significant proportion of children and young people do not improve, despite being offered recommended interventions (Weisz et al., ).…”