Treatment and Prevention of Depression and Anxiety in Youth: Test of Cross-Over Effects

Serial multiple mediating roles of anxiety and thyroid-stimulating hormone in the relationship between depression and psychotic symptoms in young adults with anxious depression

BACKGROUND

Psychotic symptoms (PS) frequently occur in young adults with anxious depression (AD), yet the mediators of the associations between depression and PS remain unclear. This study aimed to investigate the prevalence and risk factors of PS in first-episode and drug-naïve (FEDN) young adults with AD and attempted to elucidate the relationship between thyroid-stimulating hormone (TSH) levels, anxiety, depression, and PS, as well as to identify potential mediating roles.

METHODS

369 FEDN young adults with AD were recruited. Clinical symptoms were assessed using the Positive and Negative Syndrome Scale's positive subscale, the Hamilton Depression Rating Scale (HAMD), and the Hamilton Anxiety Rating Scale (HAMA). Fasting glucose, lipids, and thyroid function were also collected.

RESULTS

The prevalence of PS in young adults with AD (21.68 %) was 12.24 times higher than in non-AD patients. The HAMD scores (P = 0.005, OR = 1.23), HAMA scores (P < 0.001, OR = 1.62), and TSH levels (P = 0.025, OR = 1.20) were significant predictors of PS. The combined area under the curve value for distinguishing young adults with AD with and without PS was 0.86. We also identified serial multiple mediating effects of TSH levels and anxiety on the association of depression with PS.

CONCLUSIONS

These findings emphasize the role of anxiety and TSH levels as serial mediators of the association between depression and PS. Therefore, when treating PS in young adults with AD, it is important to focus not only on depression, but also on TSH levels and anxiety to maximize benefit.

Treating Emotional Disorders in Spanish Children: A Controlled Randomized Trial in a Clinical Setting

Super Skills for Life (SSL) is a CBT-transdiagnostic group intervention currently being translated and validated in multiple countries. In Spanish children, it has shown a positive impact on anxious and depressive symptoms, as well as other variables such as self-concept, prosocial behaviors, or behavioral problems. However, the effectiveness of the program to treat internalizing symptoms in children with a mental disorder in a clinical setting has not been examined so far. The aim of this study was to evaluate the effectiveness of SSL in a Spanish sample of children with a major internalizing disorder. Participants aged 8-12 years (71.6% boys) were randomly allocated to the SSL group (n = 43) or the waiting list control (WLC) group (n = 43). All children and their parents completed a series of measures before the first session and after the last session or at about the same time in the WLC group. The effectiveness of the intervention was assessed using generalized estimating equations. Significant reductions from pretest to posttest across multiple outcomes were found in children who participated in SSL group compared to those in the WLC group, including anxiety symptoms (SCAS, p = .02), anxiety interference (CALIS, p = .002), depressive symptoms (CDI, p = .033) and remission from diagnosis (K-SADS, p < .001). This study provides initial support for SSL as an effective treatment for children with emotional disorders in clinical settings. Future studies are needed to analyze long-term effects and broader benefits of the program in clinical contexts.

Psychological Capital and Its Factors as Mediators Between Interpersonal Sensitivity and Depressive Symptoms Among Chinese Undergraduates

Purpose

Current interpersonal sensitivity among college students is easily linked to mood disorders such as anxiety, depression and other mood disorders. This study aims to examine the mediating role of psychological capital and its dimensions in the relationship between interpersonal sensitivity and depressive symptoms among undergraduates.

Methods

The cross-sectional survey was conducted by using cluster stratified random sampling method across six Chinese universities between November and December 2022. The questionnaire consists of the Interpersonal Sensitivity sub-scale, the Patient Health Questionnaire, the Psychological Capital Questionnaire and the Socio-Demographic Feature Questionnaire.

Results

A total of 2580 respondents participated in the survey, with the majority being females (69.73%) and an average age of 19.22±1.28 years. Descriptive and correlation analyses were performed using SPSS v24.0, while direct and indirect effects were analyzed using PROCESS v3.4 macro. The findings revealed that interpersonal sensitivity had a significant direct effect on depression symptoms among undergraduates (β =0.416, 95% Boot CI [0.380, 0.453], p < 0.001) Additionally, psychological capital and its components were found to be negatively correlated with depression (p < 0.001). Further analysis demonstrated that hope, optimism, and resilience significantly mediated the association between interpersonal sensitivity and depressive symptoms (indirect effect: hope = 0.056, optimism = 0.074, resilience = 0.099; p < 0.001 for all).

Conclusion

These results suggest that psychological capital, including its dimensions of hope, optimism, and resilience plays a crucial role in mitigating the negative effects of interpersonal sensitivity on depressive symptoms among undergraduates.

The German version of the Revised Children's Anxiety and Depression Scale-Psychometric properties and normative data for German 8- to 17-year-olds

OBJECTIVES

Anxiety and depression are internalizing mental disorders often commencing in childhood and manifesting in adolescence. The Revised Anxiety and Depression Scale (RCADS) is an internationally widely used standardized diagnostic tool, but the German version has only been validated in a pediatric chronic pain sample; normative data are not available. The aim of this study is to test its reliability (internal consistency) and validity (factorial, convergent, known-groups) in a representative German school sample and to provide norm data.

METHODS

Data were collected from N = 1562 German schoolchildren (Mage  = 12.2; SDage  = 2.33; range 8-17 years; 52.4% girls).

RESULTS

Cronbach's α ranged from 0.73 to 0.96 for the total and the six subscales (five anxiety and one depression). Confirmatory factor analysis showed the 6-factor model had acceptable to good model fit with CFI = 0.93, TLI = 0.93, RMSEA = 0.05, SRMR = 0.05, which was better than 1- and 2-factor models. The (sub)scales correlated moderate to high negatively with health-related quality of life (-0.31 ≤ τ ≤ -0.51; p < 0.001) and positively with functional impairment (0.31 ≤ τ ≤ 0.48; p < 0.001). Mean scores of anxiety and depression scales were significantly higher in girls and partly in adolescents.

CONCLUSION

Findings provide support for the good psychometric properties of the German RCADS in a community sample.

Benefits of Super Skills for Life in a randomized controlled trial in clinical settings for Spanish children with comorbid conditions

Emotional disorders in children are often associated with low self-concept and problems with peers, and in many cases externalizing symptoms. Super Skills for Life (SSL) is a transdiagnostic treatment for emotional problems in children that has also shown benefits in other comorbid symptoms. This study aimed to examine, for the first time, the effect of SSL on a clinical sample of Spanish children aged 8-12 years with a major emotional disorder and comorbid externalizing symptoms and low self-concept. A quasi-experimental design with two groups, pretest and posttest, was carried out. Thirty-eight children received the SSL intervention, and 36 children were assigned to a wait-list control (WLC) group. Children in SSL showed statistically fewer posttest emotional symptoms (p < .001), peer problems (p = .002), and overall internalizing and externalizing difficulties (p = .005) compared to children in WLC, in addition to higher posttest self-concept (p = .002). There were no differences in the postinterventional changes between boys and girls in internalizing and externalizing symptoms. However, significant differences were found in some facets of self-concept. The results of this study suggest that the SSL protocol may be useful in Spanish clinical contexts. Still, more research is needed to overcome some of the inherent limitations.

