A Comprehensive Evaluation of a Universal School-Based Depression Prevention Program for Adolescents

A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review

Background

Depression is a public health problem and common amongst adolescents. Cognitive behavioural therapy (CBT) is widely used to treat adolescent depression but existing research does not provide clear conclusions regarding the relative effectiveness of different delivery modalities.

Objectives

The primary aim is to estimate the relative efficacy of different modes of CBT delivery compared with each other and control conditions for reducing depressive symptoms in adolescents. The secondary aim is to compare the different modes of delivery with regard to intervention completion/attrition (a proxy for intervention acceptability).

Search Methods

The Cochrane Depression, Anxiety and Neurosis Clinical Trials Register was searched in April 2020. MEDLINE, PsycInfo, EMBASE, four other electronic databases, the CENTRAL trial registry, Google Scholar and Google were searched in November 2020, together with reference checking, citation searching and hand-searching of two databases.

Selection Criteria

Randomised controlled trials (RCTs) of CBT interventions (irrespective of delivery mode) to reduce symptoms of depression in young people aged 10-19 years with clinically relevant symptoms or diagnosis of depression were included.

Data Collection and Analysis

Screening and data extraction were completed by two authors independently, with discrepancies addressed by a third author. CBT interventions were categorised as follows: group CBT, individual CBT, remote CBT, guided self-help, and unguided self-help. Effect on depressive symptom score was estimated across validated self-report measures using Hedges' g standardised mean difference. Acceptability was estimated based on loss to follow-up as an odds ratio. Treatment rankings were developed using the surface under the cumulative ranking curve (SUCRA). Pairwise meta-analyses were conducted using random effects models where there were two or more head-to-head trials. Network analyses were conducted using random effects models.

Main Results

Sixty-eight studies were included in the review. The mean age of participants ranged from 10 to 19.5 years, and on average 60% of participants were female. The majority of studies were conducted in schools (28) or universities (6); other settings included primary care, clinical settings and the home. The number of CBT sessions ranged from 1 to 16, the frequency of delivery from once every 2 weeks to twice a week and the duration of each session from 20 min to 2 h. The risk of bias was low across all domains for 23 studies, 24 studies had some concerns and the remaining 21 were assessed to be at high risk of bias. Sixty-two RCTs (representing 6435 participants) were included in the pairwise and network meta-analyses for post-intervention depressive symptom score at post-intervention. All pre-specified treatment and control categories were represented by at least one RCT. Although most CBT approaches, except remote CBT, demonstrated superiority over no intervention, no approaches performed clearly better than or equivalent to another. The highest and lowest ranking interventions were guided self-help (SUCRA 83%) and unguided self-help (SUCRA 51%), respectively (very low certainty in treatment ranking). Nineteen RCTs (3260 participants) were included in the pairwise and network meta-analyses for 6 to 12 month follow-up depressive symptom score. Neither guided self-help nor remote CBT were evaluated in the RCTs for this time point. Effects were generally attenuated for 6- to 12-month outcomes compared to posttest. No interventions demonstrated superiority to no intervention, although unguided self-help and group CBT both demonstrated superiority compared to TAU. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking approaches were unguided self-help and individual CBT, respectively. Sixty-two RCTs (7347 participants) were included in the pairwise and network meta-analyses for intervention acceptability. All pre-specified treatment and control categories were represented by at least one RCT. Although point estimates tended to favour no intervention, no active treatments were clearly inferior. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking active interventions were individual CBT and group CBT respectively. Pairwise meta-analytic findings were similar to those of the network meta-analysis for all analyses. There may be age-based subgroup effects on post-intervention depressive symptoms. Using the no intervention control group as the reference, the magnitudes of effects appear to be larger for the oldest age categories compared to the other subgroups for each given comparison. However, they were generally less precise and formal testing only indicated a significant difference for group CBT. Findings were robust to pre-specified sensitivity analyses separating out the type of placebo and excluding cluster-RCTs, as well as an additional analysis excluding studies where we had imputed standard deviations.

Authors' Conclusions

At posttreatment, all active treatments (group CBT, individual CBT, guided self-help, and unguided self-help) except for remote CBT were more effective than no treatment. Guided self-help was the most highly ranked intervention but only evaluated in trials with the oldest adolescents (16-19 years). Moreover, the studies of guided self-help vary in the type and amount of therapist support provided and longer-term results are needed to determine whether effects persist. The magnitude of effects was generally attenuated for 6- to 12-month outcomes. Although unguided self-help was the lowest-ranked active intervention at post-intervention, it was the highest ranked at follow-up. This suggests the need for further research into whether interventions with self-directed elements enable young people to maintain effects by continuing or revisiting the intervention independently, and whether therapist support would improve long-term outcomes. There was no clear evidence that any active treatments were more acceptable to participants than any others. The relative effectiveness of intervention delivery modes must be taken into account in the context of the needs and preferences of individual young people, particularly as the differences between effect sizes were relatively small. Further research into the type and amount of therapist support that is most acceptable to young people and most cost-effective would be particularly useful.

