Behaviour Research and Therapy 183 (2024) 104646

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Behaviour Research and Therapy

journal homepage: www.elsevier.com/locate/brat

Augmented Depression Therapy for young adults: A mixed methods

randomised multiple baseline case series evaluation
James Carson a,*, Kalliopi Demetriou b, Gemma Barlow a, Kim Wright a , Maria Loades c ,
Barnaby D. Dunn a
a
Mood Disorders Centre, University of Exeter, UK
b
School of Health, Social Sciences, University of Edinburgh, UK
c
Department of Psychology, University of Bath, UK

A R T I C L E I N F O A B S T R A C T

Keywords: Augmented Depression Therapy (ADepT) is an individual psychotherapy for depression, which has been shown
Young adults to be effective in the general adult population. A randomised multiple baseline case series evaluated the feasi-
Depression bility, acceptability, and effectiveness of ADepT in young adults (aged 20–24). Eleven depressed young adults
Wellbeing
were recruited from a UK university wellbeing service to receive ADepT during the COVID-19 pandemic, with
Anhedonia
outcomes evaluated relative to pre-specified continuation targets. All participants received a minimum adequate
Positive affect
Augmented depression therapy treatment dose (>60% target); 89% judged ADepT as acceptable and satisfactory and would recommend it to
others (>60% target); only 9% showed reliable deterioration for depression or wellbeing (meeting <30% target);
and there were no trial- or treatment-related serious adverse events. Qualitative interviews revealed most par-
ticipants were satisfied with and experienced benefits from ADepT. At post-treatment, reliable improvement was
shown by 33% of participants for depression and 67% of participants for wellbeing (not meeting target of both
>60%), with medium effect size improvements for depression (g = 0.78) and large effect size improvement for
wellbeing (g = 0.93; not meeting target of both >0.80). ADepT is feasible, acceptable, and safe in young adults
but may require modification to maximise effectiveness. Further research outside of the COVID-19 pandemic is
warranted.

1. Introduction Early adolescence (ages 10 to 14), late adolescence (ages 15 to 19)

and young adulthood (ages 20 to 24) are all periods of accelerated so-
Depression is widespread and disabling, a leading contributor to the cial, emotional, and cognitive development that occur in the context of
global burden of disease, and results in marked personal, societal, and significant life transitions (Fuhrmann, Knoll, & Blakemore, 2015).1
economic costs (Kessler et al., 2003; Konig, Konig, & Konnopka, 2019). Successful navigation involves the development of an autonomous
The treatment of depression in young people (those aged 10–24 years of personal, social, and professional adult identity, which lays the foun-
age; Patton et al., 2016) is now a key public health priority. The initial dation for increased resilience and capacity for wellbeing (Patton et al.,
onset of depression typically occurs between the ages of 14–25 (Thapar, 2016). However, depression can disrupt these developmental processes,
Eyre, Patel, & Brent, 2022), often progressing to a chronic, relapsing heightening long-term vulnerability to poorer mental health, wellbeing,
course (Judd, 1997). Rates of depression are rising in 12-17-year-olds in and functioning in social, educational, and occupational domains
the US, increasing from 8.1% in 2009 to 15.8% in 2019 (Wilson & (Clayborne, Varin, & Colman, 2019; Finning et al., 2019; Keenan-Miller,
Dumornay, 2022). More recent estimates suggest a prevalence of 17% Hammen, & Brennan, 2007; Wickersham et al., 2021). Prioritising the
across the 12–25 age range (Goodwin et al., 2022). treatment of depression in young people may reduce the impact of

* Corresponding author.
E-mail address: [email protected] (J. Carson).
1
This article adopts the definitions used in the Lancet commission (Patton et al., 2016). The term young people is used to refer to the ages of ten to twenty-four,
with this being divided into early adolescence (ten to fourteen years), late adolescence (fifteen to nineteen years), and young adulthood (twenty to twenty-four
years). Where studies recruit samples that fall neatly into these categories, we use these terms. Where samples extend across categories, we report the age ranges
studied.

https://doi.org/10.1016/j.brat.2024.104646
Received 6 April 2024; Received in revised form 6 September 2024; Accepted 14 October 2024
Available online 17 October 2024
0005-7967/© 2024 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
J. Carson et al. Behaviour Research and Therapy 183 (2024) 104646

depression on social, emotional, and cognitive development, increase 12-20-year-olds, they were associated with greater depression symp-
the chance of successful navigation of key life transitions, and minimize tom severity, longer episode duration, increased suicidality, and a
the risk of a chronic, recurrent trajectory of depression developing greater number of previous episodes (Gabbay et al., 2015). Further,
(Thapar et al., 2022). Further, the neural plasticity that characterizes prodromal anhedonia symptoms and reward deficits in adolescence
this developmental period potentially represents an opportunity, as in- predict the subsequent emergence of depression (Bress, Foti, Kotov,
dividuals may be more able to benefit from psychological treatment Klein, & Hajcak, 2013; Forbes & Dahl, 2012; Morgan, Olino, McMakin,
(Fuhrmann et al., 2015). Ryan, & Forbes, 2013), and predict levels of depression, suicidality, and
Despite this window of opportunity for treating depression before it anhedonia in young adulthood (Liu et al., 2021). Qualitative studies of
becomes entrenched and disabling in adulthood, psychological thera- adolescents with depression emphasize the centrality of anhedonia and
pies for young people remain relatively under researched. Reflecting this broader wellbeing deficits (Watson, Harvey, Pass, McCabe, & Reynolds,
relative neglect, recent meta-analyses reveal the vast majority of trials of 2021) and are ranked as an important treatment outcome priority
depression psychotherapies have been conducted on general adult among 16-21-year-olds (Krause, Edbrooke-Childs, Bear, Calderon, &
samples (n = 242; 66%) and a much smaller number have focused on Wolpert, 2023).
adolescents (n = 24; 7%) or young adults (n = 19; 5%; Cuijpers et al., Whilst young people prioritise restoring positive emotion, mood and
2020). Meta-analyses of these trials show treatments for adolescents and wellbeing, most existing psychological therapies relatively neglect the
young adults are partially effective but not yet optimised. The stan- PVS (Sandman & Craske, 2022). For example, CBT targets changing
dardized effect size advantage of psychotherapy (relative to passive negative cognitions to reduce depressed mood and focuses less on
control conditions) is of a small magnitude for adolescents and of a repairing anhedonia and increasing wellbeing. Even ostensibly reward
medium magnitude for young adults and general adults (Cuijpers et al., focused interventions like Behavioural Activation (BA) are relatively
2020). However, when focusing on trials of higher quality and at low ineffective at repairing anhedonia; small scale pilot studies in young
risk of bias, there are no statistically significant differences in treatment people show BA significantly improves anhedonia, but individuals still
outcome between these age categories. Similar results emerge in other have elevated levels of anhedonia at the end of treatment (Watson et al.,
meta-analyses of depression psychotherapies in adolescence (Eckshtain 2021; Webb, Murray, Tierney, Forbes, & Pizzagalli, 2023; Webb, Mur-
et al., 2020) and the 18 to 30 age range (Medina et al., 2022). This ray, Tierney, & Gates, 2023). Comparable findings in general adult
pattern of findings holds largely irrespective of treatment type, with no populations show neither CBT or BA adequately repair PA or anhedonia
clear difference in outcomes emerging between different schools of and struggle to optimise wellbeing (Alsayednasser et al., 2022; Dunn
therapy. et al., 2020; Widnall, Price, Trompetter, & Dunn, 2020).
Potentially more meaningful metrics of outcome than effect sizes are One way to enhance therapy outcomes in adolescent depression may
the percentage of participants who show reliable improvement during be to develop novel therapies that more explicitly and effectively target
therapy. A recent meta-analysis found rates of reliable improvement PVS deficits. One emerging approach is Augmented Depression Therapy
were 54% following depression therapy in adolescent groups, compared (ADepT; Dunn, Widnall, Reed, Owens et al., 2019; Dunn et al., 2023), a
to 32% reliable improvement in control treatments (Cuijpers et al., solution focussed, cognitively augmented, behavioural activation ther-
2023). We are not aware of comparable analyses of young adult trials, apy, which targets building wellbeing and functioning alongside
but a broadly similar pattern is likely to emerge. repairing anhedonia and depressive symptoms. In ADepT, therapists
In summary, despite the opportunity presented by increased plas- support clients to clarify their values (in relationships, vocation, leisure,
ticity during this developmental phase and the fact that depression is and self-care domains) and then help them to systematically set and
less likely to have become stable and recurrent, outcomes for current work towards goals consistent with these values. Clients concomitantly
psychological therapies for depression in young people are under- learn to identify and act opposite to the psychopathological mechanisms
researched and sub-optimal. There is a need to improve existing or that maintain depression and inhibit the development of wellbeing
innovate novel psychotherapies for young people with depression. (including avoidance, rumination, self-criticism, mind-wandering,
These mixed outcomes may partly reflect that rates of engagement dampening appraisals, disconnection from senses, and enhanced nega-
with therapy are also not optimised in young people. For example, in the tive bias), aiming to take opportunities (experience thriving) and
recent IMPACT randomised controlled trial (N = 425) comparing respond effectively to challenges (develop resilience). Therapists utilise
Cognitive Behavioural Therapy (CBT), brief Psychodynamic Therapy, a positive interpersonal style to aim to help clients develop a positively
and a brief psychosocial intervention for the treatment of adolescent oriented, future-directed, and solution-focused outlook.
depression, less than 50% of the preplanned treatment sessions across There is encouraging evidence ADepT is a feasible, acceptable, and
arms were delivered and the dropout rate was 37.3% (Goodyer et al., effective treatment for reducing depression and anhedonia and building
2017; Loades et al., 2024). To be acceptable to and engage young peo- wellbeing in the general adult population (Dunn et al., 2023; Dunn,
ple, these therapies must be tailored to their developmental needs, Widnall, Reed, Owens, et al., 2019). In a mixed method case series, all
including developing an emerging sense of adult identity and moving participants engaged with treatment and there were large effect size
towards new roles in education, vocation, and relationships. improvements in depression, anhedonia, and wellbeing (Dunn, Widnall,
One approach to improving depression outcomes is to identify fea- Reed, Owens, et al., 2019). In a subsequent pilot randomised controlled
tures of depression that are prognostically important and are judged by trial, 82 depressed adults with anhedonic features were randomised to
clients as high priority to repair to achieve clinical improvement and ADepT or high intensity CBT (Dunn et al., 2023). ADepT led to large and
recovery, but that are neglected in current treatment approaches (Dunn sustained effect size improvements in depression, wellbeing, and anhe-
et al., 2023; Dunn, Widnall, Reed, Owens, et al., 2019; Dunn, Widnall, donia (Cohen’s ds > 1.10). Exploratory Bayesian analyses suggested
Reed, Taylor, et al., 2019). One such feature of depression generally and ADepT was highly unlikely to be minimum clinically important differ-
in young people in particular is anhedonia, defined as a loss of interest or ence (MCID) inferior, and has potential to be MCID superior to, CBT on
pleasure in normally enjoyable activities (American Psychiatric Asso- both depression and wellbeing outcomes. Health economic analyses
ciation, 2013). Anhedonia can be conceptualised as arising from deficits indicated ADepT was cost-effective (and potentially health economically
in positive valence system (PVS) functioning, impacting on the genera- dominant) relative to CBT.
tion of positive subjective feeling states, appraisals, and action ten- ADepT has yet to be evaluated in young people. It is possible that the
dencies that are integral to broader functioning and wellbeing (Dillon & functioning and wellbeing focus of treatment may be welcomed by
Pizzagalli, 2010; Dunn & Roberts, 2016). young people. Moreover, the values and future focus of ADepT may be
Anhedonic features are found in 50%–65% of 12-17-year-olds beneficial for young people negotiating key development transitions and
(Orchard, Pass, Marshall, & Reynolds, 2017). In a sample of discovering who they wish to be in educational, vocational, social