Explaining reversal learning deficits in anxiety with electrophysiological evidence

Reversal learning is a crucial aspect of behavioral flexibility that plays a significant role in environmental adaptation and development. While previous studies have established a link between anxiety and impaired reversal learning ability, the underlying mechanisms behind this association remain unclear. This study employed a probabilistic reversal learning task with electroencephalographic recording to investigate these mechanisms. Participants were divided into two groups based on their scores on Spielberger's State-Trait Anxiety Inventory: high trait-anxiety (HTA) and low trait-anxiety (LTA), consisting of 50 individuals in each group. The results showed that the HTA group had poorer reversal learning performance than the LTA group, including a lower tendency to shift to the new optimal option after rule reversals (reversal-shift). The study also examined event-related potentials elicited by reversals and found that although the N1 (related to attention allocation), feedback-related negativity (FRN: related to belief updating), and P3 (related to response inhibition) were all sensitive to the grouping factor, only the FRN elicited by reversal-shift mediated the relationship between anxiety and the number/reaction time of reversal-shift. From these findings, we suggest that abnormalities in belief updating may contribute to the impaired reversal learning performance observed in anxious individuals. In our opinion, this study sheds light on potential targets for interventions aimed at improving behavioral flexibility in anxious individuals.

Mental health and unemployment: A systematic review and meta-analysis of interventions to improve depression and anxiety outcomes

BACKGROUND

Unemployment is associated with substantially greater depression and anxiety, constituting a considerable public health concern. The current review provides the most comprehensive synthesis to date, and first meta-analysis, of controlled intervention trials aimed at improving depression and anxiety outcomes during unemployment.

METHODS

Searches were conducted within PsycInfo, Cochrane Central, PubMed and Embase from their inception to September 2022. Included studies conducted controlled trials of interventions focused on improving mental health within unemployed samples, and reported on validated measures of depression, anxiety, or distress (mixed depression and anxiety). Narrative syntheses and random effects meta-analyses were conducted among prevention- and treatment-level interventions for each outcome.

RESULTS

A total of 39 articles reporting on 33 studies were included for review (sample sizes ranging from 21 to 1801). Both prevention and treatment interventions tended to be effective overall, with treatment interventions producing larger effect sizes than prevention interventions. The clearest evidence for particular intervention approaches emerged for prevention-level Cognitive Therapy/CBT, followed by prevention-level work-related interventions, although neither produced entirely consistent effects.

LIMITATIONS

Risk of bias was generally high across studies. Low numbers of studies within subgroups precluded any comparisons between long-term and short-term unemployment, limited comparisons among treatment studies, and reduced the power of meta-analyses.

CONCLUSIONS

Both prevention- and treatment-level mental health-focused interventions have merit for reducing symptoms of anxiety and depression among those experiencing unemployment. Cognitive Therapy/CBT and work-related interventions hold the most robust evidence base, which can inform both prevention and treatment strategies implemented by clinicians, employment services providers, and governments.

Reliability and validity of the Chinese version of the kiddie-schedule for affective disorders and schizophrenia-present and lifetime version DSM-5 (K-SADS-PL-C DSM-5)

BACKGROUND

As the Diagnostic and Statistical Manual of Mental Disorders fifth version (DSM-5) was published, the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL) was modified to adapt the new version (K-SADS-PL DSM-5). We translated it to Chinese (K-SADS-PL-C DSM-5) and described its reliability and validity.

METHODS

A total of 154 groups of 6 to 18-year-old children and their guardians were included. Trained interviewers interviewed subjects using the K-SADS-PL-C DSM-5. Interrater reliability was assessed by audio recording. Parent-reported scales, like child behavior checklist (CBCL), the Chinese version of Swan-son Nolan and Pelham, version IV scale-parent form (SNAP-IV), social responsiveness scale (SRS-1), and children-reported scales like depression self-rating scale for children (DSRSC) and the screen for child anxiety related emotional disorders (SCARED) were used to examine the validity of depressive disorder, ADHD, ASD, and ODD.

RESULTS

The K-SADS-PL-C DSM-5 had fair to excellent interrater (0.537-1.000) and test-retest (0.468-0.885) reliability of affective disorder and neurodevelopment disorder. The convergent validity of affective disorder and neurodevelopment disorder was good, and their divergent validity was acceptable.

LIMITATIONS

i) Clinical questionnaires were insensitive in classifying disorders and had limitations in derived diagnoses. ii) Samples only came from clinical environment, iii) covered limited disease species, and iv) were small.

CONCLUSION

The K-SADS-PL-C DSM-5 can support reliable and valid diagnoses for children with affect, neurodevelopmental, and behavioral disorders in China.

Nomogram reliability for predicting potential risk in postgraduate medical students with anxiety symptoms

Purpose

This research aims to develop a Nomogram for exact anxiety symptoms prediction in postgraduate medical students so that they may be identified as high-risk individuals early and get focused care.

Methods

Using a convenient sampling method, for case-control matching, 126 participants with anxiety symptoms and 774 participants of the same age and gender but without anxiety symptoms were designated as the case group and control group, respectively. Multivariable logistic regression analysis was utilized to identify influencing factors for anxiety symptoms, then used to design and verify a Nomogram of anxiety symptoms.

Results

Multivariate logistic regression analysis showed that lack of social support (OR = 0.95, 95%CI: 0.91-0.99), low life satisfaction (OR = 0.91, 95%CI: 0.86-0.95), low subjective well-being (OR = 0.58, 95%CI: 0.41-0.83) and frequent tobacco and alcohol use (OR = 1.75, 95%CI: 1.10-2.80) were independent predictors of anxiety symptoms in postgraduate medical students (P < 0.05). The Nomogram risk prediction model based on the above four independent prediction factors was established, and the verified C-index (Concordance index) is 0.787 (95%CI: 0.744-0.803, P < 0.001).

Conclusions

Anxiety symptoms in postgraduate medical students are influenced by various variables. The Nomogram prediction model has high accuracy, validity, and reliability, which can provide reference for predicting anxiety symptoms in postgraduate medical students.

Obesity and its association with mental health among Mexican children and adolescents: systematic review

CONTEXT

Obesity and mental health issues increasingly affect children and adolescents, but whether obesity is a risk factor for mental health issues is unclear.

OBJECTIVE

To systematically review the association between obesity and mental health issues (ie, anxiety and/or depression) among Mexican children and adolescents.

DATA SOURCING, EXTRACTION, AND SYNTHESIS

A literature search of 13 databases and 1 search engine was conducted. Population, exposure, comparison, outcomes, and study design data were extracted, analyzed, and narratively synthesized. The JBI critical appraisal tool was used to evaluate evidence quality.

