Effectiveness of a cognitive behavioural therapy (CBT)-based intervention for reducing anxiety among adolescents in the Colombo District, Sri Lanka: cluster randomized controlled trial

Anxiety disorders are found to be the most prevalent psychological problems among children and adolescents. Cognitive behaviour therapy (CBT) was found to be effective at reducing anxiety. The purpose of this study was to assess the effectiveness of a universal school-based intervention for reducing anxiety among Grade 9 schoolchildren. A randomized controlled cluster trial was conducted by randomly assigning 36 schools in the Colombo district in Sri Lanka into study and control arms, each comprising 18 schools with 360 students. The levels of anxiety, self-esteem and depression status were assessed using the validated Screen for Child Anxiety Related Disorders (SCARED) tool and the Rosenberg self-esteem scale, respectively, and the Depression, Anxiety and Stress Scale 21 (DASS-21) at baseline, after intervention, and after 3 months. A CBT-based universal intervention package was administered weekly by a trained teacher for eight weeks with a one-month self-practice period to a randomly selected Grade 9 class in each school in the study arm. The control arm received routine care. Anxiety and self-esteem scores and depression status were compared between the two arms after the intervention and at 3 months of follow-up using the generalized estimation equation (GEE), controlling for confounding and clustering. The nonresponse and loss to follow-up rates were < 1%. When comparing the study arm with the control arm using GEE, anxiety levels were significantly lower [β = (-0.096), 95% CI = (-0.005) - (-0.186), p = 0.038] at follow-up but not postintervention [β = (-0.024), 95% CI = 0.006 - (-0.055), p = 0.115]. There were no significant differences in depression status after intervention (OR = 0.257, 95% CI =0.052-1.286; p = 0.098) or follow-up (OR = 0.422, 95% CI 0.177-1.008; p = 0.052), and self-esteem significantly increased after intervention (β = 0.811, 95% CI = 0.314-1.309; p = 0.001) but not at follow-up [β=0.435, 95% CI=(-0.276)-1.145, p=0.231]. This study revealed that the universal package based on CBT is effective at reducing anxiety and improving self-esteem among adolescents. The trial registration number and date were SLCTR/2018/018 and 19th of June 2018 respectively.

Effect of elevated depressive symptoms during adolescence on health-related quality of life in young adulthood-a six-year cohort study with repeated exposure measurements

Objectives

Depression is a major contributor of young people's burden of disease. In this study we aim to estimate the effect of elevated depressive symptoms on physical health-related quality of life.

Design

We used self-reported information from the prospective BELLA cohort study, which included adolescents selected from the general population in Germany. The baseline assessment (2003-2006) and the 1-, 2-, and 6-year follow-up waves provide the data basis.

Participants

The baseline study population consisted of 1,460 adolescents between the ages of 12 and 17 who, according to their caregivers, did not suffer from depression.

Variables

The primary outcome, as measured by the physical component score (PCS) of the SF-36 at a 6-year follow-up (range: 0-100), is physical health-related quality of life. The exposure of interest is depressive symptoms, as measured by the Center for Epidemiological Studies Depression Scale for Children (CES-DC) at baseline, 1-year follow-up and 2-year follow-ups (range: 0-60). We dichotomized the exposure into subthreshold (≤15) and elevated depressive symptoms (>15). For the main analyses we considered a cumulative index for elevated depressive symptoms across the three time points (range: 0-3). Considered confounders are sex, age, socioeconomic status, migrant background, social support, anxiety symptoms, physical activity, chronic diseases, and sleeping problems.

Statistical methods

We used multiple imputation to account for missing values. Within each imputed dataset, we applied inverse probability weighting (IPW) to estimate the effect of the cumulative index for elevated depressive symptoms at baseline, 1- and 2-year follow-up on physical health-related quality of life at 6-year follow-up. We derived 95% confidence intervals by bootstrapping.

Results

After adjusting with IPW, the effect of the cumulative index per one unit increase of elevated depressive symptoms on the physical component score was -1.71 (95% CI: -3.51 to -0.04). The adjusted effect estimates of single exposure of elevated depressive symptoms on physical health-related quality of life were -0.83 (95% CI: -3.69 to 1.87) at baseline, -2.96 (95% CI: -4.94 to -0.52) at 1-year follow-up and -1.32 (95% CI: -3.85 to 1.15) at 2-year follow-up.