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domains. Whilst these features of ADepT may hold promise in increasing measures during this time, ranging from full lockdown to varying de-
how acceptable and engaging psychological treatments are to young grees of limitation on social contact. All assessments and therapy were
people, the protocol may require some refinement to optimally meet the initially delivered via video conferencing or telephone. As COVID-19
clinical and developmental needs of this group. restrictions were eased, some booster sessions were delivered face-to-
As a first step towards evaluating the promise of ADepT in young face if clients requested this (see Supplementary Online Materials
people, we conducted a mixed-methods case series evaluation of the [SOM] section-1a for details of social distancing restrictions over this
approach. For pragmatic reasons, we set age eligibility criteria as being time). The design, analysis, and reporting of this study was informed by
between 18 and 24 years of age (i.e., crossing late adolescence and case series guidelines (Kratochwill et al., 2013; Smith, 2012; Tate et al.,
young adulthood), as in the United Kingdom (UK) National Health 2016). This study was approved by an NHS ethics committee
Service context the cut-off between youth and adult services is 18. We (20/SW/0144). The study was not formally pre-registered, but the ethics
recruited solely from a university context, seeking referrals struggling application submitted prior to starting the study included a detailed
with depression who had engaged with a university wellbeing service. protocol and analysis plan (see SOM-1f for minor modifications to this
Case series methods are an efficient and rigorous approach to eval- protocol).
uating treatment safety, feasibility, acceptability, gathering preliminary
evidence of effectiveness and proof-of-concept, helping to refine and 2.1. Participants
optimise treatment protocols and determining whether the treatment is
likely to be implementable in the target healthcare context (Kazdin, Study inclusion criteria were: being between 18 and 24 years old;
2011; Morley, 2018). By evaluating whether treatment effects can be scoring in the clinical range for depression (≥10 on the Patient Health
replicated across a series of individual cases, the external validity and Questionnaire-9 [PHQ-9]; Kroenke, Spitzer, & Williams, 2001); meeting
generalisability of findings are increased. Collecting intensive time se- criteria for depression based on the structured clinical interview for
ries data, within person change in outcomes from baseline to treatment diagnosis (Structured Clinical Interview for DSM Disorders [SCID-V];
and follow-up can be assessed with visual analysis. A randomised, First, Williams, Karg, & Spitzer, 2016); describing depression as their
multiple baseline design (involving the allocation of participants to primary presenting problem; having adequate English to engage with
baselines of varying lengths) enables the differentiation between natural therapy and complete research measures without the help of a trans-
recovery and treatment, increasing the internal validity of the findings lator; consenting to their General Practitioner being informed of their
(Kratochwill et al., 2013). These analyses can be augmented by reliable participation in the trial; and being willing and able to give informed
change (RC) and reliable and clinically significant change (RCSC) ana- consent to participate in the trial.
lyses, which determine the proportion of individuals that both improve The exclusion criteria were: currently receiving other psychosocial
to a greater extent than measurement error on a scale, and to a degree therapies; having current or past history of any psychotic disorder,
that is clinically meaningful (Jacobson & Truax, 1991). Benchmarking learning disability, and/or organic brain change; having a current sub-
analyses can be used to compare the magnitude of the treatment effects stance abuse issue that would interfere with their ability to use therapy;
against a relevant external comparator (Borckardt et al., 2008). Finally, displaying current marked risk to self (self-harm or suicide) or substance
embedding qualitative interviews into the design allows in-depth abuse that could not be safely managed in an outpatient setting; and
exploration of participant experience of treatment. presenting with any other significant, severe or life-threatening disease
Following best practice guidelines (Thabane et al., 2010; Mbuagbaw or disorder that the assessing clinician felt could not be safely managed
et al., 2019), bespoke, pre-specified continuation rules were set evaluate in the clinic setting. Participants that met the inclusion criteria and did
ADepT for young people. These continuation rules were adapted from not meet any exclusion criteria were given the choice to participate in
the earlier case series of ADepT for adult depression (Dunn, Widnall, the study.
Reed, Owens, et al., 2019) and informed by clinical judgment and prior
research focusing specifically on young people (e.g., Fernandez, Salem, 2.2. Sample size
Swift, & Ramtahal, 2015; Parry, Crawford, & Duggan, 2016; Wakefield
et al., 2021). Case series analyses do not follow a formal power analysis approach
for calculating minimum sample size estimations. The convention for
1. > 60% of participants attend a minimum adequate dose of therapy determining an intervention effect is a minimum of three replications.
(>50% of scheduled acute sessions). To maximise generalisability of findings (and to reduce the possibility of
2. > 60% of participants rate treatment as acceptable, that they are therapist effects confounding our results), we aimed to have at least
satisfied with it, and they would recommend it others. three therapists each treating at least three cases with ADepT. For the
3. < 30% of participants show reliable deterioration in depression and/ group analyses intended to test our continuation rule (that ADepT
or wellbeing from pre to post treatment. needed to demonstrate a large effect size on wellbeing or depression),
4. ADepT treatment participation does not lead to serious negative we aimed to be powered to detect a large effect size (Cohens’ d ≥ 0.8) in
consequences for participants (unexpected, clearly trial- or pre to post paired sample t-tests at 80% power (requiring a minimum
treatment-related serious adverse reaction). sample size of 15). This is on the basis that ADepT is an intensive
5. >60% of participants show at least reliable improvement in intervention and comparable depression interventions in routine prac-
depression and wellbeing from pre to post treatment. tice have been found to result in large within arm effect size improve-
6. Large pre-post effect size improvements on depression and wellbeing ments (Wakefield et al., 2021). Therefore, we aimed to recruit 15
are observed (Hedges’ g > 0.80). participants.

2. Methods 2.3. Randomisation

A randomised, multiple baseline case series was conducted at an Microsoft Excel was used to generate a random sequence. This
NHS-funded psychological therapies clinic in a university setting sequence was used to randomly allocate participants to different base-
(AccEPT Service, University of Exeter, UK). Currently depressed par- line assessment lengths ranging from three to eight weeks.
ticipants aged 18-24-years-old were recruited via the University of
Exeter student wellbeing service. The study ran between winter 2020 to 2.4. Intervention
summer 2022, which overlapped with the COVID-19 pandemic. Par-
ticipants and therapists were subject to a range of social distancing ADepT (Dunn et al., 2023; Dunn, Widnall, Reed, Owens, et al., 2019)

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aims to both reduce symptoms of depression and increase wellbeing. using the PHQ-9 and the GAD-7. Wellbeing was measured using the full-
ADepT is an individual therapy that consists of a 15-session acute scale WEMWBS (14-items; Tennant et al., 2007), anhedonia severity was
intervention phase and a 5-session booster phase, with booster sessions measured using the 14-item Snaith Hamilton Pleasure Scale (SHAPS;
being arranged at the client’s discretion throughout the year following Snaith et al., 1995), using the continuous scoring method (Franken,
the end of acute treatment. The first session lasts 90 min, with the Rassin, & Muris, 2007), and positive and negative affect were indexed
remaining sessions lasting 60 min, and are scheduled weekly, though using the full PANAS (Watson, Clark, & Tellegen, 1988, p. 10-items
allowing for flexibility to meet client needs. each). Functioning was measured using the 5-item Work and Social
There is a strong emphasis on therapists’ use of positive, solution- Adjustment for Youth scale (WSASY; Los Reyes et al., 2019). Recovery
focused and future-oriented style, with the aim to build and sustain a was measured using the 7-item World Health Organisation Quality of
positive relationship with the client. In the early sessions the therapists Life Recovery Module (WHO-QoL; Rowthorn, Billington, Krageloh,
present the ADepT rationale, help clients clarify their values, and then Landon, & Medvedev, 2019). Functional capability was measured using
set goals consistent with these values in the relationships, vocation, the 5-item ICEpop CAPability Measure for Adults (ICECAP-A; Al-Janabi,
hobbies, and self-care domains. The middle sessions focus on behav- Flynn, & Coast, 2012), generating a tariff score based on the unique
iourally activating the client to move towards these goals, supporting combination of answers (Al-Janabi, Flynn, Peters, Bryan, & Coast,
them in acting opposite to psychopathological mechanisms (avoidance, 2015). Two process measures were included to assess key mechanisms of
rumination, self-criticism, mind-wandering, dampening appraisals, ADepT: to index behavioural activation the 9-item Behavioural Activa-
disconnection from senses, enhanced negative bias), take opportunities tion for Depression Scale – Short Form (BADS-SF; Manos, Kanter, & Luo,
(experience thriving) and respond effectively to challenges (develop 2011) and to index values clarification the 20-item ADepT values rating
resilience). The end and booster sessions focus on developing a well- scale (AVRS; Dunn, unpublished). The AVRS was used as it specifically
being plan to help clients continue to progress towards wellbeing and indexes the core vocation, relationship, self-care and leisure domains
recovery. For the ADepT logic model, see SOM-1b; for a more compre- that are the focus of ADepT.
hensive description of the ADepT protocols, see Dunn et al. (2023). These self-report measures were supplemented with two interview
Due to the COVID-19 pandemic, it was necessary to adapt the measures at intake, pre-treatment, post-treatment, and two-month and
behavioural activation component of the ADepT protocol in response to one-year follow-up assessment. The structured clinical interview for
social distancing regulations. Where it was no possible for clients to DSM disorders (SCID-V; First et al., 2016) was used to determine if
engage in valued-based activities, therapists helped them engage with participants met criteria for a current major depressive episode at each
‘functionally equivalent’ behaviours. For example, this could include assessment point. The RIFT interview (Leon et al., 1999) was used to
replacing face-to-face socialising with digital communication or measure functioning at all assessment points (except at one year
substituting group exercising outdoors with home workouts. As re- follow-up, due to researcher error; SOM-1c describes all measures in
strictions were lifted, adaptations were made emphasising problem- more detail).
solving during activity scheduling to manage COVID-19 related anxiety.
Treatment was delivered by five experienced therapists (two clinical 2.6. Qualitative interview and experience ratings
psychologists, two NHS Talking Therapies high intensity therapists, and
one mental health nurse therapist) all with over 10 years’ experience of Participants were invited to complete a 45-min interview at the end
treating depression and related conditions using evidence-based thera- of treatment, conducted by the first author (JC). A bespoke topic guide
pies. The two clinical psychologists had prior experience of delivering was followed to explore participant experience of therapy, perceived
ADepT; the remaining three therapists were new to the approach. These impacts of treatment, views on possible mechanisms of change, and any
three therapists underwent one days training before starting to take on barriers or facilitators to engaging with treatment. At the end of inter-
clients, learning ADepT during the case series. One of the experienced view, participants also quantitatively rated the acceptability of the
ADepT therapists led a peer supervision group (90 min per week during intervention (1 = not at all acceptable to 5 = extremely acceptable), how
acute phase; 30 min per fortnight during booster phase). satisfied they were with the intervention (1 = not at all satisfied to 5 =
extremely satisfied), and whether they would recommend this treatment
2.5. Measures to friends or family suffering from depression (1 = not at all likely to 5 =
very likely). All qualitative interviews were recorded and then
Participants completed a series of measures weekly during the transcribed.
baseline phase (ranging from 3 to 8 weeks), the acute treatment phase,
and for eight weeks after completing acute treatment. Adhering to single 2.7. Analysis plan
case experimental design guidelines, all participants were intended to
complete a minimum of three weekly assessments during each phase. Feasibility, acceptability, and engagement (continuation rules one
Participants additionally completed an extended assessment battery (a and two) were assessed in terms of descriptive data, including the per-
mixture of self-report and interview measures) at intake, pre-treatment, centage of acute and booster sessions attended, the proportion of clients
post-acute-treatment, two-month follow-up, and one-year follow-up. All attending a minimum adequate dose of therapy (at least 50% of acute
self-report measures were administered online via the Qualtrics survey sessions), and participant ratings of therapy acceptability, satisfaction
tool. Interviews were predominantly via online video conferencing, with and whether they would recommend treatment to others.
some later in the study conducted in person if the participant requested Potential harms (continuation rules three and four) were assessed in
this. terms of the number of participants showing reliable deterioration from
Weekly measures were the 9-item Patient Health Questionnaire pre to post treatment on the two co-primary outcomes, depression and
(PHQ-9; Kroenke et al., 2001) to assess depression severity; the 7-item wellbeing. The number of trial or treatment related serious adverse
short-form of the Warwick-Edinburgh Mental Wellbeing Scale to mea- events were also recorded. Following the earlier ADepT pilot trial (Dunn
sure wellbeing (SWEMWBS; Shah, Cader, Andrews, McCabe, & et al., 2023), adverse events were defined as any untoward or unin-
Stewart-Brown, 2021); the 7-item Generalised Anxiety Disorder scale to tended medical occurrence or response, whether it is causally related to
assess anxiety severity (GAD-7; Spitzer, Kroenke, Williams, & Lowe, the trial or treatments or not. As suicidal ideation and mild self-harm are
2006); and the short-form of the Positive the Positive and Negative a standard part of the clinical presentation for depression, these were
Affect Scale (PANAS-S) to assess positive and negative affect (each only logged as adverse events if some actions were taken around suici-
five-items; Thompson, 2007). dality or the degree of self-harm put the individual at risk of serious
In the extended battery, depression and anxiety were again measured physical injury. Adverse events were further classified as serious if they