RESULTS

A total of 16 studies with 12 103 participants between 8 and 18 years old were included. Four studies focused on anxiety outcomes, 10 on depression, and 2 on both (ie, anxiety and depression). Evidence is unclear about the association of obesity with anxiety. However, most evidence shows that Mexican children and adolescents with overweight or obesity are more likely to have depression or report a higher number of depressive symptoms than normal-weight participants. Such likelihood is greater for females.

CONCLUSION

Health promotion interventions to treat or prevent obesity could also consider mental health outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42019154132.

Depression in young people

Depression rates in young people have risen sharply in the past decade, especially in females, which is of concern because adolescence is a period of rapid social, emotional, and cognitive development and key life transitions. Adverse outcomes associated with depression in young people include depression recurrence; the onset of other psychiatric disorders; and wider, protracted impairments in interpersonal, social, educational, and occupational functioning. Thus, prevention and early intervention for depression in young people are priorities. Preventive and early intervention strategies typically target predisposing factors, antecedents, and symptoms of depression. Young people who have a family history of depression, exposure to social stressors (eg, bullying, discordant relationships, or stressful life events), and belong to certain subgroups (eg, having a chronic physical health problem or being a sexual minority) are at especially high risk of depression. Clinical antecedents include depressive symptoms, anxiety, and irritability. Evidence favours indicated prevention and targeted prevention to universal prevention. Emerging school-based and community-based social interventions show some promise. Depression is highly heterogeneous; therefore, a stepwise treatment approach is recommended, starting with brief psychosocial interventions, then a specific psychological therapy, and then an antidepressant medication.

Online treatment of adolescents with comorbid anxiety and depression: A randomized controlled trial

OBJECTIVE

Adolescents experiencing both anxiety and mood disorders show greater life impairment than those with either disorder alone. The aim of this study was to evaluate the efficacy of an online cognitive behavior therapy (CBT) program for these comorbid youth.

METHODS

Ninety-one adolescents aged 12 to 17 years (M = 14.29, S.D. = 1.62; 66% female) participated if they met DSM-5 criteria for both an anxiety and depressive disorder. Diagnoses were assessed by structured interview and participants also completed measures of symptoms, negative thoughts, and life interference. Participants were randomly allocated to either active treatment (n = 45) or wait (n = 46). Treatment comprised access to an 8-module, online program and was supported by 8, 30-minute telephone sessions with a therapist and the youth, of which the caregiver participated in four.

RESULTS

Treated participants showed significantly greater reduction than waiting participants on the primary outcome: total number of disorders and were more likely to remit from all anxiety and mood disorders (43.8% vs 20.9%). Secondary outcomes covering symptoms of anxiety and depression showed similar group by time differences, but there was no significant group by time interaction on life interference.

CONCLUSIONS

This brief, easily accessible, online intervention that requires relatively low levels of therapist time showed promising impact for a very impaired population.

REGISTRATION

This trial was registered on the ANZ clinical trials registry-ACTRN12616000139471.

Factors Associated With Depression and Anxiety in Korean Adolescents During the COVID-19 Pandemic

OBJECTIVE

This study was performed to identify factors associated with depression and anxiety among Korean adolescents during the coronavirus disease (COVID-19) pandemic.

METHODS

We conducted a cross-sectional study of 1,898 Korean adolescents (55.2% male, 44.8% female) ranging in age from 12 to 17 years (mean±standard deviaion age, 15.4±2.6 years). Depression and anxiety were defined as a Patient Health Questionnaire-9 score ≥10 and Generalized Anxiety Disorder-7 score ≥10, respectively. Other questionnaires included sociodemographic data, psychosocial stresses, and experiences in association with COVID-19. Psychiatric scales included Gratitude Questionnaire-6, Perceived Stress Scale-10, and UCLA Loneliness Scale-3.

RESULTS

The prevalence rates of depressive and anxiety symptoms among participants were 13.8% and 21.0%, respectively. Multivariable logistic regression analysis revealed that female sex, fear of COVID-19 infection, low gratitude were risk factors for depression. Fear of COVID-19 infection, increased TV watching time, and academic-related stress were risk factors for anxiety.

CONCLUSION

Depression and anxiety were prevalent during the pandemic in Korean adolescents, and were associated with fear of COVID-19 infection. Providing appropriate information on COVID-19, helping adolescents manage academic-related stress and maintain daily life patterns, and implementing interventions to foster gratitude are important for preventing depression and anxiety in Korean adolescents.

Effects of Anonymity versus Examinee Name on a Measure of Depressive Symptoms in Adolescents

There is evidence in the literature that anonymity when investigating individual variables could increase the objectivity of the measurement of some psychosocial constructs. However, there is a significant gap in the literature on the theoretical and methodological usefulness of simultaneously assessing the same measurement instrument across two groups, with one group remaining anonymous and a second group revealing identities using names. Therefore, the aim of this study was to compare the psychometric characteristics of a measure of depressive symptoms in two groups of adolescents as a consequence of identification or anonymity at the time of answering the measuring instrument. The participants were 189 adolescents from Metropolitan Lima; classrooms were randomly assigned to the identified group (n = 89; application requesting to write one’s own name) or to the anonymous group (n = 100; application under usual conditions), who responded to the Childhood Depression Inventory, short version (CDI-S). Univariate characteristics (mean, dispersion, distribution), dimensionality, reliability, and measurement invariance were analyzed. Specific results in each of the statistical and psychometric aspects evaluated indicated strong psychometric similarity. The practical and ethical implications of the present results for professional and research activity are discussed.

Monoaminergic system involvement in the antidepressant-like and anxiolytic-like properties of novel β-dihydroagarofuran sesquiterpene alkaloid and triterpenes isolated from Gymnosporia heterophylla aerial parts in mice

Gymnosporia heterophylla (synonym Maytenus) is widely used in folk medicine for the treatment of various illness including neurological diseases. This study presents the antidepressant-like and anxiolytic-like effects of novel bioactive constituents; 3,4-seco-1-hydroxy-21-oxoolean-3,11-olide (A2), 1β,2β-diacetoxy-9β-benzoyloxy-6α-nicotinoyloxy-β-dihydroagarofuran (A5) as well as known 3-acetoxy-1β-hydroxyLupe-20(29)-ene (selective COX-2; A4) from the aerial parts of G. heterophylla. The antidepressant-like effect was studied using the forced swim test (FST) while the elevated plus maze test (EPMT) and open field test (OFT) were employed for anxiolytic-like effect. Acute treatment with A4 and A5 (0.5, 5 or 10 mg/kg) significantly reduced the duration of immobility and immobile episodes with prolongation of immobility latency in the FST with peak effects observed at 10 and 0.5 mg/kg, respectively. Moreover, antidepressant-like effect of A4 and A5 were relatively better than that of fluoxetine. Conversely, the pretreatment of mice with prazosin (1 mg/kg, α₁-adrenoceptor antagonist), yohimbine (1 mg/kg; α₂-adrenoceptor antagonist), or sulpiride (50 mg/kg; dopamine D₂-receptor antagonist) reversed antidepressant-like effect of A4 and A5 but not WAY 100635 (10 mg/kg, i.p., selective 5-HT_1A receptor antagonist), GR 127935 (5 mg/kg, i.p., selective 5-HT_1B receptor antagonist), metergoline (4 mg/kg, i.p, non-selective 5-HT₂ receptor antagonist), ketanserin (5 mg/kg, i.p., a selective 5-HT_2A receptor antagonist) or p-chlorophenylalanine (pCPA) (100 mg/kg, i.p., tryptophan hydroxylase inhibitor) in the FST. Interestingly, A2, A4 and A5 significantly increased the time spent in the open arms of the EPM suggestive of anxiolytic-like action. Findings from this study showed that the novel β-dihydroagarofuran sesquiterpene alkaloid and triterpenes possesses antidepressant-like and anxiolytic-like effects through enhancement of monoaminergic signaling.