Conclusion

Findings suggest that elevated depressive symptoms during adolescence decrease physical health-related quality of life in young adulthood.

Development of an implementation plan for a school-based multimodal approach for depression and suicide prevention in adolescents

Strong Teens and Resilient Minds (STORM) is a multimodal, school-based approach for depression and suicide prevention in adolescents that is currently implemented in a region in the Netherlands. The STORM approach will be implemented in new regions in the coming years. This study used the implementation mapping protocol to report on the development of the STORM implementation plan. First, a needs assessment was conducted through semi-structured interviews with stakeholders and brainstorming sessions with regional programme leaders in the two regions that started implementing STORM in 2023. This led to the identification of six main barriers to implementation: high level of demands for schools, insufficient understanding of the programme content, insufficient network collaboration, no perceived relative advantage of STORM by stakeholders, lack of attention to sustainability, and high work pressure. Second, performance and change objectives were formulated based on these barriers. For example, a performance objective for potential providers was that they felt supported by STORM. Third, implementation strategies were selected from theory and translated into practical applications through brainstorming sessions with programme leaders. The following strategies were included in the implementation plan: collaborate with similar initiatives within the region, free up time for STORM tasks, tailor strategies, identify and prepare STORM champions, and promote network weaving. Last, a plan to evaluate the implementation of STORM and the application of the STORM implementation plan was formulated. Planned evaluation research will provide more insight into the usefulness and impact of the STORM implementation plan.

The Effectivity of a School-Based Early Intervention Targeting Psychological Complaints and Non-Suicidal Self-Injury in Adolescents

Background: Recent research suggests a concerning trend of non-suicidal self-injury (NSSI) and suicidal behaviors emerging at younger ages (as early as age 12). Early onset of NSSI is linked to more severe outcomes. While universal school-based prevention programs have shown promise in addressing suicidal behaviors, there is limited research on their effectiveness in preventing NSSI onset among adolescents. This study aims to evaluate the efficacy of a universal prevention program in schools for NSSI and mental complaints while enhancing resilience and mental health in 11-14-year-old adolescents. Methods: In total, 329 Flemish secondary school students (55.6% female), aged 11 to 14 years, participated in a 4 h classroom universal prevention, with a focus on emotion regulation, mental health, and specific strategies to prevent NSSI and reduce stigma. For both the intervention and control group (N = 124), a pre-, post-, and one-month follow-up questionnaire was administered, containing reliable and valid measures for NSSI and suicidality, emotion regulation, help-seeking behaviors, well-being, and psychological distress. Results: The prevention program effectively reduced NSSI and psychological distress, particularly for adolescents with a history of NSSI. Conclusions: These findings support previous research on the effectiveness of school-based programs in reducing mental complaints and suggest promising outcomes for NSSI prevention.

Child Maltreatment Types by Age: Implications for Prevention

Child maltreatment is a global public health issue known to affect an average of 600,000 U.S. children of all ages (0-18 years old) annually. However, a preponderance of preventive programs target children on the younger end of the spectrum, specifically those aged 0-5. Annual reports of the prevalence of maltreatment provide opportunities to analyze trends, but in 2009, these reports stopped reporting the ages of victims for each type of maltreatment (i.e., neglect, physical abuse, emotional abuse, and sexual abuse). This omission limits the ability to match (or design) prevention programs responsive to the ages of those at greatest risk. Using data from the National Child Abuse and Neglect Data System (NCANDS) from 2011-2020, this secondary data analysis describes trends for four types of maltreatment by age from an epidemiological perspective. Implications for practice (i.e., prevention) and policy are presented. The findings of this study offer the first step in what is hoped to be a line of research that seeks to identify, match, and/or develop evidence-based programs to prevent child maltreatment among the populations at highest risk.