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were fatal, life threatening, required or extended hospitalization, and/or materials (SOM-1e: qualitative analytic process).
resulted in significant or persistent disability, incapacity or defect. If
serious adverse events occurred, a judgment was made by the project 3. Results
investigator and the clinic leads as to whether or not they were likely
trial or treatment related. 3.1. Recruitment, data completeness and clinical and demographic
Treatment effectiveness (continuation rule five and six) was exam- characteristics
ined via a variety of visual and statistical analyses. Following previous
ADepT evaluations (Dunn et al., 2023; Dunn, Widnall, Reed, Owens, Thirteen individuals were referred by the wellbeing service, eleven
et al., 2019) the co-primary effectiveness outcomes were PHQ-9 of whom agreed to take part. All eleven participants completed baseline
depression and WEMWBS wellbeing and all other measures were and pre-treatment assessments and engaged with therapy. Nine partic-
viewed as secondary outcomes. Analyses were conducted in the Statis- ipants completed the post-treatment and two-month follow-up assess-
tical Package for Social Sciences (SPSS; Version 29.0.1.0) and using R ments, six of whom additionally completed the one-year follow-up.
and RStudio (R Core Team, 2021). Where additional exploratory ana- Eight participants completed the qualitative interview (five of whom
lyses have been conducted, they are reported as post hoc. Weekly completed all assessments; one did not complete the two-month or one-
outcome data for each participant for each outcome were plotted, add- year follow-up assessment, and two more did not complete the one-year
ing mean level, trend, and standard deviation (SD) bands for the base- follow-up assessment). All participants completed a minimum of three
line, acute treatment, and follow-up phase. These were visually weekly assessments for each phase of the case series (baseline, treat-
interpreted by assessing if mean level observed during treatment and ment, and follow up), except for participant two and three, who did not
follow-up fell outside the SD bands observed during baseline (Manolov complete any follow up measures. The two clinical psychologists with
& Moeyaert, 2017). prior experience of delivering ADepT treated two and three clients
For the extended assessment battery, the number and percentage of respectively; the remaining three therapists who were new to the
individuals reporting reliable improvement (RC) and reliable and clin- approach treated one, two and three clients respectively.
ically significant improvement (RCSC) on each measure at each follow Table 1 summarises participant clinical and demographic charac-
up period, relative to pre-treatment levels, were calculated (Jacobson & teristics at intake. The sample were aged between 20 and 24 (five fe-
Truax, 1991). To determine clinically significant change cut-offs these male, six male), so all fell into the young adult range. Mean self-reported
calculations used Criterion C where normative data were available and scores at intake indicated PHQ-9 depression severity ranged from
where they were not, Criterion A. The value for RC and threshold for moderate (two participants scoring 10–14), to moderately severe (five
RCSC, respectively, were 3.52 and 9.24 for PHQ-9 Depression; 5.96 and participants scoring 15 to 19), to severe (four participants scoring ≥20).
28.71 for WEMWBS Wellbeing; 3.72 and 25.14 for SHAPS Anhedonia; All participants scored in the languishing wellbeing range on the
3.22 and 8.02 for GAD-7 Anxiety; 2.48 and 7.63 for WSASY Functioning; WEMWBS (≤42, bottom 15% of general population distribution). GAD-7
6.52 and 24.86 for PANAS Positive Affect and 23.25 for PANAS Negative anxiety severity ranged from mild (one participant scoring 5–9), to
Affect; 0.24 and 0.77 for ICECAP-A Capability; 7.54 and 24.35 for moderate (three participants scoring 10–14), to severe (seven partici-
BADS-SF behavioural activation; and 3.25 and 9.17 for LIFE-RIFT pants scoring ≥15). All participants reported clinically significant
functioning (see SOM Section X for details of how these cut-offs were anhedonia on the SHAPS (scoring ≥25; more than 1.96 standard de-
calculated. These RC and RCSC analyses were not conducted on scales viations above general population averages), and a vast majority fell
without reliability data (AVRS, WHO-QoL). outside general population averages on the PANAS (10/11 scoring more
A series of repeated measures ANOVAs were run on each continuous than 0.5 SDs below positive affect norms and 10/11 scoring more than
outcome variable (with time as the within-subjects factor: intake, pre- 0.5 SDs above negative affect norms). All participants scored outside of
treatment, post-treatment, and two month follow up). Data were ana- one standard deviation below the mean for ICECAP-A capability and
lysed on a complete case basis. One year follow up data were not BADS-SF behavioural activation (WSASY functioning scores were not
included in these ANOVAs as it was only available for six of eleven comparable to population norms due to the scoring method used in this
participants, meaning analyses would have been underpowered. Pair- study; see SOM-1c).
wise comparisons were conducted on outcome measures with significant Nine participants had undergone previous psychological treatment
or trend-significant (>0.05 p < .10) effects of time in the ANOVAs. To (coaching, counselling, psychotherapy, and/or cognitive behavioural
assess magnitude of change, a series of paired sample t-tests compared therapy). Four participants were taking antidepressant medication, and
pre-treatment scores to post-treatment, two-month follow-up and one- one was taking anti-anxiety medication (on an ad-hoc basis). Partici-
year follow-up, reporting Hedges’ g (and its 95% confidence interval) pants identified as being of white ethnic origin, apart from one partici-
as the measure of effect size. These were interpreted according to pant who identified as being mixed race. While not formally assessed,
Cohen’s rules of thumb (<0.2 negligible; 0.2 to 0.5 small; 0.5 to 0.8 several participants presented with comorbidities. These included
medium; >0.8 large; Cohen, 1977). These effect sizes were bench- identifying as neurodiverse, presenting with post-traumatic stress dis-
marked to previous ADepT studies (Dunn et al., 2023; Dunn, Widnall, order (PTSD), complex PTSD, and interpersonal and emotion regulation
Reed, Owens, et al., 2019). difficulties, engaging in self-harm and reporting suicidality. Two par-
The qualitative analysis used the Framework Method (Galde et al., ticipants had one previous suicide attempt. All participants were facing
2013). The first author (JC) adopted a critical realist stance, acknowl- significant life challenges related to the COVID-19 pandemic, including
edging the role researcher subjectivity plays in making sense of partic- anxiety around health, social isolation, and loneliness, adapting to on-
ipant experiences. The approach to generating codes and themes was line university study, and diminished opportunities to engage in activ-
inductive, inferring directly from interview transcripts, deductive, ities normally available at university.
inferring from relevant theory and reflective, using journalling to
acknowledge the influence of researcher subjectivity. Influences 3.2. Engagement and acceptability, recommendation and satisfaction
included the first author’s role as a PhD student exploring the potential ratings
of ADepT to treat young adult depression and their supervision by its
developer (the senior author). A graduate research assistant (who had a Table 2 summarises engagement with treatment and participant
lack of exposure to ADepT yet had an interest in clinical interventions for acceptability, satisfaction, and treatment recommendation ratings. All
depression) read and identified themes in three randomly selected in- eleven participants completed the minimum adequate dose of treatment
terviews; these were then discussed with JC and incorporated into the of at least 50% of acute sessions, with nine completing all fifteen acute
final framework. The full analytic process is described in supplementary sessions. This exceeds the target set in continuation rule one (>60%

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J. Carson et al. Behaviour Research and Therapy 183 (2024) 104646

Table 1
Participant demographic and clinical characteristics and intake scores for PHQ-9 depression, WEMWBS wellbeing, GAD-7 anxiety, SHAPS anhedonia, PANAS positive
and PANAS negative affect, WSASY functioning, ICECAP-A capability, and BADS-SF behavioural activation.
P Age Sex PHQ-9 WEMWBS GAD-7 SHAPS PANAS-PA PANAS-NA WSASY ICECAP-A BADS-SF

1 20 F 21 29 16 40 21 31 10 0.60 21
2 20 M 24 16 19 50 10 40 16 0.37 2
3 20 M 18 25 12 43 14 35 15 0.27 18
4 20 M 24 28 20 34 17 34 8 0.58 20
5 21 M 17 32 16 27 29 41 9 0.61 16
6 21 F 16 34 17 38 19 30 13 0.44 10
7 20 F 14 34 12 38 18 31 10 0.67 20
8 20 M 13 23 14 32 13 31 12 0.27 5
9 22 M 15 25 5 39 17 18 11 0.41 7
10 21 F 18 29 15 37 12 33 13 0.44 16
11 24 F 21 28 19 40 13 33 9 0.34 19

M 20.82 – 18.27 27.55 15.00 38.00 16.63 32.45 11.45 0.45 14.00
SD 1.25 – 3.80 5.24 4.27 5.93 5.28 6.00 2.58 0.14 6.78

Note: P = participant; M = Mean; SD = Standard Deviation; F = female; M = male. PA = positive affect; NA = negative affect.

Table 2
Participant attendance, and acceptability, satisfaction, and recommendation ratings.
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 Mean (SD)

Acute session attendance 15 11 14 15 15 15 15 15 15 15 15 14.54 (1.21)

Booster session attendance 5 0 0 5 4 5 3 4 3 5 5 3.54 (1.92)
Acceptability 5 – 2 5 – – 5 5 5 4 5 4.50 (1.07)
Satisfaction rating 5 – 1 5 – – 5 3 4 4 5 4.00 (1.41)
Recommendation rating 5 – 1 5 – – 5 3 5 3 5 4.00 (1.51)

Note: P = participant; 5 = extremely acceptable/satisfied/likely to recommend; 4 = very, 3 = moderately, 2 = not very, 1 = extremely unacceptable/unsatisfied/
unlikely to recommend.

complete a minimum adequate treatment dose). In terms of booster harm, and suicidal ideation on a number of occasions. In no instances
session, 9/11 participants (81%) made use of at least three booster did these cross into the threshold of adverse events (defined as taking
sessions, with 5/11 participants (45%) using all five sessions. On actions around suicide or engaging in self-harm to a degree that it put
average participants attended 14.54 acute sessions (97% of acute the individual at risk of serious physical injury) and in no instances were
treatment dose) and, including boosters, 18.08 total sessions (90% of these enactments judged to be trial- or treatment-related. Additionally,
total treatment dose). no other unexpected serious adverse events, attributable to the trial or
Eight Participants (P1, P3, P4, P7, P8, P9, P10 and P11) completed a treatment, were reported. This meets continuation rule four (no evi-
qualitative interview, which included quantitative ratings of experience dence of trial or treatment related serious adverse reactions).”
of therapy. For acceptability, 6/8(75%) participants rated treatment as
extremely acceptable, 1/8 participants rated it as very acceptable, and 3.4. Visual analysis of weekly measures
1/8(13%) participants rated it as not very acceptable. For satisfaction,
4/8(50%) participants were extremely satisfied, 2/8(25%) participants Table 3 summarises the results of visual analysis for measures taken
were very satisfied, 1/8(13%) participants were moderately satisfied, weekly (see SOM-2a for graphs of each outcome for each participant).
and 1/8(13%) participants was extremely dissatisfied. In terms of Inspection of the baseline data revealed relatively high levels of within
treatment recommendations, 5/8(63%) participants would be extremely participant variability over time (i.e., unstable baseline phases), with
likely to recommend ADepT to others, 2/8(25%) participants would be little evidence of spontaneous improvement prior to treatment onset
moderately likely to recommend ADepT to others, and 1/8(13%) par- across measures and participants.
ticipants would be extremely unlikely to recommend ADepT to others. In Level analyses included all eleven participants for the treatment
summary, 7/8 (88%) participants who completed the interviews rated phase and nine participants for the follow-up phase (as two participants
treatment as at least moderately acceptable, that they were at least did not complete the follow-up phase measures). Change across phases
moderately satisfied with it, and that they would be at least moderately was defined as the SD bands of the treatment or follow-up phase not
likely to recommend it to others, exceeding continuation rule two (i.e. overlapping with the SD bands of the baseline phase, which could either
>60% target). be in the direction of clinical improvement or deterioration. For PHQ-9
depression, during acute treatment 4/11(36%) improved and 1/11(9%)
3.3. Safety and potential harms worsened; during follow-up 5/9(56%) improved, and none worsened.
For SWEMWBS wellbeing, improvement was shown for 3/11(27%)
Focusing on the two primary outcomes, rates of reliable deteriora- participants during acute treatment, with 1/9(9%) worsening. However,
tion were examined. Of the participants completing post-treatment, 1/9 9/9(100%) participants showed improvement during follow-up. For
participants (11%) showed reliable deterioration from pre-to post- GAD-7 anxiety, 4/11(36%) improved during acute treatment and 2/11
treatment (P4; a six-point reduction) on the WEMWBS, but then moved (18%) worsened; 4/11(44%) improved at follow up and 2/9(22%)
to reliable and clinical significant improvement at two-month follow-up. worsened. For PANAS-S positive affect, improvements were shown by 3/
No participants (0%) showed reliable deterioration from pre-to post- 11(27%) during acute treatment and 8/9(89%) during follow-up, with
treatment on the PHQ-9. This exceeds continuation rule three (<30% one worsening during treatment 1/11(9%). For PANAS-S negative
reliable deterioration on either of the primary outcomes). affect, during acute treatment 3/11(27%) improved and 3/11(27%)
During the study the self-harm and suicide risk protocol was enacted worsened; during follow-up 1/9(9%) improved and 5/9(56%)
in response to clients reporting urges to self-harm, minor acts of self- worsened.