The Development of Psychosocial Therapeutic and Preventive Interventions for Mental Disorders (R61/R33): A User's Guide

One of the four major goals outlined in the National Institute of Mental Health (NIMH) strategic plan (2021) is to develop and test new treatments and prevention strategies. The aim of the Funding Opportunity Announcement (FOA) for the R61/R33 grant mechanism has been to support the efficient pilot testing of exploratory clinical trials of novel interventions for mental disorders in adults and children through an experimental therapeutics approach. The present commentary (a) describes the R61/R33 grant mechanism, defines terms, and summarizes information about current grants in the system, (b) outlines the review criteria, and (c) highlights several common critiques. Frequent concerns expressed by applicants as well as reviewers include defining and measuring the target/mechanism, establishing dose, selecting an appropriate control group, measuring fidelity, and determining power. Finally, alternative pathways for conducting randomized clinical trials for intervention development are discussed in contrast to or in addition to the experimental therapeutics approach for discovering novel interventions aimed at reducing and preventing mental illness across the lifespan.

The impact of school life and family involvement on Western China junior high school students’ wellbeing at multidimensional levels

Background

The focus of students’ health concerns has gradually progressed from the single factor of physical health to comprehensive health factors, and the physical and mental health of students are now generally considered together. This study focuses on exploring the status of junior high school students’ physical health and their subjective health assessment with the major societal factors that affect students’ lives: School Life and Family involvement. In addition, we explore the main factors influencing students’ subjective health.

Methods

A cross-sectional survey was conducted with 190 Tibetan junior high school students in the Maozhuang Township. The intentional sampling was used to choose the research object. The structured questionnaire comprised four parts, namely social and demographic information, family condition, school life, and subjective health quality which was assessed by PROMIS (Chinese version of the Pediatric Patient-Reported Outcomes Measurement Information System).

Result

The average height and weight of boys and girls are statistically different (p-values of 0.026 and 0.044, respectively), but there is no statistically significant difference in BMI (Body Mass Index) between boys and girls (p-value of 0.194). The average values of the five dimensions of depression, anger, anxiety, fatigue, and peer relationships in the PROMIS of the research subjects were 58.9 ± 5.3, 53.3 ± 8.0, 58.1 ± 7.3, 52.8 ± 8.0, 39.3 ± 6.6. In the demographic dimension, the grade was the main factor influencing anger (p < 0.01) and fatigue (p < 0.01), while gender was related to peer relationships (p = 0.02). In the family dimension, the father’s educational level was related to peer relationships (p = 0.05), while the family financial situation was related to depression (p = 0.01). In the school life dimension, relationship with classmates was found to affect anger (p = 0.05), while homework was related to anxiety (p = 0.02) and fatigue (p = 0.05).

Conclusion

the physical health index BMI and subjective health evaluation of students are worse than students of more developed areas in China. Their family environment and school life all have varying degrees of impact on the five subjective health outcomes. There are differences in gender and grade level. The government and society need to pay more attention to the physical and mental health of students in remote and underdeveloped areas and improve their health through a student nutrition plan and the establishment of mental health offices.

Awareness, Prevention, Detection, and Therapy Applications for Depression and Anxiety in Serious Games for Children and Adolescents: Systematic Review

BACKGROUND

Depression and anxiety in children and adolescents are major health problems worldwide. In recent years, serious games research has advanced in the development of tools to address these mental health conditions. However, there has not been an extensive analysis of these games, their tendencies, and capacities.

OBJECTIVE

This review aims to gather the most current serious games, published from 2015 to 2020, with a new approach focusing on their applications: awareness, prevention, detection, and therapy. The purpose is also to analyze the implementation, development, and evaluation of these tools to obtain trends, strengths, and weaknesses for future research lines.

METHODS

The identification of the serious games through a literature search was conducted on the databases PubMed, Scopus, Wiley, Taylor and Francis, Springer, PsycINFO, PsycArticles, Web of Science, and Science Direct. The identified records were screened to include only the manuscripts meeting these criteria: a serious game for PC, smartphone, or virtual reality; developed by research teams; targeting only depression or anxiety or both; aiming specifically at children or adolescents.

RESULTS

A total of 34 studies have been found that developed serious games for PC, smartphone, and virtual reality devices and tested them in children and adolescents. Most of the games address both conditions and are applied in prevention and therapy. Nevertheless, there is a trend that anxiety is targeted more in childhood and depression targeted more in adolescence. Regarding design, the game genres arcade minigames, adventure worlds, and social simulations are used, in this order. For implementation, these serious games usually require sessions of 1 hour and are most often played using a PC. Moreover, the common evaluation tools are normalized questionnaires that measure acquisition of skills or reduction of symptoms. Most studies collect and compare these data before and after the participants play.

CONCLUSIONS

The results show that more awareness and detection games are needed, as well as games that mix the awareness, prevention, detection, and therapy applications. In addition, games for depression and anxiety should equally target all age ranges. For future research, the development and evaluation of serious games should be standardized, so the implementation of serious games as tools would advance. The games should always offer support while playing, in addition to collecting data on participant behavior during the game to better analyze their learning. Furthermore, there is an open line regarding the use of virtual reality for these games due to the capabilities offered by this technology.

Vitamin D and the Risks of Depression and Anxiety: An Observational Analysis and Genome-Wide Environment Interaction Study

Previous studies have suggested that vitamin D (VD) was associated with psychiatric diseases, but efforts to elucidate the functional relevance of VD with depression and anxiety from genetic perspective have been limited. Based on the UK Biobank cohort, we first calculated polygenic risk score (PRS) for VD from genome-wide association study (GWAS) data of VD. Linear and logistic regression analysis were conducted to evaluate the associations of VD traits with depression and anxiety traits, respectively. Then, using individual genotype and phenotype data from the UK Biobank, genome-wide environment interaction studies (GWEIS) were performed to identify the potential effects of gene × VD interactions on the risks of depression and anxiety traits. In the UK Biobank cohort, we observed significant associations of blood VD level with depression and anxiety traits, as well as significant associations of VD PRS and depression and anxiety traits. GWEIS identified multiple candidate loci, such as rs114086183 (p = 4.11 × 10⁻⁸, LRRTM4) for self-reported depression status and rs149760119 (p = 3.88 × 10⁻⁸, GNB5) for self-reported anxiety status. Our study results suggested that VD was negatively associated with depression and anxiety. GWEIS identified multiple candidate genes interacting with VD, providing novel clues for understanding the biological mechanism potential associations between VD and psychiatric disorders.