Association between life events, anxiety, depression and non-suicidal self-injury behavior in Chinese psychiatric adolescent inpatients: a cross-sectional study

Background

Non-suicidal self-injury (NSSI) is a major public health concern among adolescents. Further research is needed into contributors to this behavior, in particular among adolescents with psychiatric disorders. The aim of the present study was to explore the impact of life events and emotional stress on NSSI among hospitalized psychiatric adolescents.

Methods

In this cross-sectional study, 505 Chinese psychiatric adolescent inpatients 10-19  years old completed questionnaires about sociodemographic characteristics and NSSI as well as the Adolescent Self-Rating Life Events Checklist (ASLEC), the State-Trait Anxiety Inventory Form Y, and the Center for Epidemiological Studies Depression Scale. Chi-square test was used to compare the incidence of NSSI in psychiatric adolescent patients with different sociodemographic. T-test was used to compare the total scores and dimension scores of the ASLEC, STAI-Y, and CES-D between the NSSI group and the non-NSSI group. A binary logistic regression model was built to explore the relationships among sociodemographic characteristics, questionnaire scores and NSSI.

Results

Most psychiatric adolescent inpatients (393, 77.8%) reported NSSI behavior. The higher risk for NSSI was observed among female (odds ratio [OR] 2.665, 95% confidence interval [CI] 1.575-4.510), younger adolescents (10-14 years; OR 2.021, 95% CI 1.258-3.245), with a suicide history (OR 2.479, 95% CI 1.549-3.967), or with depression symptom (OR 3.217, 95% CI 1.572-6.582) and those with higher scores of ASLEC (OR 1.019, 95% CI 1.010-1.029).

Conclusion

Our study in China is one of the first to apply to adolescent inpatients the diagnostic criteria of NSSI in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders. Our analysis suggests that NSSI prevalence is disturbingly high among adolescents with mental illness in China. A better understanding of contributing factors, especially negative life events and negative emotions, may guide interventions that can reduce its prevalence.

Knowledge Gains from the Implementation of a Child Sexual Abuse Prevention Program and the Future of School-Based Prevention Education

School-based child sexual abuse (CSA) programs effectively increase students' CSA-related knowledge. This study focuses on an implementation trial of Safe Touches, an empirically supported, school-based CSA prevention program, that was disrupted by the COVID-19 pandemic. We sought to demonstrate gains in CSA-related knowledge following Safe Touches but were limited to a pre-post design. A total of 2,210 students across five counties in a Mid-Atlantic state received the Safe Touches workshop between September 2019 and March 2020. McNemar's chi-square test was used to assess changes in the proportion of correct responses pre-workshop (Time 1) and one-week post-workshop (Time 2). Students' CSA-related knowledge increased significantly based on changes in mean CSA knowledge scores and the number of correct item-level responses assessed at Time 1 and Time 2 (p < .000). Leveraging the experience of the facilitators' who delivered these workshops prior to the disruption of implementation, we gathered facilitators' perspectives to explore the viability of offering Safe Touches virtually. In July 2020, 16 facilitators completed an electronic survey designed to understand the viability of a virtual Safe Touches workshop. Three themes emerged from facilitator feedback on virtual programming: student engagement concerns, handling disclosures, and technology access to a virtual program. The findings of this study indicate that the Safe Touches workshop significantly increased CSA-related knowledge and, overall, facilitators supported further exploration and development of a virtual Safe Touches workshop. The transition of empirically supported school-based CSA prevention programs to a virtual delivery modality is necessary to maintain an effective means of primary prevention and opportunity for disclosure.

Developmentally appropriate mental health literacy content for school-aged children and adolescents

Although improving the mental health of children and adolescents has become a global priority, resources outlining developmentally appropriate content for improving mental health literacy (MHL) across school-aged children are scarce. A comprehensive, life-course approach to building MHL is needed to address the evolving competencies, needs, capacities, and risk factors for mental health, especially to establish school-based interventions that can be equitably and sustainably implemented. We conducted a theoretical review highlighting the relation of research and practice in building MHL through developmentally appropriate knowledge and competencies for children and adolescents. A two-pronged review of the literature was conducted to provide an overview of (1) research with a focus on neurobiological, psychological, cognitive, and social developmental milestones of school-aged children relevant for building MHL and (2) evidence-based and theory-driven content for the development of universal MHL interventions for children and adolescents considering the four components of MHL. A map of relevant key milestones highlights the range of development that occurs and ample opportunity for increasing universal MHL during these sensitive years primed for learning. We reflect on current understandings and global considerations for MHL interventions with an emphasis on applying developmental science to the future strengthening of intervention development, uptake, adaptation, implementation, evaluation, and scale-up.

