Psychological therapies for anxiety and depression in children and adolescents with long-term physical conditions

Rationale and design of a systematic review: effectiveness and acceptance of technology-based psychological interventions in different clinical phases of depression management

INTRODUCTION

Although many effective treatment options exist, depression is still undertreated indicating gaps in the healthcare system. The complementary provision of mental healthcare through technologies (eg, computer, smartphone) has the potential to fill treatment gaps and to overcome access barriers to mental healthcare. Until now, no systematic review integrates the evidence on different technology-based psychological interventions (TBIs) concerning their effectiveness and acceptance in different clinical phases of depression management (bridging waiting periods, acute treatment and aftercare). The aim of this project is to structure evidence on TBIs regarding different phases of depression management, and to determine effectiveness and acceptance for each clinical phase considering both active (eg, face-to-face treatment) and inactive (eg, waitlist) controls as comparators.

METHODS AND ANALYSIS

We will include studies on adults with a formal diagnosis of unipolar depression. Treatments delivered by technologies based on scientific psychological theories will be considered as experimental interventions. The primary effectiveness outcome will be depressive symptoms at study endpoint measured by symptom severity rating scales, and the primary acceptance outcome will be dropping out of the study due to any reason. We will consider only randomised controlled trials, which will be identified by key database searches (including Cochrane Central Register of Controlled Trials, Medline, PsycINFO, PSYNDEX, CINAHL) complemented through searches in clinical trial registries (eg, clinicaltrials.gov) and grey literature searches (eg, Open Grey). Two review authors will independently conduct study selection, data extraction and quality assessment of included studies (using the Cochrane Collaboration's tool for assessing risk of bias). Meta-analyses applying random-effect models as well as subgroup, meta-regression and sensitivity analyses will be performed.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study, as we conduct research on secondary data. We will disseminate results via peer-reviewed journal publications, presentations on conferences and via plain language summaries.

PROSPERO REGISTRATION NUMBER

CRD42016050413; Pre-results.

Behavioral activation for children and adolescents: a systematic review of progress and promise

Behavioral activation (BA) effectively treats depression in adults, and shows promise in treating anxiety. Research into its application to children and adolescents is emerging. This review aimed to explore the scope of studies, current evidence of effectiveness and how the intervention has been delivered and adapted, to inform future research. A systematic review was undertaken searching PsycInfo, PubMed including Medline, EMBASE, and Scopus for terms relating to BA and children and adolescents. Two researchers scored abstracts for inclusion. Data extraction was completed by one researcher and checked by another. 19 studies were identified, across 21 published articles. 12 were case studies, with three pre-post pilot designs and four randomized-controlled trials. Case studies found early support for the feasibility and potential effectiveness of BA to address both anxiety and depression. The RCTs reported largely positive outcomes. Meta-analysis of depression scores indicated that BA may be effective; however, high heterogeneity was observed. Sample sizes to date have been small. BA has been delivered by trained therapists, doctoral trainee psychologists, social workers, or psychology graduates. Studies are uniquely in high-income settings. Adaptations include flexibility in content delivery, youth friendly materials, and parental involvement. There is some limited evidence to support BA as effective for young people. Feasibility and acceptability are supported. Fully powered trials are now required, with expansion to delivery in low- and middle-income settings, and detailed consideration of implementation issues that consider culture and environment.

E-Health interventions for anxiety and depression in children and adolescents with long-term physical conditions

BACKGROUND

Long-term physical conditions affect 10% to 12% of children and adolescents worldwide; these individuals are at greater risk of developing psychological problems, particularly anxiety and depression. Access to face-to-face treatment for such problems is often limited, and available interventions usually have not been tested with this population. As technology improves, e-health interventions (delivered via digital means, such as computers and smart phones and ranging from simple text-based programmes through to multimedia and interactive programmes, serious games, virtual reality and biofeedback programmes) offer a potential solution to address the psychological needs of this group of young people.

