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Review
. 2023 Dec;64(12):1720-1734.
doi: 10.1111/jcpp.13820. Epub 2023 May 24.

Research Review: The internalizing paradox - youth anxiety and depression symptoms, psychotherapy outcomes, and implications for research and practice

John R Weisz  1 , Olivia M Fitzpatrick  1 , Katherine E Venturo-Conerly  1 , Ariel Sternberg  1 , Joshua S Steinberg  1 , Mei Yi Ng  2
Affiliations
Review

Research Review: The internalizing paradox - youth anxiety and depression symptoms, psychotherapy outcomes, and implications for research and practice

John R Weisz et al. J Child Psychol Psychiatry. 2023 Dec.

Abstract

Background: Youth anxiety and depression have long been combined within the empirically derived internalizing syndrome. The two conditions show substantial comorbidity, symptom co-occurrence, and overlap in treatment procedures, but paradoxically diverge in psychotherapy outcomes: strong, positive effects for anxiety and weak effects for depression.

Methods: Drawing on recent research, we examine candidate explanations for this paradox to help identify strategies for addressing it by improving outcomes for youth depression.

Results: Candidate explanations include that youth depression, compared with youth anxiety, has more varied comorbidities and more heterogeneous symptom combinations, has greater uncertainty regarding mediators and mechanisms of change, is treated with more complex and potentially confusing protocols, and has characteristics that may impede client engagement. Candidate strategies for shrinking the psychotherapy effectiveness gap include personalizing through transdiagnostic modular treatment, simplifying therapy by focusing on empirically supported principles of change, developing effective strategies for engaging family members as intervention allies, using shared decision-making to inform clinical decisions and boost client engagement, capitalizing on youth-friendly technological advances, and shortening and digitizing treatments to enhance their accessibility and appeal.

Conclusions: Recent advances suggest explanations for the internalizing paradox, which in turn suggest strategies for shrinking the youth anxiety-depression psychotherapy outcome gap; these form an agenda for a promising new era of research.

Keywords: Children; adolescents; anxiety; depression; internalizing; psychotherapy; youth.

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Conflict of interest statement

Conflict of interest statement: See Acknowledgements for full disclosures.

Figures

Figure 1.
Figure 1.
Practice elements identified by Chorpita and Daleiden (2009) for empirically tested psychotherapies for youth anxiety and youth depression. Reprinted with permission, American Psychological Association.
Figure 2.
Figure 2.
Estimated change in mean effect size over time for treatment of (a) anxiety and (b) depression. The lines indicate the mean Hedges’ g, and the blue shading around lines represents the 95% confidence interval. There was no significant change in mean effects across the years for anxiety, but there was a significant decline for depression. From Weisz, Kuppens, et al. (2019). Reprinted with permission, Association for Psychological Science.
See this image and copyright information in PMC

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