Does Online Implementation Make a Difference in the Effects of a Mental Health Curriculum at Schools?

COVID-19 changed and challenged education, with schools obliged to adapt to online settings. This study aims to evaluate the impact of a mental health curriculum implemented at schools, considering the implementation settings: online, onsite, and mixed (online and onsite). From kindergarten to high school, 933 students were evaluated by teachers regarding their social and emotional learning, strengths and difficulties, and academic outcomesin two measuring times: pre- and post-test. A qualitative analysis of teachers' adaptations to the online implementation was also conducted. Results revealed a positive impact with both mixed and onsite implementation. However, the mixed format demonstrated significant positive changes between the pre-and post-test, namely in relationship skills, responsible decision-making, internalized problems, and academic achievement. The mixed format with few online activities appears to have a more positive impact on students. Nevertheless, implementing social and emotional skills (SES) activities exclusively online seems to positively affect some SES domains more than onsite and mixed formats. Teachers used synchronous (e.g., digital platforms) and asynchronous (e.g., extra resources) adaptations for the implementation. This study shows that implementing mental health programs at schools, in this case, PROMEHS, is beneficial for students, even amidst the pandemic, and regardless of the implementation settings.

Mental Health and Positive Development Prevention Interventions: Overview of Systematic Reviews

CONTEXT

Previous reviews of mental health interventions have focused on adolescents (10-19 years), with a paucity of comprehensive evidence syntheses on preventive interventions for school-aged children (5-10 years).

OBJECTIVE

To summarize and synthesize the available evidence from systematic reviews of mental health and positive development interventions for children aged 5-14.9 years in both high-income (HIC) and low- and middle-income countries (LMIC), with a focus on preventive and promotive strategies.

DATA SOURCES

This overview includes all relevant reviews from OVID Medline, The Cochrane Library, and Campbell Systematic Reviews through December 2020.

STUDY SELECTION

We included systematic reviews that synthesized empirical studies using experimental or quasi-experimental designs to evaluate the effectiveness of interventions in children aged 5-14.9 years.

DATA EXTRACTION

Data extraction and quality assessment were completed independently and in duplicate by two review authors. The AMSTAR2 tool was used to assess methodological quality.

RESULTS

We included 162 reviews. The greatest evidence was found in support of school-based universal and anti-bullying interventions in predominantly HIC. Moderate evidence was found for the use of substance abuse prevention, and early learning and positive development interventions in mixed settings. In LMIC-only contexts, the most promising evidence was found for positive youth development programs.

LIMITATIONS

The review was primarily limited by paucity of high-quality research due to methodological issues and high heterogeneity.

CONCLUSIONS

This overview of reviews highlights the need for further research to consolidate findings and understand the specific criteria involved in creating positive mental health and development outcomes from the various interventions considered.

Implementing a peer-to-peer, self-management intervention for young people with depression and anxiety in Denmark

Background

Depressive and anxiety disorders share major risk factors and can often be effectively prevented or treated with similar interventions. However, less than half of young people with mental health problems seek professional help and hence innovative approaches to support this group are needed. To this end Coping with Anxiety and Depression shows promise. The aim of this paper was to evaluate the implementation of Coping with Anxiety and Depression for young people aged 15–25 years showing symptoms of anxiety and/or depression in a Danish community setting.

Methods

The programme was implemented in 39 Danish municipalities. To evaluate the implementation of the programme, we collected quantitative and qualitative data simultaneously and subsequently we triangulated it in the data analysis. The qualitative data collection comprised semi-structured interviews in seven case municipalities. In each municipality we conducted interviews with a local municipality coordinator of the program, a group interview with two voluntary instructors facilitating the program and a group interview with two to seven participants in the programme. In total, seven local coordinators, 14 voluntary instructors and 23 participants (8 men and 15 women) were interviewed. We also carried out a baseline and post-intervention survey. Interview data was coded via an inductive and deductive analysis approach. Survey data was analysed via descriptive statistics in the statistical software programme STATA 16.