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Table 3
Summary of visual analysis assessing change in level from baseline to treatment and follow-up phase for each participant.
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 Improved Worsened

PHQ-9 depression
Change in level during treatment N N N Y* N Y* N Y- Y* Y* N 4 (36%) 1 (9%)
Change in level during follow-up N – – Y* N N Y* N Y* Y* Y* 5 (56%) 0 (0%)

WEMWBS wellbeing
Change in level during treatment Y- N N Y* N N N Y* N Y* N 3 (27%) 1 (9%)
Change in level during follow up Y* – – Y* Y* Y* Y* Y* Y* Y* Y* 9 (100%) 0 (0%)

GAD-7 anxiety
Change in level during treatment N N N Y* Y- Y* N N Y- Y* Y* 4 (36%) 2 (18%)
Change in level during follow-up N – – Y* N Y* Y* N Y- Y- Y* 4 (44%) 2 (22%)

PANAS positive affect

Change in level during treatment N N Y- N Y* Y* N N N Y* N 3 (27%) 1 (9%)
Change in level during follow-up Y* – – Y* Y* Y* Y* N Y* Y* Y* 8 (89%) 0 (0%)

PANAS negative affect

Change in level during treatment Y- N Y* Y* Y- N N Y- N Y* N 3 (27%) 3 (27%)
Change in level during follow-up Y- – – N Y- Y- N Y- N Y- Y* 1 (11%) 5 (56%)

Note: P = participant; Y = yes; N = no; - = no data; * = improvement; - = worsening.

3.5. Extended assessment battery: reliable change and reliable and to post, and no change from post to two-month or one year follow-up.
clinically significant change For WEMWBS wellbeing, there was no significant difference between
intake and pre, a significant improvement from pre to post, and no
Table 4 summarises individual reliable change (RC) and reliable and significant difference from post to two-month or one-year follow up for
clinically significant change (RCSC) analyses (all relative to pre- WEMWBS wellbeing. A similar pattern to the WEMWBS was shown for
treatment) at each follow-up assessment. Focusing on the primary out- the remaining outcome measures that exhibited a main effect of time
comes, PHQ-9 depression and WEMWBS wellbeing, rates of RC (except some pairwise comparisons were only trend significant).
improvement at post-treatment were 3/9(33%) and 6/9(67%) respec- Paired sample t-tests (all relative to pre-treatment) showed large
tively; at two month-follow up rates of RC improvement were 5/9(56%) effect size improvements at post-treatment for WEMWBS wellbeing,
and 7/9(78%) respectively; and at one-year follow up rates of RC WSAS-Y and RIFT functioning, AVRS ADepT values, ICECAP-A capa-
improvement were 3/6(50%) and 6/6 (100%) respectively. Compared bility; medium effect size improvements for PHQ-9 depression, GAD-7
to RC, rates of RCSC improvement were lower for both primary out- anxiety, SHAPS anhedonia, WHO-QoL recovery, and BADS-SF behav-
comes across all timepoints. One participant showed RC deterioration at ioural activation; small effect size improvements for PANAS positive
post-treatment on the WEMWBS, but then moved to RCSC improvement affect and PANAS negative affect. This pattern fails to meet continuation
at two-month follow-up. One other participant showed RC deterioration rule six (large effect size improvements post-treatment for both
on the PHQ-9 at one-year follow-up. Another participant showed reli- depression and wellbeing co-primary outcomes). At two-month follow-
able deterioration on depression at the one-year follow up. up, effect size improvements were now large for all measures apart from
Comparable analyses were conducted on each of the secondary PANAS negative affect (changes remained small) and GAD-7 anxiety
outcomes (GAD-7 anxiety, SHAPS anhedonia, PANAS positive and (improvements remained medium). At one year follow-up (n = 6 only),
negative affect, WSAS-Y and LIFE-RIFT functioning, ICECAP capability, the large effect sizes were sustained in all cases apart from PHQ-9
and BADS-SF behavioural activation; also summarised in Table 4). Rates depression (reduced to small), PANAS positive affect (reduced to me-
of reliable improvement were variable for these secondary outcomes dium), and BADS-SF behavioural activation (reduced to medium); GAD-
measures post-treatment (lowest 22% for PANAS negative; highest 56% 7 anxiety remained medium and PANAS negative affect decreased to
for SHAPS anhedonia and PANANS positive); at two-month follow-up negligible.
(lowest 11% for PANAS negative; highest 67% for WSAS-Y functioning); Table 6 benchmarks the group level case series outcomes against
and at one-year follow-up (lowest 17% for PANAS negative; highest 66% effect sizes from previous research with ADepT. Pre to post effect sizes
for ICECAP-A capability and PANAS positive). However, on all measures for the present young adult case series were moderate for depression (g
at least three participants showed reliable improvement at post- = 0.78) and therefore smaller than the adult case series (g = 1.28),
treatment and two-month follow-up except PANAS negative. ADepT pilot trial arm (g = 1.61), and CBT arm pilot trial arm (g = 1.44).
In summary, across the co-primary outcomes and secondary out- For wellbeing the young adult case series pre to post effect size was large
comes, rates of reliable improvement were modest (and fell short of the (g = 0.93), but still smaller than the adult case series (g = 1.31), ADepT
pre-specified 60% continuation criteria on the primary outcomes). pilot trial arm (g = 1.31), and CBT arm pilot trial arm (g = 1.11).

3.6. Extended assessment battery: group level analyses 3.7. Qualitative interviews

Table 5 and Fig. 1 summarise the findings of group level analyses Detailed thematic analyses of the qualitative interviews are pre-
(repeated measures ANOVAs and paired sample t-tests comparing pre- sented in the supplementary materials (SOM-2d). Key findings are
treatment to post-treatment, two-month follow-up, and one-year summarised here (Fig. 2). Prior to starting ADepT participants were
follow-up). ANOVA analyses found a significant change over time for struggling with their mental health, reported both positive and negative
all variables, with the following exceptions. There was a non-significant previous experiences of therapy and were motivated to make a change.
trend (p = .06) for SHAPS anhedonia and there was no significant 6/8 found undergoing ADepT a positive experience and described
change over time for PANAS negative affect. Pairwise comparisons on ADepT as having helped them to make some significant improvements
the significant or trend significant findings were used to resolve these to their depression and wellbeing. 2/8 had mixed or negative experi-
main effects. For PHQ-9 depression, there was a significant decrease ences (P3 and P8). One described ADepT as not being a good fit for them
from intake to pre, a significant decrease in depression severity from pre (P8) and the other described ADepT as not feeling like therapy (P3).

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Table 4
Numbers of reliable change, reliable and clinically significant change, and reliable deterioration.
P1 P4 P5 P6 P7 P8 P9 P10 P11 RC RCSC

PHQ-9 depression
Pre 20 18 19 14 10 13 12 17 15 ​ ​
Post 22 17 14* 12 9 13 9 12* 8** 3(33%) 1(11%)
2m 21 9** 15* 14 8 10 5** 11* 7** 5(56%) 3(33%)
1y 27ᵈ – 12* – 2** 13 – 15 3** 3(50%) 2(33%)

WEMWBS wellbeing
Pre 25 32 30 40 34 22 22 21 31 ​ ​
Post 24 26ᵈ 43** 40 48** 40** 37* 35* 47** 6(67%) 4(44%)
2m 35* 49** 36* 42 46** 34* 37* 21 39* 7(78%) 2(22%)
1y 36* – 39* – 64** 42** – 29* 45** 6(100%) 3(50%)

GAD-7 anxiety
Pre 16 19 15 16 14 13 5 12 18 ​ ​
Post 16 7** 14 10* 13 13 4 12 1** 3(33%) 2(22%)
2m 16 7** 16 10* 10 11 3 16 5** 3(33%) 2(22%)
1y 21ᵈ – 14 – 3** 10 – 10 4** 2(33%) 2(33%)

SHAPS anhedonia
Pre 41 34 38 30 36 33 39 41 29 ​ ​
Post 36* 36 32* 28 36 32 26* 27* 19** 5(56%) 1(11%)
2m 38 22** 37 28 34 34 27* 42 24** 3(33%) 2(22%)
1y 42 – 37 – 28* 26* – 33* 26 3(50%) 0(0%)

PANAS positive affect

Pre 16 16 33 17 29 16 13 10 18 ​ ​
Post 16 10 28 29** 24 21 25** 23* 30** 4(44%) 3(33%)
2m 28** 40** 33 30** 30 18 25** 11 27** 5(56%) 5(56%)
1y 23** – 28 – 43** 38** – 11 29** 4(66%) 4(66%)

PANAS negative affect

Pre 33 25 43 25 37 30 20 26 21 ​ ​
Post 36 19 39 28 28* 39ᵈ 15 30 13** 2(22%) 1(11%)
2m 40ᵈ 20 37 23 30* 34 14 34ᵈ 16 1(11%) 0(0%)
1y 43ᵈ – 38 – 15** 44ᵈ – 27 15 1(17%) 1(17%)

WSASY functioning
Pre 13 9 13 15 10 11 13 10 10 ​ ​
Post 10* 9 7** 11* 7** 10 10* 7** 5** 7(78%) 4(44%)
2m 10* 7 10* 8* 9 8* 6** 8 7** 6(67%) 2(22%)
1y 13 – 11 – 6** 8* – 9 4** 3(50%) 2(33%)

ICECAP-A capability
Pre 0.53 0.44 0.7 0.44 0.6 0.14 0.46 0.26 0.44 ​ ​
Post 0.51 0.51 0.68 0.51 0.75 0.41* 0.71* 0.60* 0.89** 4(44%) 1(11%)
2m 0.58 0.75* 0.61 0.78** 0.85** 0.32 0.75* 0.36 0.84** 5(56%) 3(33%)
1y 0.67 – 0.61 – 0.94** 0.47* – 0.51* 0.84** 4(66%) 2(33%)

BADS-SF behavioural activation

Pre 20 22 14 20 19 6 11 17 27 ​ ​
Post 23 14ᵈ 14 19 28** 21* 22* 30** 35** 5(56%) 3(33%)
2m 20 32** 19 21 31** 5 29** 21 36** 4(44%) 4(44%)
1y 19 – 15 – 40** 20 – 26** 30** 3(50%) 3(50%)

LIFE-RIFT functioning
Pre 16 13 11 16 11 17 18 16 12 ​ ​
Post 14 11 13 9** 8 12* 11* 13 10 3(33%) 1(11%)
2m 11* 6** 11 11* 8 14 – – 10 3(33%) 1(11%)

Note: * = reliable change and ** = reliable and clinically significant change (relative to pre-assessment); ᵈ reliable deterioration; - = missing data; RC = reliable change;
RCSC = reliable and clinically significant change. RIFT not administered at one year follow-up.