Impaired probabilistic reversal learning in anxiety: Evidence from behavioral and ERP findings

•

High and low anxious participants finish a probabilistic reversal learning task.

•

High anxious participants showed a worse performance and less likely to lose-shift.

•

Feedback-related negativity (FRN) was correlated with the frequency of lose-shift.

•

High anxious participants showed a smaller FRN in response to lose-shift.

•

Anxious people’s reversal learning is affected by impaired sensitivity to losses.

Background

Reversal learning reflects an individual’s capacity to adapt to a dynamic environment with changing stimulus–reward contingencies. This study focuses on the potential influence of anxiety on reversal learning skills.

Methods

We asked 40 participants with a high level of trait anxiety (HTA) and 40 counterparts with a low anxiety level (LTA) to finish a probabilistic reversal learning task with event-related potential (ERP) recording, during which stimulus–reward contingencies are reversed after players have learned the optimal choice.

Results

We found that compared to their LTA counterparts, the HTA participants showed worse learning performance and were less likely to make lose-shift choices. The FRN amplitude might help interpret these behavioral results, which is suggested to be associated with punishment sensitivity and was positively correlated with the number of lose-shift in this study. Seeing that anxiety level predicted the FRN amplitude for lose-shift, we explain that anxious individuals’ inflexible behavioral responses to losses are due to their impaired sensitivity to negative feedback.

Conclusions

A higher level of anxiety is associated with weaker reversal learning performance, possibly because of abnormal sensitivity to negative outcomes. These findings have implications for the understanding of behavioral symptoms in anxiety.

Depressive and anxiety disorders in concert-A synthesis of findings on comorbidity in the NESDA study

BACKGROUND

Comorbidity of depressive and anxiety disorders is common and remains incompletely comprehended. This paper summarizes findings from the Netherlands Study of Depression and Anxiety (NESDA) regarding prevalence, temporal sequence, course and longitudinal patterns; sociodemographic, vulnerability and neurobiological indicators; and functional, somatic and mental health indicators of comorbidity.

METHODS

Narrative synthesis of earlier NESDA based papers on comorbidity (n=76).

RESULTS

Comorbidity was the rule in over three-quarter of subjects with depressive and/or anxiety disorders, most often preceded by an anxiety disorder. Higher severity and chronicity characterized a poorer comorbidity course. Over time, transitions between depressive and anxiety disorders were common. Consistent comorbidity risk indicators in subjects with depressive and anxiety disorders were childhood trauma, neuroticism and early age of onset. Psychological vulnerabilities, such as trait avoidance tendencies, were more pronounced in comorbid than in single disorders. In general, there were few differences in biological markers and neuroimaging findings between persons with comorbid versus single disorders. Most functional, somatic, and other mental health indicators, ranging from disability to cardiovascular and psychiatric multimorbidity, were highest in comorbid disorders.

LIMITATIONS

The observational design of NESDA limits causal inference. Attrition was higher in comorbid relative to single disorders.

CONCLUSIONS

As compared to single disorders, persons with comorbid depressive and anxiety disorders were characterized by more psychosocial risk determinants, more somatic and other psychiatric morbidities, more functional impairments, and poorer outcome. These results justify specific attention for comorbidity of depressive and anxiety disorders, particularly in treatment settings.

The Effect of Early Maternal Separation Combined With Adolescent Chronic Unpredictable Mild Stress on Behavior and Synaptic Plasticity in Adult Female Rats

Our aims were to evaluate the depression model of early maternal separation (MS) combined with adolescent chronic unpredictable mild stress (CUMS) in female adult SD rats to observe the behavior and the expressions of synaptic proteins in rats and to provide a reference for the screening of antidepressant drug activity. In our study, MS and CUMS were conducted to establish a dual stress model on female rats. Behavioral tests, including the sucrose preference test, open field test, and zero maze test, were used to detect depression-like and anxiety-like behavior of animals. Nissl staining was used to detect the number of neuronal cells in the hippocampus CA1 and DG regions of rats from each group. Synaptophysin (SYN), postsynaptic density-95 (PSD-95), and growth-associated protein-43 (GAP-43) expressions in the hippocampus were detected by western blot. Expression of the hippocampus SYN protein was further detected by immunohistochemistry. Rats in the MS+CUMS group presented more serious depression-like and anxiety-like behavior than in the MS group. Also, few Nissl bodies in the hippocampus CA1 and DG regions, less percentage of SYN-positive cells, and downregulated expressions of SYN, PSD-95, and GAP43 were found in the hippocampus of rats in MS+CUMS group. In conclusion, adult female rats that underwent MS and CUMS performed more critical depression-like and anxiety-like behaviors, and this process may be resulted from synaptic plasticity impairment.

Effectiveness of the Super Skills for Life programme in enhancing the emotional wellbeing of children and adolescents in residential care institutions in a low- and middle-income country: A randomised waitlist-controlled trial

BACKGROUND

The present study examined the effectiveness of a transdiagnostic prevention programme, Super Skills for Life (SSL), among children and adolescents with emotional problems in residential care institutions (RCIs) in the low- and middle-income country of Mauritius using a randomised waitlist-controlled trial (RCT). SSL is based on the principles of cognitive behavioural therapy, behavioural activation, social skills training, and uses video-feedback and cognitive preparation as part of the treatment.

METHODS

The RCT involved 100 children and adolescents aged 9 to 14 years, from six RCIs, randomly allocated to either an SSL intervention group (IG) or a waitlist-control (WLC) group. A set of questionnaires measuring internalising and externalising problems, emotion regulation and self-esteem, and experimental tasks measuring attentional bias and inhibitory control, were completed at baseline, post-intervention and 3-month follow-up. Participants also completed a 2-min video speech task during the first and final sessions of the SSL intervention.

RESULTS

Children and adolescents in the IG showed significant improvements in internalising symptoms (e.g. anxiety and depression), externalising symptoms (e.g. conduct problems and hyperactivity), and inhibitory control, and an increase in adaptive (except putting into perspective strategy) and decrease in maladaptive emotion regulation strategies, at both post-intervention and follow-up. These findings were not replicated among children in the WLC.

LIMITATIONS

The small sample size and lack of an active control group were the major limitations of this study.

CONCLUSIONS

This study provides evidence for the effectiveness of a transdiagnostic prevention programme for emotional problems in RCIs in a low- and middle-income country.