Results

The evaluation showed that the implementation of the programme is feasible, and that most participants (83%) were satisfied with the programme to a high/very high extent. In total, 84% of the participants strongly agreed/agreed that it was advantageous that instructors themselves had experience with anxiety and depression. Qualitative data showed that the participants were very positive about the group format. It also showed that recruitment and retention of participants and especially young instructors were challenging but doable. Thus our findings suggest that the programme can be implemented in a way that is perceived as useful and satisfying to young people.

Conclusions

Coping with Anxiety and Depression constitutes a feasible peer-to-peer, group-based community programme that is well-received by its target group. Recruitment and retention of participants and instructors is challenging but doable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00777-w.

A School-Based Approach to Building Resilience and Mental Health Among Adolescents on the Autism Spectrum: A Longitudinal Mixed Methods Study

Tackling mental health difficulties in adolescents on the autism spectrum requires a comprehensive prevention approach. A 3-year multisite proof-of-concept longitudinal study implemented an evidence-based multilevel resilience intervention in schools to promote protective factors at the adolescent, parent, and school level. The intervention, consisting of the adolescent, parent and teacher components of the Resourceful Adolescent Program–Autism Spectrum Disorder (RAP-ASD) augmented with the Index for Inclusion, was implemented in 6 secondary schools with 30 adolescents with an autism diagnosis in Grades 7 and 8, 31 parents of 23 of the adolescents, and school staff. The intervention was implemented with good validity and acceptability. Quantitative data from adolescents and parents were analysed using the Reliable Change Index, and qualitative data were analysed using Consensual Qualitative Research. Triangulated quantitative and qualitative outcomes from the majority of adolescents and their parents showed some evidence for promoting resilience for adolescents with a diagnosis or traits of autism, as reflected in reliable improvements in coping self-efficacy and school connectedness, and a reduction in anxiety symptoms and emotional and behavioural difficulties. A reliable improvement in depressive symptoms was more modest and was only achieved by a small minority of adolescents. This multilevel, strength-focused, resilience-building approach represents a promising and sustainable school-based primary prevention program to improve the quality of life for adolescents on the spectrum by promoting their mental health and providing their families with much needed support.

Impact of counselling provision in primary schools on child and adolescent mental health service referral rates: a longitudinal observational cohort study

BACKGROUND

In the United Kingdom, schools play an increasingly important role in supporting young peoples' mental health. While there is a growing evidence base to support the effectiveness of school-based interventions, less is known about how these provisions impact on local Child and Adolescent Mental Health Service (CAMHS) referral rates. There is a concern that an increase in school-based provision might lead to an increase in CAMHS referrals and overwhelm services. We aimed to examine the longitudinal association between Place2Be counselling provision in primary schools on CAMHS referral rates in South London.

METHOD

This was a retrospective cohort study using linked data from the National Pupil Database (NPD) and CAMHS referrals to the South London and Maudsley's NHS Foundation Trust (SLaM) identified through the Clinical Record Interactive Search (CRIS) tool. The cohort included a total of 285 state-maintained primary schools in four London boroughs for the academic years of 2007-2012. During the study period, 23 of these schools received school-based mental health provision from Place2Be. The primary outcome was the incident rate ratio (IRR) of school-level accepted CAMHS referrals in 2012/13 in schools with, or without, Place2Be provision.

RESULTS

There was no significant association between elevated rates of CAMHS referral and Place2Be provision, even after comprehensive adjustment for school-level and pupil characteristics (IRR 0.91 (0.67-1.23)). School-level characteristics, including higher proportion of white-British pupils (IRR 1.009 (1.002-1.02)), medical staff ratio (IRR 6.49 (2.05-20.6)) and poorer Ofsted school inspection ratings (e.g. IRR 1.58 (1.06-2.34) for 'Requires Improvement' vs. 'Outstanding') were associated with increased CAMHS referral rates.

CONCLUSIONS

Place2Be provision did not result in increased specialist mental health referrals; however, other school-level characteristics did. Future research should investigate pupils' Place2Be clinical outcomes, as well the outcomes of individuals referred to CAMHS to better understand which needs are being met by which services.