Participants described several processes as being important to their they were perceived as present by the participants, but hindered when
depression and wellbeing gains made during ADepT, including: getting they were perceived as absent. For example, one of the participants (P3)
to know themselves and their depression better through psycho- that had a negative experience felt that they were not making progress,
education; learning what is important to them and makes them happy that they had expressed this to their therapist, and that it had not been
through wellbeing focused values clarification; spending less time acknowledged and responded to. This led to the eventual disengagement
ruminating and more time engaged in activities through behavioural of this participant from therapy. Circumstantial factors both helped and
activation; adopting a positive attitude using positive reappraisal stra- hindered participants attempt at therapeutic change. For example,
tegies like journalling; responding to challenges with greater resilience COVID-19 and the associated social distancing measures had a sub-
using problem solving; and taking good care of themselves using self- stantial impact. Participants experienced increased stress about the
compassion. physical health risks associated with COVID-19, felt lonelier and more
Several barriers and facilitators to engagement with (and gaining isolated, and struggled with the loss of social and leisure opportunities.
benefit from) therapy were reported. Therapist factors, such as use of a COVID-19 was both an amplifying factor for their depression and a
positive therapeutic style, kindness and warmth, empathy and under- barrier to their recovery. Whilst efforts were made in ADepT to find
standing, authenticity, and responsiveness to feedback helped when ‘functionally equivalent’ forms of activation for behaviours not

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J. Carson et al. Behaviour Research and Therapy 183 (2024) 104646

Table 5 COVID-19 pandemic (UK National Health Service), showed that a

Results of ANOVA comparing measures over time and effect sizes (Hedges g) younger age was associated with a greater risk of unplanned discharge
from paired sample-t comparisons of pre-treatment levels to post-treatment, (Verbist et al., 2024). Several randomised control trials on psychosocial
two-month follow-up and one year follow-up on each outcome variable. and behavioural interventions for adolescents and young adults during
ANOVA Comparisons Post (n Two- One-year the COVID-19 pandemic reported low dropout rates, however, the in-
= 9) month FU (n = terventions were typically short in duration and the samples were
FU (n = 6)
non-clinical, recruited from the general population with elevated
9)
self-reported depression symptoms (He et al., 2023). The acceptability of
PHQ-9 F= (I>Pre > 0.78 1.08 0.46 ADepT to a sample of clinically depressed young adults, along with their
depression 12.15, p [Post = FU]) (0.06, (0.28, (− 0.29,
< .001 1.46) 1.85) 1.16)
high levels of engagement during the COVID-19 pandemic, is
WEMWBS F= ([I=Pre]> 0.93 1.45 1.54 encouraging.
wellbeing 7.40, p [Post = FU]) (0.17, (0.52, (0.37, There was mixed evidence regarding the efficacy of ADepT. The
< .001 1.67) 2.34) 2.66) convention for determining an intervention effect using case series de-
GAD-7 F= ([I=Pre]> 0.61 0.60 0.52
signs is to aim for three replications in visual analyses (Kazdin, 2011;
anxiety 4.46, p [Post = FU])a (− 0.06, (− 0.07, (− 0.24,
= .01 1.26) 1.24) 1.25) Morley, 2018). Changes in level (relative to the baseline phase) were
SHAPS F= ([I=Pre]> 0.79 0.81 0.94 observed for 4/11(36%) for depression and 3/11(27%) for wellbeing
anhedonia 2.86, p [Post = FU]) (0.07, (0.09, (0.04, during treatment, and during the eight week follow up phase, by 5/9
= .06 1.47) 1.51) 1.79) (56%) for depression and 9/9(100%) for wellbeing, exceeding the target
PANAS F= ([I=Pre = 0.46 0.93 0.73
of three replications for both core outcomes at both timepoints. It is
positive affect 4.71, p Post]>FU) (− 0.18, (0.17, (− 0.10,
= .01 1.08) 1.65) 1.51) important to note these replications were across therapists, however,
PANAS F= – 0.21 0.20 0.09 and no single therapist met the criteria for three replications specified.
negative 1.32, p (− 0.40, (− 0.40, (− 0.59, Rates of reliable improvement were 33% for depression and 56% for
affect = .29 0.80) 0.79) 0.76)
wellbeing at post-treatment, failing to meet the >60% target in
WSASY F= ([I=Pre]> 1.53 1.46 1.04
functioning 10.44, p [Post = FU]) (0.57, (0.53, (0.10, continuation rule five. This relatively low rate of reliable improvement
< .001 2.46) 2.36) 1.93) for depression symptoms during ADepT acute treatment is equivalent to
WHO-QoL F= ([I=Pre]> 0.79 1.23 1.31 findings from passive control conditions in meta-analyses of psycho-
recovery 6.25, p [Post = FU]) (0.07, (0.37, (0.24, logical treatments for adolescent depression (e.g., 32% reliable
< .01 1.47) 2.04) 2.31)
improvement reported in Cuijpers et al., 2023). Although rates of reli-
ICECAP-A F= ([I=Pre]> 0.95 1.15 1.06
capability 6.51, p [Post = FU]) (0.19, (0.32, (0.11, able improvement at two-month follow-up did improve to 56% for
< .01 1.68) 1.94) 1.96) depression and 78% for wellbeing, they still did not fully meet the
BADS-SF F= ([I=Pre]> 0.66 0.92 0.78 continuation target of >60% for both.
behavioural 5.74, p [Post = FU])b (0.02, (0.16, (0.07,
The effect sizes for improvement at post-treatment were moderate
activation < .01 1.32) 1.64) 1.57)
AVRS ADepT F= ([I=Pre]> 1.32 2.00 4.49
for depression (g = 0.78) and large for wellbeing (g = 0.93), narrowly
values 18.67, p [Post = FU]) (0.44, (0.86, (1.73, failing to satisfy continuation rule six, which specified effect size im-
< .001 2.17) 3.11) 7.26) provements of > 0.8 for both outcomes. These effect sizes are smaller
LIFE-RIFT F= ([I=Pre]> 1.03 1.35 – than those observed in previous studies of ADepT (Dunn et al., 2023;
6.14, p [Post = FU]) (0.24, (0.34,
Dunn, Widnall, Reed, Owens, et al., 2019), particularly for depression
< .01 1.79) 2.31)
(adult case series [g = 1.28]; adult pilot trial [g = 1.61]), though also for
Note: Data are effect size = Hedge’s g (95% CI); FU = Follow-up; a = pre to post wellbeing (adult case series [g = 1.31]; adult pilot trial [1.31]). Again,
and pre-FU only trend significant (p > .05 <0 .10); b = pre to post only trend however, at the two-month follow-up both effect sizes were large, with
significant (p > .05 <0 .10). RIFT not administered at one year follow-up.
wellbeing gains now comparable to previous ADepT studies (g = 1.45)
and depression gains still slightly smaller (g = 1.08).
permitted due to social distancing regulations, these did not always In sum, relatively modest improvement was observed during acute
result in the same degree of benefit on wellbeing. For example, an online treatment, but outcomes during follow-up were more substantial in the
solo workout at home resulted in less of a wellbeing gain than exercising two-months immediately after acute treatment. This time course of
outdoors with friends doing a team sport. Finally, several features of improvement differs to earlier case series and pilot trial evaluations of
ADepT acted as facilitators of therapeutic progress. The booster sessions ADepT in general adult samples (Dunn et al., 2019, 2023), which show
were seen as very valuable in building participants agency to sustain substantive improvement during the acute-treatment phase that is then
change and the handouts and homework exercises were described as sustained (but does not improve further) during follow-up. It is unclear
useful, though at times difficult to keep up with. what caused the continued improvements from post-treatment to follow
up. One possible explanation of this finding is that the COVID-19
4. Discussion pandemic (by limiting behavioural activation opportunities, increasing
loneliness, etc) inhibited initial improvement during early treatment. As
This multiple randomised baseline case series of eleven young adults social distancing restrictions were removed, participants may have been
with depression demonstrated that Augmented Depression Therapy is able to benefit from skills learned during therapy (values clarification,
safe, acceptable, and engages young adults (meeting continuation rules goal setting, activity scheduling, etc). It is also possible that the severity
one-to-four). However, preliminary evidence of effectiveness was of the sample may have increased the dose necessary for the treatment
mixed, with greater improvements observed in wellbeing than depres- response, and/or contributed a non-linear treatment response.
sion (only partially meeting continuation rules five and six). A critical issue when interpreting individual time series data (in the
The relatively high engagement with ADepT is noteworthy given the absence of a control group) is assessing whether improvements are a
difficulties encountered engaging young people in clinical trials and consequence of treatment being introduced or other uncontrolled vari-
routine care. For instance, in the IMPACT trial, adolescents only adhered ables (Kratochwill et al., 2013; Smith, 2012; Tate et al., 2016). If
to approximately 55% of the intended dose of CBT, short-term psycho- improvement is a consequence of treatment, there should be no obvious
dynamic psychotherapy, and interpersonal therapy (Goodyer et al., pattern of improvement during the baseline phase and improvement
2017). Further, routine outcome data from 13,019 clients engaging with should occur during treatment and follow-up phases (irrespective of
Improving Access to Psychological Therapies services during the baseline phase length). In the current weekly time series data, there was

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J. Carson et al. Behaviour Research and Therapy 183 (2024) 104646

Fig. 1. Mean scores for PHQ-9 Depression, WEMWBS Wellbeing, GAD-7 Anxiety, SHAPS Anhedonia, PANAS Positive Affect, PANAS Negative Affect, WSASY
Functional Impairment, WHO-QoL Recovery, ICECAP-A Capability, BADS-SF Behavioural Activation, and AVRS ADepT Values at each assessment point.
Note: Data are mean (one standard error of the mean) values. Red dashed line = clinical cut off; green dashed line = general population average level (not available
for Functional Impairment, Recovery, and ADepT Values).

generally no clear pattern of improvement during the baseline phase on One intriguing finding is that the pattern of results across measures
any measure, with several participants then going on to show significant indicated more substantial improvement for positive outcomes such as
improvements in overall level during treatment and follow-up (relative wellbeing, positive affect, functioning, and recovery and only modest
to baseline). This is consistent with the improvements observed being improvement for negative outcomes such as depression and anxiety.
largely due to the introduction of treatment rather than other uncon- This evidence is consistent with the hypothesis that wellbeing and
trolled variables. An important caveat here is due to relatively high mental ill health are partly dissociable constructs (Franken, Lamers, Ten
levels of variability within participants over time in each phase, our Klooster, Bohlmeijer, & Westerhof, 2018; Ryff & Keyes, 1995; Zautra,
analyses focused solely on change in level between phases and did not Affleck, Tennen, Reich, & Davis, 2005) The underlying rationale for
examine change in slope (as the slope lines were not reliable). Stronger ADepT emphasizes “living well alongside depression and anxiety”,
inferences about a genuine treatment effect can be made when differ- meaning that wellbeing may be experienced despite the presence of
ences between phases can be detected in both slope and level. depression and anxiety symptoms. Acceptance and Commitment Ther-
A similar pattern was observed for most measures in the extended apy (ACT) approaches take a similar recovery stance to ADepT and a
assessment battery (measured intake, pre-treatment, post-treatment and recent review of meta-analyses of ACT trials has shown a similar pattern
follow-up), with no significant improvement during the baseline phase of greater effect sizes being somewhat greater for wellbeing and quality
and then a significant improvement during treatment for all measures. of life, relative to symptom change (Gloster, Walder, Levin, Twohig, &
Again, this is consistent with a genuine treatment effect. The one Karekla, 2020). However, this diverges from previous evaluations of
exception was PHQ-9 depression, where there was a small and signifi- ADepT in depressed adults, where comparable improvements were
cant group level improvement from intake to pre-treatment assessment, observed for both positive outcomes and symptom relief (Dunn et al.,
and then a bigger and also significant further group level improvement 2023; Dunn, Widnall, Reed, Owens, et al., 2019). Thus, positive out-
from pre-treatment assessment to post-treatment assessment. In this comes and symptoms relief may have different relationships depending
analysis we cannot rule out effects being a result of the passage of time on developmental stage and disease chronicity (Kraiss, Kohlhoff, & Ten
alone, although this concern is slightly offset by the individual level Klooster, 2022; Westerhof & Keyes, 2010), with the present results
intensive time series data for the PHQ-9 depression not showing clear tentatively suggesting that wellbeing and mental ill health may be more
improvements in the baseline phase. dissociable in young adults with shorter depression histories.
Overall, findings are suggestive of the observed improvements being It is not possible to know how the effectiveness of ADepT was
a consequence of the treatment rather than other uncontrolled variables, influenced by the COVID-19 pandemic and associated social distancing
however, a definitive answer to this question would require randomised measures in the UK. However, examining the performance of psycho-
controlled trial designs that incorporate a control group. logical interventions for depression generally during COVID-19 can offer

10
J. Carson et al. Behaviour Research and Therapy 183 (2024) 104646

Fig. 1. (continued).