OBJECTIVES

To assess the effectiveness of e-health interventions in comparison with attention placebos, psychological placebos, treatment as usual, waiting-list controls, or non-psychological treatments for treating anxiety and depression in children and adolescents with long-term physical conditions.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group's Controlled Trials Register (CCMDTR to May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 8, 2017), Web of Science (1900 - 18 August 2016, updated 31 August 2017) and Ovid MEDLINE, Embase, PsycINFO (cross-search 2016 to 18 Aug 2017). We hand-searched relevant conference proceedings, reference lists of included articles, and the grey literature to May 2016. We also searched international trial registries to identify unpublished or ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised trials, and cross-over trials of e-health interventions for treating any type of long-term physical condition in children and adolescents (aged 0 to 18 years), and that measured changes in symptoms or diagnoses of anxiety, depression, or subthreshold depression. We defined long-term physical conditions as those that were more than three-months' duration. We assessed symptoms of anxiety and depression using patient- or clinician-administered validated rating scales based on DSM III, IV or 5 (American Psychological Association 2013), or ICD 9 or 10 criteria (World Health Organization 1992). Formal depressive and anxiety disorders were diagnosed using structured clinical interviews. Attention placebo, treatment as usual, waiting list, psychological placebo, and other non-psychological therapies were eligible comparators.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed titles, abstracts, and full-text articles; discrepancies were resolved through discussion or addressed by a third author. When available, we used odds ratio (OR) to compare dichotomous data and standardised mean differences (SMD) to analyse continuous data, both with 95% confidence intervals (CI). We undertook meta-analysis when treatments, participants, and the underlying clinical question were adequately similar. Otherwise, we undertook a narrative analysis.

MAIN RESULTS

We included five trials of three interventions (Breathe Easier Online, Web-MAP, and multimodal cognitive behavioural therapy (CBT)), which included 463 participants aged 10 to 18 years. Each trial contributed to at least one meta-analysis. Trials involved children and adolescents with long-term physical conditions, such as chronic headache (migraine, tension headache, and others), chronic pain conditions (abdominal, musculoskeletal, and others), chronic respiratory illness (asthma, cystic fibrosis, and others), and symptoms of anxiety or depression. Participants were recruited from community settings and hospital clinics in high income countries.For the primary outcome of change in depression symptoms versus any control, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.06, 95% CI -0.35 to 0.23; five RCTs, 441 participants). For the primary outcome of change in anxiety symptoms versus any comparator, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.07, 95% CI -0.29 to 0.14; two RCTs, 324 participants). For the primary outcome of treatment acceptability, there was very low-quality evidence that e-health interventions were less acceptable than any comparator (SMD 0.46, 95% CI 0.23 to 0.69; two RCTs, 304 participants).For the secondary outcome of quality of life, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.83, 95% CI -1.53 to -0.12; one RCT, 34 participants). For the secondary outcome of functioning, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.08, 95% CI -0.33 to 0.18; three RCTs, 368 participants). For the secondary outcome of status of long-term physical condition, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD 0.06, 95% CI -0.12 to 0.24; five RCTs, 463 participants).The risk of selection bias was considered low in most trials. However, the risk of bias due to inadequate blinding of participants or outcome assessors was considered unclear or high in all trials. Only one study had a published protocol; two trials had incomplete outcome data. All trials were conducted by the intervention developers, introducing another possible bias. No adverse effects were reported by any authors.

AUTHORS' CONCLUSIONS

At present, the field of e-health interventions for the treatment of anxiety or depression in children and adolescents with long-term physical conditions is limited to five low quality trials. The very low-quality of the evidence means the effects of e-health interventions are uncertain at this time, especially in children aged under 10 years.Although it is too early to recommend e-health interventions for this clinical population, given their growing number, and the global improvement in access to technology, there appears to be room for the development and evaluation of acceptable and effective technologically-based treatments to suit children and adolescents with long-term physical conditions.