Secondary Outcomes of Implemented Depression Prevention in Adolescents: A Randomized Controlled Trial

Our most recent RCT provides evidence that indicated depression prevention is effective in reducing depressive symptoms in adolescents when implemented in the school community. In the present study we further test the potential effects of this prevention approach on symptoms related to depression: anxiety, suicidality, somatic symptoms, and perfectionism. We conducted exploratory analyses in 130 adolescents with elevated depressive symptoms aged between 12 and 16 years old (M = 13.59; SD = 0.68; 63.8% girls) who were randomly assigned to the experimental (OVK 2.0) or active control condition (psycho-education). Self-reported anxiety, suicidality, somatic symptoms, and perfectionism were assessed at pretest, post intervention, as well as 6- and 12-months follow-up. Latent growth curve analyses revealed that there was a significant decrease in anxiety in both conditions and that this decrease was significantly larger in the intervention condition than in the control condition. Somatic symptoms and socially prescribed perfectionism decreased significantly in the intervention condition and suicidality decreased significantly in the control condition. Yet there was no difference in decrease in suicidality, somatic symptoms, and perfectionism between the two conditions. This study suggest that screening on depressive symptoms and providing a CBT depression prevention program for adolescents with elevated depressive symptoms, can decrease comorbid symptoms of anxiety and therefore ensure better outcomes. We discuss the clinical implications as well suggestions for future research. Clinical Trial Registration: The study is registered in the Dutch Trial Register for RCTs (NTR5725). Date registered: 11th of March 2016.

Randomized Clinical Trial of an Internet-Based Adolescent Depression Prevention Intervention in Primary Care: Internalizing Symptom Outcomes

Approximately 20% of people will experience a depressive episode by adulthood, making adolescence an important developmental target for prevention. CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral, Humanistic, and Interpersonal Training), an online depression prevention intervention, has demonstrated efficacy in preventing depressive episodes among adolescents reporting elevated symptoms. Our study examines the effects of CATCH-IT compared to online health education (HE) on internalizing symptoms in adolescents at risk for depression. Participants, ages 13-18, were recruited across eight US health systems and were randomly assigned to CATCH-IT or HE. Assessments were completed at baseline, 2, 6, 12, 18, and 24 months. There were no significant differences between groups in change in depressive symptoms (b = -0.31 for CATCH-IT, b = -0.27 for HE, p = 0.80) or anxiety (b = -0.13 for CATCH-IT, b = -0.11 for HE, p = 0.79). Improvement in depressive symptoms was statistically significant (p < 0.05) for both groups (p = 0.004 for CATCH-IT, p = 0.009 for HE); improvement in anxiety was significant for CATCH-IT (p = 0.04) but not HE (p = 0.07). Parental depression and positive relationships with primary care physicians (PRPC) moderated the anxiety findings, and adolescents' externalizing symptoms and PRPC moderated the depression findings. This study demonstrates the long-term positive effects of both online programs on depressive symptoms and suggests that CATCH-IT demonstrates cross-over effects for anxiety as well.

A 12-month follow-up of a transdiagnostic indicated prevention of internalizing symptoms in school-aged children: the results from the EMOTION study

BACKGROUND

Anxious and depressive symptoms in youth are highly prevalent, are often comorbid and have a high rate of relapse. Preventive interventions are promising, but follow-up results are lacking. The transdiagnostic EMOTION program is an indicated preventive cognitive behavioral therapy (CBT) intervention targeting children aged 8-12 years.

METHODS

The present study investigates the 12 months follow-up effects of the EMOTION intervention in a cluster randomized controlled trial (RCT) with 795 children that included both child self-reports and parental reports.

RESULTS

Mixed model analyses showed a larger decrease of symptoms in the intervention group than in the control group for child self-reported anxious symptoms (The Multidimensional Anxiety Scale for Children (MASC) difference 4.56, CI 1.83 to 7.29, p = .001). Parental reports for both anxious (MASC difference 2.50, CI .26 to 4.74, p = .029) and depressive (The Mood and Feelings Questionnaire-short form (SMFQ) difference 1.55, CI .83 to 2.26, p ≤ .001) symptoms in children also showed a reduction. No statistically significant difference was found for child self-reported depressive symptoms (SMFQ difference .69, CI - .22 to 1.60, p = .139).

CONCLUSION

The transdiagnostic EMOTION program has shown the potential for long-term reductions in symptoms of both anxiety and depression in school-aged children. However, results regarding depressive symptoms must be considered preliminary as only parental report indicated effect.Trial registration The regional ethics committee (REC) of Norway approved the study. Registration number: 2013/1909; Project title: Coping Kids: a randomized controlled study of a new indicated preventive intervention for children with symptoms of anxiety and depression. ClinicalTrials.gov Identifier; NCT02340637.

One-Year follow-up effects of a cognitive behavior therapy-based transdiagnostic program for emotional problems in young children: A school-based cluster-randomized controlled trial

BACKGROUND

The present study examined the long-term efficacy of a transdiagnostic prevention program, Super Skills for Life (SSL), among young children with emotional problems. SSL is based on the principles of cognitive behavioral therapy, behavioral activation, and social skills training.

METHODS

One-hundred and twenty-three Spanish-speaking children, aged 6 to 8 years, and their parents participated in the study. They were recruited from ten schools. Schools were randomly allocated to either the intervention (IG) or waiting-list control (WLC) groups. The children's parent completed a set of questionnaires to measure their child's anxiety and depressive symptoms, general difficulties and positive attributes, and psychosocial impairment. Parent's assessment at baseline and at a 12-month follow-up was assessed using an intent-to-treat approach.

RESULTS

The IG, compared to WLC group, showed significant baseline-to-follow-up reductions in anxiety and depressive symptoms, as well as in behavioral difficulties and psychosocial impairment in various life domains.

LIMITATIONS

The small sample size and the reliance on parental reports were the major limitations of this study.

CONCLUSIONS

This study provides initial evidence of the long-term effects of SSL, suggesting that it is a promising indicated preventive intervention for young children with emotional problems.

Social and Non-social Reward: A Preliminary Examination of Clinical Improvement and Neural Reactivity in Adolescents Treated With Behavioral Therapy for Anxiety and Depression

Background

Pediatric anxiety and depression are highly prevalent and debilitating disorders that often co-occur. Neural circuitry of reward processing has been shown to be implicated in both, and there is an emerging evidence base linking treatment response to brain patterns of reward processing. The current study aimed to add to this literature by investigating the association between clinical improvement and social and non-social reward in youth previously treated for anxiety and depression.

Methods

The current study leveraged clinical improvement data from a successful randomized controlled trial testing the efficacy of a transdiagnostic, brief behavioral treatment for youth diagnosed with anxiety or depression. Participants (N = 15) interested in engaging in a neuroimaging follow-up underwent an fMRI scan, during which they completed social (i.e., Face Task) and non-social (i.e., Piñata Task, a youth-friendly monetary incentive delay task) reward tasks. Whole-brain activation and functional connectivity analyses identified neural responses to the tasks separately; a third set of analyses directly compared clinical improvement-related findings to understand the impact of task context on neural reactivity to reward.