young adults with clinical presentations in other countries. Young

Table 6
people and individuals with pre-existing mental health diagnoses
Benchmarking analyses comparing effect sizes in current case series with pre-
experienced the greatest and most persistent increases in depression and
vious ADepT research.
anxiety (Cowie & Myers, 2021; Creswell et al., 2021; O’Connor et al.,
ADepT young ADepT adult ADepT arm CBT arm of 2021). The lack of evidence demonstrating the effectiveness of psy-
adult case case series of adult pilot ADepT adult
series (n = 9) (n = 13) trial (n = 35) pilot trial (n
chological interventions specifically on young adults with a depression
= 37) diagnosis, makes comparisons of effectiveness with the current study
difficult, highlighting the need for a replication outside of the COVID-19
PHQ-9 0.78 (0.06, 1.28 (0.38, 1.61 (1.31, 1.44 (1.14,
depression 1.46) 2.24) 1.92) 1.75) pandemic.
WEMWBS 0.93 (0.17, 1.31 (0.42, 1.31 (1.01, 1.11 (0.80, Young adults in this case series described COVID-19 as an amplifying
wellbeing 1.67) 2.29) 1.62) 1.41) factor for their depression and a barrier to their recovery. They
GAD-7 0.61 (− 0.06, 1.05 (0.18, 1.64 (1.34, 0.99 (0.69, described how they were feeling stress about the health risks associated
anxiety 1.26) 1.98) 1.95) 1.30)
SHAPS 0.61 (− 0.06, 0.99 (0.08, 1.43 (1.13, 0.83 (0.52,
with COVID-19, feeling lonely and isolated, and struggling with the loss
anhedonia 1.26) 1.97) 1.74) 1.14) of social, vocational and leisure opportunities. Mirroring our findings,
PANAS 0.46 (− 0.18, 1.58 0.61, 1.48 (1.17, 1.01 (0.70, qualitative studies revealed that young people were struggling with
positive 1.08) 2.67) 1.78) 1.31) loneliness, loss of social contact, anxiety and worries about the
affect
pandemic and their future, and a sense of loss and frustration at the loss
PANAS 0.21 (− 0.40, 0.71 (− 0.16, 1.23 (0.92, 1.00 (0.69,
negative 0.80) 1.65) 1.53) 1.31) of social, occupational, and leisure opportunities (McKinlay, May,
affect Dawes, Fancourt, & Burton, 2022; Pearcey et al., 2023). Extensive evi-
WSASY 1.53 (0.57, 1.35 (0.18, 0.95 (0.64, 0.75 (0.44, dence demonstrates that the prevalence of symptoms of depression in
functioning 2.46) 1.98) 1.26) 1.05) the UK rapidly increased with the emergence of the pandemic, peaking
Note: data are effect size = Hedge’s g (95% CI) for case series and Cohen’s during each of the lockdowns (Chandola, Kumari, Booker, & Benzeval,
d (95% CI) for pilot trial. 2022; Fancourt, Steptoe, & Bu, 2021; Li & Gutman, 2023, pp. 1–11;
Niedzwiedz, Benzeval, Hainey, Leyland, & Katikireddi, 2021; Pierce
useful context. One recent meta-analysis explored the effectiveness of et al., 2021; Thorpe & Gutman, 2022). Young people and individuals
psychological interventions for depression and anxiety symptoms during with pre-existing mental health diagnoses, were most likely to experi-
the pandemic (He et al., 2023). The between group effect sizes reported ence the greatest increases in and most persistent distress (Cowie &
for a subset of individual studies focusing on adolescents or young adults Myers, 2021; Creswell et al., 2021; O’Connor et al., 2021). Given the
were moderate-to-large for depression (SMDs − 0.044 to − 0.107). At impact of COVID-19 on young people with a mental health diagnosis in
face value this suggests interventions for youth depression remained the UK, it is perhaps unsurprising that only modest symptom relief was
effective during COVID-19. However, these studies were conducted in observed. Further, given the severe restrictions on social, vocational and
China, in general population samples with elevated levels of depression leisure opportunities, it is encouraging that improvements were never-
(not clinical diagnoses), and it is unclear if findings will generalise to theless observed in positive outcomes such as functioning, positive

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J. Carson et al. Behaviour Research and Therapy 183 (2024) 104646

Fig. 2. thematic framework of participant experiences of ADepT.

affect, and wellbeing. target of a minimum of three therapists meeting this criteria). Second, of
Valuable insights were gained about how to optimise recruitment the eleven participants starting the case series, two did not complete the
and screening procedures for a future iteration of this case series. The post-treatment and follow-up extended assessments. Both participants
primary recruitment method was suboptimal, with only 11 of the target were less satisfied with ADepT and had weekly session data that
15 clients being recruited. This was likely in part a consequence of the demonstrated no evidence of improvement during acute therapy. The
COVID-19 context. Additionally, the triage arrangements with the uni- complete case analyses that excluded these individuals may therefore be
versity wellbeing service resulted in a sample being recruited that were inflating observed effects. Third, many analyses were conducted,
best characterised as complex depression, with co-morbidities including without corrections being made for multiple comparisons. While this
anxiety, emotional and interpersonal regulation difficulties, complex increases the likelihood of finding a false positive in any individual
PTSD, and features of neurodiversity, that had not responded to a front- analyses, it is unlikely that the overall pattern of consistent improve-
line intervention. Increased severity of depression, a history of treatment ment across multiple measures and time points is an artefact of this
resistance, trauma history, and presence of comorbidities have been analytic approach.
shown to predict less optimal depression treatment response (Andreescu Moreover, three out of the five therapists were learning ADepT as
et al., 2007; Asarnow et al., 2009; Assmann et al., 2018; Gorwood et al., they delivered it during the case series. This may have reduced the
2010; Mars et al., 2021; Meyer & Curry, 2021; Meyer & Curry, 2021, effectiveness of ADepT for participants treated by these therapists,
2021; Wichers, van der Wouw, Brouwer, Lok, & Bockting, 2023). This especially in early sessions. As no fidelity or competency assessments
means it remains unclear how less complex depression in young adults were conducted, it is unclear to what extent the protocol was delivered
would respond to ADepT. It is prudent to repeat the current case series in as specified. Post hoc exploratory analyses2 suggested comparable im-
a sample of young adults with depression, with additional recruitment provements in positive outcomes irrespective of therapist experience,
and screening protocols, treated outside of the COVID-19 pandemic. but greater symptom relief in experienced relative to novice therapists.
A strength of the current design was integrating a mixed methods It is also important to note the study is at risk of allegiance bias as the
approach, supplementing quantitative outcome evaluation with a senior author is the developer of ADepT.
qualitative process evaluation. All six participants who reported benefits Additionally, due to the division in service provision for adolescents
also showed improvement on depression or wellbeing measures either and young adults in the UK, the current study only treated a sample from
during the acute treatment phase or the follow-up phase, suggesting 20 to 24 years of age. Elsewhere in the world it is increasingly standard
alignment between the qualitative and the quantitative findings. to offer services to adolescents and young adults together, meeting the
Further, the mechanisms of change discussed in the interviews aligned needs of the 14–24 population (Hetrick et al., 2017; McGorry et al.,
with the logic model of the intervention, including the importance of 2022). It remains unknown if ADepT is well suited to young people
activating towards values consistent activities, developing a positive below the age of 20. Further, the current sample were predominantly
outlook, and an emphasis on self-care.
It is important to highlight several limitations of this study. First, the
actual sample (n = 11) was smaller than the target sample (n = 15). This 2
increases the risk of type two errors in the between group statistical Post hoc analyses (SOM-2b and 2c) reported the number of individuals
meeting depression remission criteria on the SCID-V and PHQ-9 (scoring <10)
analyses, due to reduced statistical power. However, given statistical
at each assessment point and whether outcomes varied depending on prior
significance was observed across all measures (aside from negative
therapist experience of ADepT, focusing on the two co-primary depression and
affect) and that similar findings emerged in the individual level visual wellbeing outcomes, was also examined. Rates of remission were 1/9(11%) on
analyses, the conclusions reached are likely to be robust. The reduced the SCID-V and 3/9(33%) on the PHQ-9 at post-treatment (increasing at two-
sample size meant that we also did not fully meet our planned recruit- month follow up, with minimal change at one-year). The extent of clinical
ment targets for assessing generalisability of findings across therapists improvement in participant wellbeing during treatment was comparable for
(only two therapists treated at least three cases each, falling short of the experienced therapists versus those new to ADepT, but participant depression
repair was greater for experienced therapists relative to those new to it.

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J. Carson et al. Behaviour Research and Therapy 183 (2024) 104646

Caucasian and university students; recruiting a more diverse population Alsayednasser, B., Widnall, E., O’Mahen, H., Wright, K., Warren, F., Ladwa, A., et al.
(2022). How well do cognitive behavioural therapy and behavioural activation for
for further work would improve the generalisability of the findings.
depression repair anhedonia? A secondary analysis of the cobra randomized
Finally, the PANAS-SF generally refers to high-arousal, positively emo- controlled trial. Behaviour Research and Therapy, 159, Article 104185. https://doi.
tions, such as enthusiasm, rather than lower-intensity positive emotions, org/10.1016/j.brat.2022.104185
such as serenity. Further, although the AVRS values is a bespoke mea- Andreescu, C., Lenze, E. J., Dew, M. A., Begley, A. E., Mulsant, B. H., Dombrovski, A. Y.,
et al. (2007). Effect of comorbid anxiety on treatment response and relapse risk in
sures intended to capture valued living in life domains specifically target late-life depression: Controlled study. British Journal of Psychiatry, 190, 344–349.
by ADepT, it is yet to be validated. As such, a future iteration of this case https://doi.org/10.1192/bjp.bp.106.027169
series could benefit from measuring low-arousal positive affect and Asarnow, J. R., Emslie, G., Clarke, G., Wagner, K. D., Spirito, A., Vitiello, B., et al. (2009).
Treatment of selective serotonin reuptake inhibitor-resistant depression in
incorporating a validated measure of values. adolescents: Predictors and moderators of treatment response. Journal of the
In conclusion, this study showed that ADepT is a safe, feasible, and American Academy of Child & Adolescent Psychiatry, 48(3), 330–339. https://doi.org/
acceptable treatment that is engaging to young adults. However, treat- 10.1097/chi.0b013e3181977476
Assmann, N., Schramm, E., Kriston, L., Hautzinger, M., Harter, M., Schweiger, U., et al.
ment was associated with greater improvements in wellbeing relative to (2018). Moderating effect of comorbid anxiety disorders on treatment outcome in a
depression and improvements in depression were modest. It remains randomized controlled psychotherapy trial in early-onset persistently depressed
unclear if ADepT is optimised to reduce depression in young people. As outpatients. Depression and Anxiety, 35(10), 1001–1008. https://doi.org/10.1002/
da.22839
the study continuation rules were not fully met, it would be premature to Borckardt, J. J., Nash, M. R., Murphy, M. D., Moore, M., Shaw, D., & O’Neil, P. (2008).
proceed at this stage to randomised controlled trial evaluation of ADepT Clinical practice as natural laboratory for psychotherapy research: A guide to case-
for young adults. It is recommended to repeat this case series outside of based time-series analysis. American Psychologist, 63(2), 77–95. https://doi.org/
10.1037/0003-066X.63.2.77
the COVID-19 pandemic context to further assess the potential of ADepT
Bress, J. N., Foti, D., Kotov, R., Klein, D. N., & Hajcak, G. (2013). Blunted neural response
for young people with depression. to rewards prospectively predicts depression in adolescent girls. Psychophysiology, 50
(1), 74–81. https://doi.org/10.1111/j.1469-8986.2012.01485.x
Chandola, T., Kumari, M., Booker, C. L., & Benzeval, M. (2022). The mental health
CRediT authorship contribution statement impact of COVID-19 and lockdown-related stressors among adults in the UK.
Psychological Medicine, 52(14), 2997–3006. https://doi.org/10.1017/
James Carson: Writing – original draft, Project administration, S0033291720005048
Clayborne, Z. M., Varin, M., & Colman, I. (2019). Systematic review and meta-analysis:
Investigation, Formal analysis. Kalliopi Demetriou: Project adminis- Adolescent depression and long-term psychosocial outcomes. Journal of the American
tration, Investigation. Gemma Barlow: Project administration, Inves- Academy of Child & Adolescent Psychiatry, 58(1), 72–79. https://doi.org/10.1016/j.
tigation. Kim Wright: Writing – review & editing, Supervision. Maria jaac.2018.07.896
Cohen, J. (1977). Statistical power analysis for the behavioral sciences. Rev. Lawrence
Loades: Writing – review & editing, Supervision. Barnaby D. Dunn:
Erlbaum Associates, Inc.
Writing – review & editing, Supervision, Formal analysis, Cowie, H., & Myers, C. A. (2021). The impact of the COVID-19 pandemic on the mental
Conceptualization. health and well-being of children and young people. Children & Society, 35(1),
62–74. https://doi.org/10.1111/chso.12430
Creswell, C., Shum, A., Pearcey, S., Skripkauskaite, S., Patalay, P., & Waite, P. (2021).
Young people’s mental health during the COVID-19 pandemic. Lancet Child &
Declaration of competing interest Adolescent Health, 5(8), 535–537. https://doi.org/10.1016/S2352-4642(21)00177-2
Cuijpers, P., Karyotaki, E., Ciharova, M., Miguel, C., Noma, H., Stikkelbroek, Y., et al.
The authors declare that they have no known competing financial (2023). The effects of psychological treatments of depression in children and
adolescents on response, reliable change, and deterioration: A systematic review and
interests or personal relationships that could have appeared to influence meta-analysis. European Child & Adolescent Psychiatry, 32(1), 177–192. https://doi.
the work reported in this paper. org/10.1007/s00787-021-01884-6
Cuijpers, P., Karyotaki, E., Eckshtain, D., Ng, M. Y., Corteselli, K. A., Noma, H., et al.
(2020). Psychotherapy for depression across different age groups: A systematic
Acknowledgements review and meta-analysis. JAMA Psychiatry, 77(7), 694–702. https://doi.org/
10.1001/jamapsychiatry.2020.0164
Dillon, D. G., & Pizzagalli, D. A. (2010). Maximizing positive emotions: A translational,
The authors would like to thank all participants, clinicians, and transdiagnostic look at positive emotion regulation. In Emotion regulation and
administrative staff who contributed to this study. Investigation and psychopathology: A transdiagnostic approach to etiology and treatment (pp. 229–252).
project management was led by Carson, Demetriou, and Barlow, with The Guilford Press.
Dunn, B. D., German, R. E., Khazanov, G., Xu, C., Hollon, S. D., & DeRubeis, R. J. (2020).
Dunn supervising. Formal analysis and writing was led by Carson,
Changes in positive and negative affect during pharmacological treatment and
Wright, Loades, and Dunn. This research did not receive any specific cognitive therapy for major depressive disorder: A secondary analysis of two
grant from funding agencies in the public, commercial or not-for-profit randomized controlled trials. Clinical Psychological Science, 8(1), 36–51. https://doi.
sectors. James Carson is funded by the Economic and Social Sciences org/10.1177/2167702619863427
Dunn, B. D., & Roberts, H. (2016). Improving the capacity to treat depression using
Research Council (ESRC), via the Southwest Doctoral Training Part- talking therapies: Setting a positive clinical psychology agenda. In The Wiley
nership (SWDTP). The views expressed in this publication are those of handbook of positive clinical psychology (pp. 183–204). Wiley Blackwell. https://doi.
the author(s) and not necessarily those of the ESRC or SWDTP. org/10.1002/9781118468197.ch13.
Dunn, B. D., Widnall, E., Reed, N., Owens, C., Campbell, J., & Kuyken, W. (2019).
Bringing light into darkness: A multiple baseline mixed methods case series
Appendix A. Supplementary data evaluation of augmented depression therapy (ADepT). Behaviour Research and
Therapy, 120, Article 103418. https://doi.org/10.1016/j.brat.2019.103418
Dunn, B. D., Widnall, E., Reed, N., Taylor, R., Owens, C., Spencer, A., et al. (2019).
Supplementary data to this article can be found online at https://doi. Evaluating augmented depression therapy (ADepT): Study protocol for a pilot
org/10.1016/j.brat.2024.104646. randomised controlled trial. Pilot and Feasibility Studies, 5, 63. https://doi.org/
10.1186/s40814-019-0438-1
Dunn, B. D., Widnall, E., Warbrick, L., Warner, F., Reed, N., Price, A., et al. (2023).
Data availability Preliminary clinical and cost effectiveness of augmented depression therapy versus
cognitive behavioural therapy for the treatment of anhedonic depression (ADepT): A
The authors do not have permission to share data. single-centre, open-label, parallel-group, pilot, randomised, controlled trial.
EClinicalMedicine, 61, Article 102084. https://doi.org/10.1016/j.
eclinm.2023.102084
References Eckshtain, D., Kuppens, S., Ugueto, A., Ng, M. Y., Vaughn-Coaxum, R., Corteselli, K.,
et al. (2020). Meta-analysis: 13-Year follow-up of psychotherapy effects on youth
depression. Journal of the American Academy of Child & Adolescent Psychiatry, 59(1),
Al-Janabi, H., Flynn, T. N., & Coast, J. (2012). Development of a self-report measure of
45–63. https://doi.org/10.1016/j.jaac.2019.04.002
capability wellbeing for adults: The ICECAP-A. Quality of Life Research, 21(1),
Fancourt, D., Steptoe, A., & Bu, F. (2021). Trajectories of anxiety and depressive
167–176. https://doi.org/10.1007/s11136-011-9927-2
symptoms during enforced isolation due to COVID-19 in england: A longitudinal
Al-Janabi, H., Flynn, T. N., Peters, T. J., Bryan, S., & Coast, J. (2015). Test–retest
observational study. The Lancet Psychiatry, 8(2), 141–149. https://doi.org/10.1016/
reliability of capability measurement in the UK general population. Health
S2215-0366(20)30482-X
Economics, 24(5), 625–630. https://doi.org/10.1002/hec.3100

