Autobiographical Memory-Based Intervention for Depressive Symptoms in Young Adults: A Randomized Controlled Trial of Cognitive-Reminiscence Therapy

Increasingly, research indicates that therapies that target the recall of autobiographical memories as the core foci of interest have promise in the treatment of depression [1]. The integration of reminiscence and cognitive psychotherapies has led to the development of cognitive-reminiscence therapy (CRT) [2], an effective treatment for depression in older adults [3]. In CRT, individuals engage in two kinds of reminiscence: integrative reminiscence, involving the identification of continuity and meaning across experiences and reconciliation of past negative events, and instrumental reminiscence, involving the recollection of past coping and problem-solving experiences to enhance self-efficacy and perceived control, and to draw on past solutions to problems. Across a series of sessions focusing on different domains in life (e.g. turning points, stressful experiences, etc.), therapists draw on both of the following: (1) cognitive models of depression and cognitive therapy techniques and (2) stress and coping models of depression and problem-solving techniques to guide the reminiscence activities.Although reminiscence therapies have been empirically validated almost exclusively in older adult populations, in a recent review [4] we argued that they are likely to be equally beneficial for depressed younger adults. This is supported by studies with young adults indicating that adaptive reminiscence is associated with decreases in depressive symptoms [5], and brief reminiscence activities have positive effects on self-concept, affect and psychological resources [6].The current study is the first to examine CRT, and reminiscence therapies generally, for treating depression in young adults. The primary outcome was depressive symptoms. Secondary outcomes were anxiety and psychological variables proposed to be mediating variables in CRT [2]. Ethics approval was obtained from the university human research ethics committee. Twenty-six young adults were recruited from a community youth mental health service for 12- to 25-year-olds and randomized, by parties external to the study, to receive CRT or usual care (see fig. 1 for participant flowchart). The inclusion and exclusion criteria were as follows: (1) 18 years or over; (2) primary presenting problem of depressive symptoms, and at least moderately elevated symptoms as indicated by a score of 7 or higher on the depression subscale of the Depression, Anxiety and Stress Scale 21-item short-form [7]; (3) not receiving treatment for depression (except for antidepressant medication stabilized for at least 6 weeks); (4) not at high risk of suicide or harm to others, or having co-morbid psychotic or manic symptoms, or intellectual disability. At pre-intervention, 3 weeks, post-intervention and at the 1- and 3-month follow-up, participants completed the depression and anxiety subscales from the Depression, Anxiety and Stress Scale short-form, the Rosenberg Self-Esteem Scale, the New General Self-Efficacy Scale, the presence subscale of the Meaning in Life Questionnaire, and a 3-item version of The Life Orientation Test - revised. Participants completed all measures by logging onto a specially developed online portal.Participants in the CRT group received 6 weekly sessions of individual, face-to-face manualized CRT. The CRT manual was derived from a previously validated protocol [3] but adapted to combine integrative and instrumental reminiscence, be individual rather than group based, have age-appropriate and psychosocially relevant content for young adults, and have more specificity in therapeutic techniques based on recent research on mediators of change in reminiscence-based therapy [5]. The manual is available upon request from the first author. The therapist for the CRT group was the first author, who at the time was a registered provisional psychologist undertaking doctoral-level training in clinical psychology. An adherence checklist of the components of CRT completed after each session showed 100% adherence, except for brief structured problem-solving therapy which was used in only 85.7% of the required sessions due to time constraints. Further details of the therapy and study protocol have been published elsewhere [8]. Participants in the usual care group (n = 12) were allocated to a registered mental health professional in the service for brief (usually 6-10 sessions) evidence-based psychotherapy; 8 participants received a cognitive-behavioural intervention (such as cognitive therapy, acceptance and commitment therapy, or problem-solving therapy), and 4 received supportive counselling.Linear mixed models with restricted maximum-likelihood estimation were conducted to assess for effects. The data were analysed using an intention-to-treat approach. Fixed effects of group, time and interaction were modelled, and an unstructured residual covariance matrix was used to allow for random effects within participants between the repeated measures over time. Planned paired sample t tests were conducted to assess changes between time points. An alpha level of 0.01 was used for the t tests to lower the risk of type 1 errors. A reliable change index was also used to assess change in depressive symptoms [9].χ2 and t tests showed that the groups did not significantly differ on demographic characteristics or the number of therapy sessions they received from pre-intervention to follow-up (p > 0.05). The mean age was 20.8 years (SD = 1.9), 50% were female, 54% were currently studying, 61.5% were employed, and 50% had received previous support for depression. Participants had an average of 6.3 (SD = 2.3) sessions from baseline to 3-month follow-up. One participant in each group entered the study on a stabilized antidepressant treatment.Table 1 shows descriptive statistics for outcome measures and results of all linear mixed models. For depressive symptoms, there was an effect for group and time, but not for interaction. Follow-up t tests showed large effects on depressive symptoms in the CRT group at the 6-week and 3-month follow-up, but no significant differences over time in the usual care group. At 6 weeks, 86% of the participants in the CRT group reported a reliable improvement in depressive symptoms, 7% showed no change, and 7% had deteriorated. In the usual care group, 50% had improved, 37.5% showed no change, and 12.5% had deteriorated. At the 3-month follow-up, 77% of the participants in the CRT had reliably improved and 23% showed no reliable change. In the usual care group 67% reported reliable improvements, 22% stayed the same, and 11% deteriorated.For secondary outcomes, there were main effects for time on all measures, effects for group on anxiety, self-esteem and self-efficacy, and interaction effects on anxiety, self-esteem and meaning in life. Follow-up t tests showed large effects from baseline to the 6-week time point on all outcome measures in the CRT group, which were maintained at the 3-month follow-up, with the exception of anxiety symptoms. In the usual care group the only significant effect was on optimism at the 6-week time point, which was not maintained at follow-up.The results show that individually administered CRT had large effects on depressive symptoms, which were manifest immediately following the final session, and maintained after 3 months. On secondary outcomes, large effects were found and maintained at follow-up. These findings provide evidence that guided reviewing of autobiographical memory with young adults has effects on a range of psychological resources: self-worth, confidence in the capacity to achieve goals and cope with challenges, the perception of meaning in one's life, and a positive future orientation. These findings are novel in providing preliminary evidence that this intervention approach is feasible and effective for young adults. The brevity of this therapeutic intervention is advantageous. On the basis of these findings, an expanded randomized controlled trial of CRT for depression in young adults appears warranted.There are limitations to this study, inherent in its pilot nature. The small sample size limits the generalizability and the statistical power to detect anything but large differences. A diagnostic assessment for depression was not conducted. Future studies might compare CRT to other efficacious psychological treatments for young adult populations, such as behavioural activation or problem-solving therapy, and also account for other factors such as therapeutic alliance, allegiance effects, and perceived credibility and treatment expectancies. Mediation analyses were not conducted due to the small sample size, and future research may clarify whether changes in the secondary outcomes mediate later changes in depressive symptoms. While preliminary in nature, the finding of effects on anxiety are suggestive of the transdiagnostic utility of CRT, and this might be examined in more detail. Further, examining whether changes in memory specificity might act as another mechanism of depression reduction [10] is warranted.The authors would like to thank Luke Barisic for his assistance with the online survey methodology.The authors have no conflicts of interest to declare.