Efficacy and Effectiveness of Universal School-Based Wellbeing Interventions in Australia: A Systematic Review

The World Health Organisation defines health in terms of wellbeing, and wellbeing has become both a construct and a measure of impact in early intervention and prevention programs in schools. In Australia, schools report on their wellbeing initiatives and there is a plethora of government-funded wellbeing programs already in place in schools. However, education systems and stakeholders worldwide are facing significant challenges with mixed evaluation results of program impact and intervention effect. To better support students, schools, school-based healthcare workers, and community, it is important to know about the effectiveness of school-based programs; yet in the last decade, there has been no national appraisal of these programs in Australia. This systematic review aims to report on the effectiveness of Australian school-based wellbeing programs through a search of 13 databases. Out of 2888 articles, 29 met inclusion criteria. The results found that seventeen interventions comprising 80% of the total number of participants reported no statistically significant intervention effect on wellbeing outcomes. We argue that supporting wellbeing through robust program intervention is important as wellbeing presents both an indication of later onset of more serious mental health issues, and an opportunity for early intervention to break the trajectory leading to full disorder.

Adolescent Health Promotion Interventions Using Well-Care Visits and a Smartphone Cognitive Behavioral Therapy App: Randomized Controlled Trial

Background

Adolescent health promotion is important in preventing risk behaviors and improving mental health. Health promotion during adolescence has been shown to contribute to the prevention of late onset of the mental health disease. However, scalable interventions have not been established yet.

Objective

This study was designed to test the efficacy of two adolescent health promotion interventions: a well-care visit (WCV) with a risk assessment interview and counseling and self-monitoring with a smartphone cognitive behavioral therapy (CBT) app. Our hypothesis was that participants who had received both WCV and the CBT app would have better outcomes than those who had received only WCV or those who had not received any intervention. We conducted a prospective multi-institutional randomized controlled trial.

Methods

Participants were 217 adolescents aged 13-18 years. They were randomly divided into two intervention groups (WCV group and WCV with CBT app group) and a nonintervention group. WCV comprised a standardized physical examination along with a structured interview and counseling for youth risk assessment, which was designed with reference to the Guideline for Health Supervision of Adolescents of Bright Futures. A smartphone-based CBT program was developed based on the CBT approach. The CBT app comprised a 1-week psychoeducation component and a 1-week self-monitoring component. During the CBT program, participants created several self-monitoring sheets based on the CBT model with five window panels: event, thoughts, feelings, body response, and actions. The primary outcome was the change in scores for depressive symptoms. Secondary outcomes included changes in scores for self-esteem, quality of life, self-monitoring, and an adolescent health promotion scale. These outcomes were evaluated at baseline and at 1, 2, and 4 months after baseline. The exploratory outcome was the presence of suicidal ideation during the observation period. Intervention effects were estimated using mixed effect models.

Results

In total, 94% (204/217) of the participants completed the 4-month evaluation. Both intervention groups showed a significant effect in the form of reduced scores for depressive symptoms at 1 month in high school students; however, these effects were not observed at 2 and 4 months. The intervention effect was significantly more predominant in those scoring above cutoff for depressive symptoms. There was significantly less suicidal ideation in the intervention groups. As for secondary outcomes, there was significant increase in health promotion scale scores at the 4-month follow-up among junior high school students in the WCV group. Moreover, the CBT app was significantly effective in terms of obtaining self-monitoring skills and reducing depressive symptoms.

Conclusions

Although adolescent health promotion interventions may have short-term benefits, the frequency of WCV and further revision of the CBT app should be considered to evaluate long-term effectiveness.

Trial Registration

University Hospital Medical Information Network Clinical Trials Registry UMIN 000036343; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000041246

School educational models and child mental health among K-12 students: a scoping review

BACKGROUND

The promotion of mental health among children and adolescents is a public health imperative worldwide, and schools have been proposed as the primary and targeted settings for mental health promotion for students in grades K-12. This review sought to provide a comprehensive understanding of key factors involved in models of school education contributing to student mental health development, interrelationships among these factors and the cross-cultural differences across nations and societies.