13
J. Carson et al. Behaviour Research and Therapy 183 (2024) 104646

Fernandez, E., Salem, D., Swift, J. K., & Ramtahal, N. (2015). Meta-analysis of dropout youth with lived experience of depression. European Child & Adolescent Psychiatry, 32
from cognitive behavioral therapy: Magnitude, timing, and moderators. Journal of (1), 123–137. https://doi.org/10.1007/s00787-021-01839-x
Consulting and Clinical Psychology, 83(6), 1108–1122. https://doi.org/10.1037/ Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief
ccp0000044 depression severity measure. Journal of General Internal Medicine, 16(9), 606–613.
Finning, K., Ukoumunne, O. C., Ford, T., Danielsson-Waters, E., Shaw, L., Romero De https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Jager, I., et al. (2019). The association between child and adolescent depression and Leon, A. C., Solomon, D. A., Mueller, T. I., Turvey, C. L., Endicott, J., & Keller, M. B.
poor attendance at school: A systematic review and meta-analysis. Journal of (1999). The range of impaired functioning tool (LIFE-RIFT): A brief measure of
Affective Disorders, 245, 928–938. https://doi.org/10.1016/j.jad.2018.11.055 functional impairment. Psychological Medicine, 29(4), 869–878. https://doi.org/
First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, R. L. (2016). User’s guide for the 10.1017/s0033291799008570
SCID-5-CV structured clinical interview for DSM-5® disorders: Clinical version. American Li, C. L. Y., & Gutman, L. M. (2023). Life satisfaction in UK emerging adults during the
Psychiatric Publishing, Inc. COVID-19 pandemic (pp. 1–11). New Brunswick, N.J.: Current Psychology. https://
Forbes, E. E., & Dahl, R. E. (2012). Research review: Altered reward function in doi.org/10.1007/s12144-023-04580-7
adolescent depression: What, when and how? The Journal of Child Psychology and Liu, Q., Ely, B. A., Schwartz, J. J., Alonso, C. M., Stern, E. R., & Gabbay, V. (2021).
Psychiatry and Allied Disciplines, 53(1), 3–15. https://doi.org/10.1111/j.1469- Reward function as an outcome predictor in youth with mood and anxiety
7610.2011.02477.x symptoms. Journal of Affective Disorders, 278, 433–442. https://doi.org/10.1016/j.
Franken, K., Lamers, S. M. A., Ten Klooster, P. M., Bohlmeijer, E. T., & Westerhof, G. J. jad.2020.09.074
(2018). Validation of the Mental Health Continuum-Short Form and the dual Loades, M. E., Midgley, N., Herring, G. T., O’Keeffe, S., Goodyer, I. M., Barrett, B., et al.
continua model of well-being and psychopathology in an adult mental health setting. (2024). In context: Lessons about adolescent unipolar depression from the improving
Journal of Clinical Psychology, 74(12), 2187–2202. https://doi.org/10.1002/ mood with psychoanalytic and cognitive therapies trial. Journal of the American
jclp.22659 Academy of Child & Adolescent Psychiatry, 63(2), 122–135. https://doi.org/10.1016/
Franken, I. H., Rassin, E., & Muris, P. (2007). The assessment of anhedonia in clinical and j.jaac.2023.03.017
non-clinical populations: Further validation of the Snaith-Hamilton pleasure scale Los Reyes, A., Makol, B. A., Racz, S. J., Youngstrom, E. A., Lerner, M. D., & Keeley, L. M.
(SHAPS). Journal of Affective Disorders, 99(1–3), 83–89. https://doi.org/10.1016/j. (2019). The work and social adjustment scale for youth: A measure for assessing
jad.2006.08.020 youth psychosocial impairment regardless of mental health status. Journal of Child
Fuhrmann, D., Knoll, L. J., & Blakemore, S.-J. (2015). Adolescence as a sensitive period and Family Studies, 28(1), 1–16. https://doi.org/10.1007/s10826-018-1238-6
of brain development. Trends in Cognitive Sciences, 19(10), 558–566. https://doi.org/ Manolov, R., & Moeyaert, M. (2017). Recommendations for choosing single-case data
10.1016/j.tics.2015.07.008 analytical techniques. Behavior Therapy, 48(1), 97–114. https://doi.org/10.1016/j.
Gabbay, V., Johnson, A. R., Alonso, C. M., Evans, L. K., Babb, J. S., & Klein, R. G. (2015). beth.2016.04.008
Anhedonia, but not irritability, is associated with illness severity outcomes in Manos, R. C., Kanter, J. W., & Luo, W. (2011). The behavioral activation for depression
adolescent major depression. Journal of Child and Adolescent Psychopharmacology, 25 scale-short form: Development and validation. Behavior Therapy, 42(4), 726–739.
(3), 194–200. https://doi.org/10.1089/cap.2014.0105 https://doi.org/10.1016/j.beth.2011.04.004
Gloster, A. T., Walder, N., Levin, M. E., Twohig, M. P., & Karekla, M. (2020). The Mars, B., Gibson, J., Dunn, B. D., Gordon, C., Heron, J., Kessler, D., et al. (2021).
empirical status of acceptance and commitment therapy: A review of meta-analyses. Personality difficulties and response to community-based psychological treatment
Journal of Contextual Behavioral Science, 18, 181–192. https://doi.org/10.1016/j. for anxiety and depression. Journal of Affective Disorders, 279, 266–273. https://doi.
jcbs.2020.09.009 org/10.1016/j.jad.2020.09.115
Goodwin, R. D., Dierker, L. C., Wu, M., Galea, S., Hoven, C. W., & Weinberger, A. H. Mbuagbaw, L., Kosa, S. D., Lawson, D. O., Stalteri, R., Olaiya, O. R., Alotaibi, A., et al.
(2022). Trends in U.S. Depression prevalence from 2015 to 2020: The widening (2019). The reporting of progression criteria in protocols of pilot trials designed to
treatment gap. American Journal of Preventive Medicine, 63(5), 726–733. https://doi. assess the feasibility of main trials is insufficient: A meta-epidemiological study. Pilot
org/10.1016/j.amepre.2022.05.014 and feasibility studies, 5, 120. https://doi.org/10.1186/s40814-019-0500-z
Goodyer, I. M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., Hill, J., et al. (2017). McGorry, P. D., Mei, C., Chanen, A., Hodges, C., Alvarez-Jimenez, M., & Killackey, E.
Cognitive behavioural therapy and short-term psychoanalytical psychotherapy (2022). Designing and scaling up integrated youth mental health care. World
versus a brief psychosocial intervention in adolescents with unipolar major Psychiatry, 21(1), 61–76. https://doi.org/10.1002/wps.20938
depressive disorder (IMPACT): A multicentre, pragmatic, observer-blind, McKinlay, A. R., May, T., Dawes, J., Fancourt, D., & Burton, A. (2022). ’You’re just there,
randomised controlled superiority trial. The Lancet Psychiatry, 4(2), 109–119. alone in your room with your thoughts’: A qualitative study about the psychosocial
https://doi.org/10.1016/S2215-0366(16)30378-9 impact of the COVID-19 pandemic among young people living in the UK. BMJ Open,
Gorwood, P., Rouillon, F., Even, C., Falissard, B., Corruble, E., & Moran, P. (2010). 12(2), Article e053676. https://doi.org/10.1136/bmjopen-2021-053676
Treatment response in major depression: Effects of personality dysfunction and prior Medina, J. C., Paz, C., Garcia-Mieres, H., Nino-Robles, N., Herrera, J. E., Feixas, G., et al.
depression. British Journal of Psychiatry, 196(2), 139–142. https://doi.org/10.1192/ (2022). Efficacy of psychological interventions for young adults with mild-to-
bjp.bp.109.067058 moderate depressive symptoms: A meta-analysis. Journal of Psychiatric Research, 152,
He, J., Lin, J., Sun, W., Cheung, T., Cao, Y., Fu, E., et al. (2023). The effects of 366–374. https://doi.org/10.1016/j.jpsychires.2022.06.034
psychosocial and behavioral interventions on depressive and anxiety symptoms Meyer, A. E., & Curry, J. F. (2021). Moderators of treatment for adolescent depression.
during the COVID-19 pandemic: A systematic review and meta-analysis. Scientific Journal of Clinical Child and Adolescent Psychology, 50(4), 486–497. https://doi.org/
Reports, 13(1), Article 19094. https://doi.org/10.1038/s41598-023-45839-0 10.1080/15374416.2020.1796683
Hetrick, S. E., Bailey, A. P., Smith, K. E., Malla, A., Mathias, S., Singh, S. P., et al. (2017). Morgan, J. K., Olino, T. M., McMakin, D. L., Ryan, N. D., & Forbes, E. E. (2013). Neural
Integrated (one-stop shop) youth health care: Best available evidence and future response to reward as a predictor of increases in depressive symptoms in
directions. Medical Journal of Australia, 207(10), S5–S18. https://doi.org/10.5694/ adolescence. Neurobiology of Disease, 52, 66–74. https://doi.org/10.1016/j.
mja17.00694 nbd.2012.03.039
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to Morley, S. (2018). Single-case methods in clinical psychology: A practical guide. Routledge/
defining meaningful change in psychotherapy research. Journal of Consulting and Taylor & Francis Group.
Clinical Psychology, 59(1), 12–19. https://doi.org/10.1037/0022-006X.59.1.12 Niedzwiedz, C. L., Benzeval, M., Hainey, K., Leyland, A. H., & Katikireddi, S. V. (2021).
Judd, L. L. (1997). The clinical course of unipolar major depressive disorders. Archives of Psychological distress among people with probable COVID-19 infection: Analysis of
General Psychiatry, 54(11), 989–991. https://doi.org/10.1001/ the UK household longitudinal study. BJPsych Open, 7(3), e104. https://doi.org/
archpsyc.1997.01830230015002 10.1192/bjo.2021.63
Kazdin, A. E. (2011). Single-case research designs: Methods for clinical and applied settings O’Connor, R. C., Wetherall, K., Cleare, S., McClelland, H., Melson, A. J.,
(2nd ed.). Oxford University Press. Niedzwiedz, C. L., et al. (2021). Mental health and well-being during the COVID-19
Keenan-Miller, D., Hammen, C. L., & Brennan, P. A. (2007). Health outcomes related to pandemic: Longitudinal analyses of adults in the UK COVID-19 mental health &
early adolescent depression. Journal of Adolescent Health, 41(3), 256–262. https:// wellbeing study. British Journal of Psychiatry, 218(6), 326–333. https://doi.org/
doi.org/10.1016/j.jadohealth.2007.03.015 10.1192/bjp.2020.212
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., et al. Orchard, F., Pass, L., Marshall, T., & Reynolds, S. (2017). Clinical characteristics of
(2003). The epidemiology of major depressive disorder: Results from the national adolescents referred for treatment of depressive disorders. Child and Adolescent
comorbidity survey replication (NCS-R). JAMA, 289(23), 3095–3105. https://doi. Mental Health, 22(2), 61–68. https://doi.org/10.1111/camh.12178
org/10.1001/jama.289.23.3095 Parry, G. D., Crawford, M. J., & Duggan, C. (2016). Iatrogenic harm from psychological
Konig, H., Konig, H. H., & Konnopka, A. (2019). The excess costs of depression: A therapies–time to move on. The British Journal of Psychiatry: The Journal of Mental
systematic review and meta-analysis. Epidemiology and Psychiatric Sciences, 29, e30. Science, 208(3), 210–212. https://doi.org/10.1192/bjp.bp.115.163618
https://doi.org/10.1017/S2045796019000180 Patton, G. C., Sawyer, S. M., Santelli, J. S., Ross, D. A., Afifi, R., Allen, N. B., et al. (2016).
Kraiss, J. T., Kohlhoff, M., & Ten Klooster, P. M. (2022). Disentangling between- and Our future: A Lancet commission on adolescent health and wellbeing. The Lancet
within-person associations of psychological distress and mental well-being: An Psychiatry, 387(10036), 2423–2478. https://doi.org/10.1016/S0140-6736(16)
experience sampling study examining the dual continua model of mental health 00579-1
among university students. Current Psychology, 1–12. https://doi.org/10.1007/ Pearcey, S., Burgess, L., Shum, A., Sajid, E., Sargent, M., Klampe, M.-L., et al. (2023).
s12144-022-02942-1 How the COVID-19 pandemic affected young people’s mental health and wellbeing
Kratochwill, T. R., Hitchcock, J. H., Horner, R. H., Levin, J. R., Odom, S. L., in the UK: A qualitative study. Journal of Adolescent Research, 0(0), Article
Rindskopf, D. M., et al. (2013). Single-case intervention research design standards. 07435584231151902. https://doi.org/10.1177/07435584231151902
Remedial and Special Education, 34(1), 26–38. https://doi.org/10.1177/ Pierce, M., McManus, S., Hope, H., Hotopf, M., Ford, T., Hatch, S. L., et al. (2021). Mental
0741932512452794 health responses to the COVID-19 pandemic: A latent class trajectory analysis using
Krause, K. R., Edbrooke-Childs, J., Bear, H. A., Calderon, A., & Wolpert, M. (2023). What longitudinal UK data. The Lancet Psychiatry, 8(7), 610–619. https://doi.org/
treatment outcomes matter most? A Q-study of outcome priority profiles among 10.1016/S2215-0366(21)00151-6