Results

Activation-based findings were sparse; however, connectivity as a function of degree of treatment response was apparent and robust. Within the context of social reward, significant clusters within frontal and temporal regions driven by happy face contrasts, the social reward stimulus, were observed. This supports connectivity between these regions and both amygdala and ventral striatum seeds as a function of degree of clinical improvement. Connectivity within the context of non-social reward also yielded significant clusters in temporal and parietal regions. Here too, the magnitude and direction of region coupling depended on the degree of clinical improvement and the task conditions. No differences in connectivity by task type as a function of clinical improvement were found.

Conclusion

Findings serve as preliminary evidence that neural regions found to be related to clinical improvement within the context of social and non-social reward are similar to regions that have been shown to support reward processing in normative samples. Implications for treatment and future work are discussed.

Clinical risk factors among youth at high risk for suicide in South Africa and Guyana

INTRODUCTION

Suicide is the second leading cause of death among youth worldwide, but low- and middle-income countries (LMICs) account for 78% of all suicides. The LMICs South Africa and Guyana rank high in the global suicide rates. To better understand and prevent suicide among the youth, the present study targets youths at high risk for suicide, in an LMIC, to contextually and representatively identify clinical risk factors for suicide.

METHODS

One hundred-ninety youths, aged 11-21, separated from biological parents at the time of assessment, in South Africa and Guyana, were administered the Child Behavior Checklist and Behavior Assessment System for Children to assess clinical symptoms. The youths were asked about current suicide ideation and previous attempt(s). Self-report responses to clinical items yielded scale scores for depression, social stress, atypicality, somatization, anxiety, and ADHD. Using an integrative data analytic technique, clinical scale scores were standardized and used to predict suicidal behaviors in a binary logistic regression analysis.

RESULTS

Approximately 22% of Black South African youths and 60% of Guyanese youths endorsed suicide ideation and attempt or suicide attempt only. In fully adjusted analyses, the odds of atypicality and somatization were 1.96 and 1.67 times greater among the youths who endorsed suicidal ideation when compared with those who did not (p < .04). Youth social stress was significantly associated with the suicide attempt, controlling for model covariates (odds ratio [OR], 1.88, p = .05). Gender moderated the effect of somatization on youth suicide.

CONCLUSION

Our results contextualize how social stress, atypicality, and somatization relate to LMIC youth suicide. Further study on high-risk samples will contribute to generalizable suicide-prevention models.

Indicated preventive interventions for depression in children and adolescents: A meta-analysis and meta-regression

Depression contributes about 2% to the global burden of disease. A first onset of depressive disorder or subsyndromal depressive symptoms is common in adolescence, indicating that early prevention is a priority. However, trials of preventive interventions for depression in youths show conflicting results. This systematic review and meta-analysis investigated the effectiveness of group-based cognitive behavioral therapy (GB-CBT) as a preventive intervention targeting subsyndromal depression in children and adolescents. In addition, the impact of different covariates (type of comparator and use of booster sessions) was assessed. Relevant articles were identified from previous systematic reviews, and supplemented with an electronic search spanning from 01/09/2014 to 28/02/2018. The retrieved articles were assessed for eligibility and risk of bias. Relevant data were extracted. Intervention effectiveness was pooled using a random-effects model and the impact of covariates assessed using meta-regression. 38 eligible articles (34 trials) were obtained. The analysis showed GB-CBT to significantly reduce the incidence (relative risk 0.43, 95% CI 0.21-0.87) and symptoms (Cohen's d -0.22, 95% CI -0.32 to -0.11) of depression at post-test compared to all controls. Comparisons with passive comparators suggested that the effect decayed over time. However, compared to active controls, a significant intervention effect was evident only after 12 month or more. Our results suggest that the preventive effect of GB-CBT wears off, but still lasts longer than the effect of active comparators. Only a few studies included booster sessions, precluding firm conclusions. Future studies should clarify to what extent maintenance strategies can prolong the preventive effect of GB-CBT.

Prospective predictors of first-onset depressive disorders in adolescent females with anxiety disorders

BACKGROUND

Anxious youth are at increased risk for later depressive disorders, but not all anxious youth develop depression. Sequential comorbidity models emphasize shared risk factors and anxiety sequelae, but some anxious youth who later develop depression may have risk factors that are relatively specific to depression, in addition to a liability to anxiety. We examined several variables that appear relatively specific to risk for depression-the personality traits of low positive affectivity and high sadness, and an electrophysiological measure of blunted response to reward - in predicting first-onset depressive disorders and depressive symptoms in clinically anxious adolescent girls.

METHODS

A sample of 114 adolescents with baseline anxiety disorders completed personality and psychopathology measures, psychophysiology tasks, and diagnostic interviews. Interviews and a measure of depressive symptoms were re-administered over 27 months.

RESULTS

After controlling for baseline depressive symptoms, blunted reward sensitivity uniquely predicted first-onset depressive disorders and depressive symptoms 27 months later. Post-hoc analyses indicated that blunted reward sensitivity only predicted first-onset depressive disorders and depressive symptoms in girls with high social anxiety symptoms.

LIMITATIONS

Analyses were unable to account for concurrent anxiety symptoms and disorders.

CONCLUSIONS

The depression-specific risk factor, blunted reward sensitivity, may comprise one pathway to subsequent depressive disorders and symptoms in anxious youth and indicate which anxious youth need intervention to prevent later depression, particularly in socially anxious girls.

A video-based transdiagnostic REBT universal prevention program for internalizing problems in adolescents: study protocol of a cluster randomized controlled trial

BACKGROUND

Internalizing problems are the most prevalent mental health problems in adolescents. Transdiagnostic programs are promising manners to treat multiple problems within the same protocol, however, there is limited research regarding the efficacy of such programs delivered as universal prevention programs in school settings. Therefore, the present study aims to investigate the efficacy of a video-based transdiagnostic rational emotive behavioral therapy (REBT) universal prevention program, for internalizing problems. The second objective of the present paper will be to investigate the subsequent mechanisms of change, namely maladaptive cognitions.

METHODS

A two-arm parallel randomized controlled trial will be conducted, with two groups: a video-based transdiagnostic REBT universal prevention program and a wait list control. Power analysis indicated that the study will involve 338 participants. Adolescents with ages between 12 and 17 years old, from several middle schools and high schools, will be invited to participate. Assessments will be conducted at four time points: baseline (T1), post-intervention (T2), 3 months follow-up (T3) and 12 months follow-up (T4). Intent-to-treat analysis will be used in order to investigate significant differences between the two groups in both primary and secondary outcomes.

DISCUSSION

This is the first randomized controlled trial that aims to investigate the efficacy and mechanisms of change of a video-based transdiagnostic REBT universal prevention program, delivered in a school context. The present study has important implications for developing efficient prevention programs, interactive, that will aim to target within the same protocol both anxiety and depressive symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02756507 . Registered on 25 April 2016.