METHODS

This scoping review followed the framework of Arksey and O'Malley and holistically reviewed the current evidence on the potential impacts of school-related factors or school-based interventions on student mental health in recent 5 years based on the PubMed, Web of Science, Embase and PsycExtra databases.

RESULTS/FINDINGS

After screening 558 full-texts, this review contained a total of 197 original articles on school education and student mental health. Based on the five key factors (including curriculum, homework and tests, physical activities, interpersonal relationships and after-school activities) identified in student mental development according to thematic analyses, a multi-component school educational model integrating academic, social and physical factors was proposed so as to conceptualize the five school-based dimensions for K-12 students to promote student mental health development.

CONCLUSIONS

The lessons learned from previous studies indicate that developing multi-component school strategies to promote student mental health remains a major challenge. This review may help establish appropriate school educational models and call for a greater emphasis on advancement of student mental health in the K-12 school context among different nations or societies.

Components of School-Based Interventions Stimulating Students' Intrapersonal and Interpersonal Domains: A Meta-analysis

Many universal school-based interventions aim to stimulate students' intrapersonal (e.g., self-esteem) and interpersonal (e.g., school climate) domains. To improve our understanding of why some of these interventions yield stronger effects than others, we identified intervention components that are related to stronger or weaker intervention effects. We systematically searched four databases (i.e., PsycINFO, PubMed, ERIC, CENTRAL) for controlled evaluations of universal school-based interventions. In total, 104 included studies (529 included effect sizes) reported on 99 unique interventions. Interventions showed small positive effects on the intrapersonal (d = 0.19) and interpersonal (d = 0.15) domains. Focusing on self-awareness and problem solving, using more active learning approaches, and using more extensive interventions predicted stronger intervention effects on aspects of both domains. In contrast, efforts to improve emotion regulation, assertiveness, cognitive coping, and using group discussions predicted weaker intervention effects. Furthermore, commonly implemented components were not necessarily related to stronger intervention effects and components that were related to stronger effects were not necessarily often implemented. Our findings highlight the need to carefully select components for inclusion in interventions.PROSPERO Registration Number: CRD42019137981.

Social threat sensitivity and its relationships with peer victimisation and internalising symptoms among adolescent girls

Consistent associations have been shown between self-reported peer victimisation and internalising symptoms. In distinct literature, anxious and depressed youth have been shown to interpret ambiguous social stimuli in a manner consistent with social threat and rejection. The aim of the current study was to determine whether this sensitivity to social threat among anxious/depressed youth explains significant variance in the relationship between self-reports of peer victimisation and internalising symptoms. Two hundred and sixty-seven students in grades seven and eight (M age = 12.62, SD = 0.65) completed measures of their own symptoms of anxiety and depression as well as their experiences of being physically or relationally victimised by their peers. They also read descriptions of 10 hypothetical ambiguous social interactions and provided responses indicating whether they interpreted each scenario as indicating social threat (rejection/negative evaluation) and the extent to which they perceived it as victimisation. As expected, anxiety and depression were positively correlated with self-reported peer victimisation and with interpretations consistent with social threat and victimisation (social threat sensitivity). In turn, social threat sensitivity was positively correlated with both self-reported relational and physical victimisation, but moreso with the former. However, the relationship between anxiety and depression and victimisation remained significant, even after controlling for social threat sensitivity. Results suggest that a sensitivity toward social threat can influence self-reports of peer victimisation among anxious and depressed youth, but that the relationship between internalising and victimisation goes beyond this sensitivity.

The healthy body image (HBI) intervention: Effects of a school-based cluster-randomized controlled trial with 12-months follow-up

We examined the effects of the Healthy Body Image (HBI) intervention on positive embodiment and health-related quality of life among Norwegian high school students. The intervention comprised three interactive workshops, with body image, media literacy, and lifestyle as main themes. In total, 2,446 12^th grade boys (43%) and girls (mean age 16.8 years) from 30 high schools participated in a cluster-randomized controlled study with the HBI intervention and a control condition as the study arms. Data were collected at baseline, post-intervention, 3- and 12-months follow-up, and analysed using linear mixed regression models. The HBI intervention caused a favourable immediate change in positive embodiment and health-related quality of life among intervention girls, which was maintained at follow-up. Among intervention boys, however, weak post-intervention effects on embodiment and health-related quality of life vanished at the follow-ups. Future studies should address steps to make the HBI intervention more relevant for boys as well as determine whether the number of workshops or themes may be shortened to ease implementation and to enhance intervention effects.