14
J. Carson et al. Behaviour Research and Therapy 183 (2024) 104646

Rowthorn, M. J., Billington, D. R., Krageloh, C. U., Landon, J., & Medvedev, O. N. (2019). United Kingdom: A systematic review and meta-analysis of 10-years of practice-
Development of a mental health recovery module for the WHOQOL. Quality of Life based evidence. British Journal of Clinical Psychology, 60(1), 1–37. https://doi.org/
Research, 28(12), 3363–3374. https://doi.org/10.1007/s11136-019-02265-y 10.1111/bjc.12259
Ryff, C. D., & Keyes, C. L. (1995). The structure of psychological well-being revisited. Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief
Journal of Personality and Social Psychology, 69(4), 719–727. https://doi.org/ measures of positive and negative affect: The PANAS scales. Journal of Personality
10.1037//0022-3514.69.4.719 and Social Psychology, 54(6), 1063–1070. https://doi.org/10.1037//0022-
Sandman, C. F., & Craske, M. G. (2022). Psychological treatments for anhedonia. Current 3514.54.6.1063
Topics in Behavioral Neurosciences, 58, 491–513. https://doi.org/10.1007/7854_ Watson, R., Harvey, K., Pass, L., McCabe, C., & Reynolds, S. (2021). A qualitative study
2021_291 exploring adolescents’ experience of brief behavioural activation for depression and
Shah, N., Cader, M., Andrews, B., McCabe, R., & Stewart-Brown, S. L. (2021). Short its impact on the symptom of anhedonia. Psychology and Psychotherapy, 94(2),
warwick-edinburgh mental well-being scale (SWEMWBS): Performance in a clinical 266–288. https://doi.org/10.1111/papt.12307
sample in relation to PHQ-9 and GAD-7. Health and Quality of Life Outcomes, 19(1), Webb, C. A., Murray, L., Tierney, A. O., Forbes, E. E., & Pizzagalli, D. A. (2023). Reward-
260. https://doi.org/10.1186/s12955-021-01882-x related predictors of symptom change in behavioral activation therapy for anhedonic
Smith, J. D. (2012). Single-case experimental designs: A systematic review of published adolescents: A multimodal approach. Neuropsychopharmacology, 48(4), 623–632.
research and current standards. Psychological Methods, 17(4), 510–550. https://doi. https://doi.org/10.1038/s41386-022-01481-4
org/10.1037/a0029312 Webb, C. A., Murray, L., Tierney, A. O., & Gates, K. M. (2023). Dynamic processes in
Snaith, R. P., Hamilton, M., Morley, S., Humayan, A., Hargreaves, D., & Trigwell, P. behavioral activation therapy for anhedonic adolescents: Modeling common and
(1995). A scale for the assessment of hedonic tone the Snaith-Hamilton Pleasure patient-specific relations. Journal of Consulting and Clinical Psychology. https://doi.
Scale. British Journal of Psychiatry, 167(1), 99–103. https://doi.org/10.1192/ org/10.1037/ccp0000830
bjp.167.1.99 Westerhof, G. J., & Keyes, C. L. (2010). Mental illness and mental health: The two
Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for continua model across the lifespan. Journal of Adult Development, 17(2), 110–119.
assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166 https://doi.org/10.1007/s10804-009-9082-y
(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092 Wichers, R. H., van der Wouw, L. C., Brouwer, M. E., Lok, A., & Bockting, C. L. H. (2023).
Tate, R. L., Perdices, M., Rosenkoetter, U., Shadish, W., Vohra, S., Barlow, D. H., et al. Psychotherapy for co-occurring symptoms of depression, anxiety and obsessive-
(2016). The single-case reporting guideline in BEhavioural interventions (SCRIBE) compulsive disorder in children and adults with autism spectrum disorder: A
2016 statement. Physical Therapy, 96(7), e1–e10. https://doi.org/10.2522/ systematic review and meta-analysis. Psychological Medicine, 53(1), 17–33. https://
ptj.2016.96.7.e1 doi.org/10.1017/S0033291722003415
Tennant, R., Hiller, L., Fishwick, R., Platt, S., Joseph, S., Weich, S., et al. (2007). The Wickersham, A., Sugg, H. V. R., Epstein, S., Stewart, R., Ford, T., & Downs, J. (2021).
warwick-edinburgh mental well-being scale (WEMWBS): Development and UK Systematic review and meta-analysis: The association between child and adolescent
validation. Health and Quality of Life Outcomes, 5, 63. https://doi.org/10.1186/1477- depression and later educational attainment. Journal of the American Academy of
7525-5-63 Child & Adolescent Psychiatry, 60(1), 105–118. https://doi.org/10.1016/j.
Thabane, L., Ma, J., Chu, R., Cheng, J., Ismaila, A., Rios, L. P., et al. (2010). A tutorial on jaac.2020.10.008
pilot studies: The what, why and how. BMC Medical Research Methodology, 10, 1. Widnall, E., Price, A., Trompetter, H., & Dunn, B. D. (2020). Routine cognitive
https://doi.org/10.1186/1471-2288-10-1 behavioural therapy for anxiety and depression is more effective at repairing
Thapar, A., Eyre, O., Patel, V., & Brent, D. (2022). Depression in young people. Lancet, symptoms of psychopathology than enhancing wellbeing. Cognitive Therapy and
400(10352), 617–631. https://doi.org/10.1016/S0140-6736(22)01012-1 Research, 44(1), 28–39. https://doi.org/10.1007/s10608-019-10041-y
Thompson, E. R. (2007). Development and validation of an internationally reliable short- Wilson, S., & Dumornay, N. M. (2022). Rising rates of adolescent depression in the
form of the positive and negative affect schedule (PANAS). Journal of Cross-Cultural United States: Challenges and opportunities in the 2020s. Journal of Adolescent
Psychology, 38(2), 227–242. https://doi.org/10.1177/0022022106297301 Health, 70(3), 354–355. https://doi.org/10.1016/j.jadohealth.2021.12.003
Thorpe, W. J. R., & Gutman, L. M. (2022). The trajectory of mental health problems for Zautra, A. J., Affleck, G. G., Tennen, H., Reich, J. W., & Davis, M. C. (2005). Dynamic
UK emerging adults during COVID-19. Journal of Psychiatric Research, 156, 491–497. approaches to emotions and stress in everyday life: Bolger and Zuckerman reloaded
https://doi.org/10.1016/j.jpsychires.2022.10.068 with positive as well as negative affects. Journal of Personality, 73(6), 1511–1538.
Verbist, I. L., Fabian, H., Huey, D., Brooks, H., Lovell, K., & Blakemore, A. (2024). https://doi.org/10.1111/j.0022-3506.2005.00357.x
Exploring access and engagement with improving access to psychological therapies
(IAPT) services, before, during, and after the COVID-19 lockdown: A service
evaluation in the northwest of england. Psychotherapy Research, 34(2), 216–227. Web References
https://doi.org/10.1080/10503307.2023.2184285
Wakefield, S., Kellett, S., Simmonds-Buckley, M., Stockton, D., Bradbury, A., & R Core Team. (2021). R: A language and environment for statistical computing. Vienna,
Delgadillo, J. (2021). Improving access to psychological therapies (iapt) in the Austria: R Foundation for Statistical Computing. URL https://www.R-project.org/.

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