The relationship between anxiety and quality of life in children with hereditary angioedema

BACKGROUND

The severe life-threatening characteristics of hereditary angioedema (HAE) with C1-inhibitor deficiency (C1-INH-HAE) can affect anxiety levels among pediatric patients. This emotional burden together with the physical restrictions of C1-INH-HAE may decrease children's health-related quality of life (HRQoL).

OBJECTIVES

(i) To compare anxiety state and trait between children with C1-INH-HAE and healthy controls; (ii) to examine the relationship between the level of anxiety of children with C1-INH-HAE, their disease activity/affected sites and their HRQoL; and (iii) to predict the HRQoL of children with C1-INH-HAE based on their anxiety level and disease activity/affected sites METHODS: Thirty-three children with C1-INH-HAE (aged 5-18 years) and 52 healthy controls were recruited from Israel and Hungary. All children completed the State-Trait Anxiety Inventory for Children (STAIC), the Pediatric Quality of Life Inventory (Peds-QL) demographic questionnaire and a disease activity and site questionnaire . Disease activity was defined as the number of attacks in last year.

RESULTS

Both anxiety state and trait were significantly higher among children with C1-INH-HAE as compared to the controls (44.74±10.56 vs 38.76±10.67, P<.01, 29.21±5.16 vs 25.23±4.09, P<.001 in comparison). Significant differences were found between C1-INH-HAE patients with HAE attacks, asymptomatic C1-INH-HAE patients, and healthy controls in both anxiety state (F_56,2 =4.69, P=.001) and trait (F_56,2 =9.06, P<.0001). A higher anxiety trait was correlated with the number of angioedema-affected sites (r=.52, P=.003). The presence of HAE attacks and higher anxiety trait predicted a lower HRQoL in children with C1-INH-HAE.

CONCLUSIONS

C1-INH-HAE children have higher anxiety trait and state, which correlate with reduced HRQoL domains.

Brief Behavioral Therapy for Pediatric Anxiety and Depression in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Anxiety and depression affect 30% of youth but are markedly undertreated compared with other mental disorders, especially in Hispanic populations.

OBJECTIVE

To examine whether a pediatrics-based behavioral intervention targeting anxiety and depression improves clinical outcome compared with referral to outpatient community mental health care.

DESIGN, SETTING, AND PARTICIPANTS

This 2-center randomized clinical trial with masked outcome assessment conducted between brief behavioral therapy (BBT) and assisted referral to care (ARC) studied 185 youths (aged 8.0-16.9 years) from 9 pediatric clinics in San Diego, California, and Pittsburgh, Pennsylvania, recruited from October 6, 2010, through December 5, 2014. Youths who met DSM-IV criteria for full or probable diagnoses of separation anxiety disorder, generalized anxiety disorder, social phobia, major depression, dysthymic disorder, and/or minor depression; lived with a consenting legal guardian for at least 6 months; and spoke English were included in the study. Exclusions included receipt of alternate treatment for anxiety or depression, presence of a suicidal plan, bipolar disorder, psychosis, posttraumatic stress disorder, substance dependence, current abuse, intellectual disability, or unstable serious physical illness.

INTERVENTIONS

The BBT consisted of 8 to 12 weekly 45-minute sessions of behavioral therapy delivered in pediatric clinics by master's-level clinicians. The ARC families received personalized referrals to mental health care and check-in calls to support accessing care from master's-level coordinators.

MAIN OUTCOMES AND MEASURES

The primary outcome was clinically significant improvement on the Clinical Global Impression-Improvement scale (score ≤2). Secondary outcomes included the Pediatric Anxiety Rating Scale, Children's Depression Rating Scale-Revised, and functioning.

RESULTS

A total of 185 patients were enrolled in the study (mean [SD] age, 11.3 [2.6] years; 107 [57.8%] female; 144 [77.8%] white; and 38 [20.7%] Hispanic). Youths in the BBT group (n = 95), compared with those in the ARC group (n = 90), had significantly higher rates of clinical improvement (56.8% vs 28.2%; χ21 = 13.09, P < .001; number needed to treat, 4), greater reductions in symptoms (F2,146 = 5.72; P = .004; Cohen f = 0.28), and better functioning (mean [SD], 68.5 [10.7] vs 61.9 [11.9]; t156 = 3.64; P < .001; Cohen d = 0.58). Ethnicity moderated outcomes, with Hispanic youth having substantially stronger response to BBT (76.5%) than ARC (7.1%) (χ21 = 14.90; P < .001; number needed to treat, 2). Effects were robust across sites.

CONCLUSIONS AND RELEVANCE

A pediatric-based brief behavioral intervention for anxiety and depression is associated with benefits superior to those of assisted referral to outpatient mental health care. Effects were especially strong for Hispanic participants, suggesting that the protocol may be a useful tool in addressing ethnic disparities in care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01147614.

Long-term Results from the Empowering a Multimodal Pathway Toward Healthy Youth Program, a Multimodal School-Based Approach, Show Marked Reductions in Suicidality, Depression, and Anxiety in 6,227 Students in Grades 6-12 (Aged 11-18)

Here, we report on findings from a 15-month follow-up of a school-based program called Empowering a Multimodal Pathway Toward Healthy Youth (EMPATHY). This was primarily intended to reduce suicidal thinking in pre-teens, adolescents, and youth students aged 11-18 in middle schools (Grades 6-8) and high SCHOOLS (Grades 9-12). It also aimed to reduce depression and anxiety. The EMPATHY multimodal program consisted of repeated data collection, identification of a high-risk group, a rapid intervention for this high-risk group including offering supervised online cognitive behavioral therapy (CBT) program, a universal CBT intervention for those in Grades 6-8, a variety of interactions with trained staff ("Resiliency Coaches"), and referral to external medical and psychiatric services where appropriate. There were four time-points at which assessments were made: baseline, 3, 7, and 15 months. Here, we report cross-sectional findings over 15 months in a total of 6,227 students who were assessed at least once during the study period. Additionally, we report longitudinal findings from the 1,884 students who completed all 4 assessments. Our results found highly statistically significant decreases in suicidality rates, with the percentage of the total school population who were actively suicidal decreasing from 4.4% at baseline (n = 143 of 3,244) to 2.8% at 15 months (n = 125 of 4,496) (p < 0.001). There were also highly statistically significant reductions in depression and anxiety scores at each time-point. Thus, Mean Depression scores at baseline for the entire student population were 3.73 ± 3.87 (n = 3,244) at baseline and decreased to 3.22 ± 3.52 (n = 4,496) (p < 0.001). Since most students were not depressed, whole population changes such as this may indicate impact in many areas. In the longitudinal analysis of students who completed all four assessments, there were also highly statistically significant improvements in depression and anxiety scores at all time-points. For example, depression scores decreased from a mean of 3.43 ± 3.67 (n = 1,884) at baseline to 2.95 ± 3.53 (n = 1,884) at 15-months (p < 0.001), while the number who were actively suicidal decreased from 69 to 37. These results suggest that school-based multimodal programs, utilizing a combination of interventions, can have meaningful benefits across entire school populations.