Psychological distress in early childhood and the risk of adolescent spinal pain with impact

BACKGROUND

Spinal pain (SP), including neck and back pain, is common and often associated with poor mental health and reduced quality of life of adolescents. Contemporary understanding of SP favours a biopsychosocial approach, and emerging evidence suggests the stronger influence of psychological rather than other factors.

OBJECTIVES

We aimed to investigate if experiencing psychological distress in early childhood increases the risk of spinal pain with impact during adolescence.

METHODS

1175 adolescents from a prospective cohort study (Raine Study Gen2) were included. Psychological distress was assessed at ages 2, 5, 8 and 10 using Child Behaviour Check List (CBCL). CBCL total and subscale scores (internalizing and externalizing symptoms) were converted to age-standardized scores and dichotomized according to t-scores (>60=high distress). Life-time spinal pain, including low back, mid back, or neck/shoulder, was measured at age 17. We were interested in adolescent SP with impact (care seeking, medication use, school absenteeism, daily activity interference, leisure activity interference) and defined cases as SP with impact (one or more) or greater impact (two or more) impacts. We investigated the longitudinal associations between childhood psychological distress and adolescent SP using univariate and multivariable logistic regression models.

RESULTS

Psychological distress in childhood increased the odds of adolescent SP with impact by 33% (OR 1.33; 95% CI 1.01-1.76), but not spinal pain with greater impact (OR 1.22; 95% 0.83-1.80). Internalizing symptoms were associated with SP with greater impact and externalizing symptoms with SP with impact after adjusting for a range of potential child and family confounders.

CONCLUSION

Psychological distress in childhood increases the risk of SP with impact in adolescence and may be a promising prevention target.

SIGNIFICANCE

Our findings provide evidence that psychological distress early in life is an independent risk factor for spinal pain with impact during adolescence. As psychological distress during childhood is potentially modifiable, it may be a promising target for research on the prevention of consequential spinal pain in adolescence. Identifying and addressing psychological distress in children may be an important component of best practice to reduce consequential spinal pain in adolescents.

A Mobile Peer Intervention for Preventing Mental Health and Substance Use Problems in Adolescents: Protocol for a Randomized Controlled Trial (The Mind Your Mate Study)

Background

Anxiety, mood, and substance use disorders have significant social and economic impacts, which are largely attributable to their early age of onset and chronic disabling course. Therefore, it is critical to intervene early to prevent chronic and debilitating trajectories.

Objective

This paper describes the study protocol of a CONSORT (Consolidated Standards of Reporting Trials)-compliant randomized controlled trial for evaluating the effectiveness of the Mind your Mate program, a mobile health (mHealth) peer intervention that aims to prevent mental health (focusing on anxiety and depression) and substance use problems in adolescents.

Methods

Participants will consist of approximately 840 year 9 or year 10 students (60 students per grade per school) from 14 New South Wales high schools in Sydney, Australia. Schools will be recruited from a random selection of independent and public schools across the New South Wales Greater Sydney Area by using publicly available contact details. The intervention will consist of 1 introductory classroom lesson and a downloadable mobile app that will be available for use for 12 months. Schools will be randomly allocated to receive either the mHealth peer intervention or a waitlist control (health education as usual). All students will be given web-based self-assessments at baseline and at 6- and 12-month follow-ups. The primary outcomes of the trial will be the self-reported use of alcohol and drugs, anxiety and depression symptoms, knowledge about mental health and substance use, motives for not drinking, and willingness to seek help. Secondary outcomes will include positive well-being, the quality of life, and the impact of the COVID-19 pandemic. Analyses will be conducted using mixed-effects linear regression analyses for normally distributed data and mixed-effects logistic regression analyses for categorical data.

Results

The Mind your Mate study was funded by an Australian Rotary Health Bruce Edwards Postdoctoral Research Fellowship from 2019 to 2022. Some of the development costs for the Mind your Mate intervention came from a seed funding grant from the Brain and Mind Centre of the University of Sydney. The enrollment of schools began in July 2020; 12 of 14 schools were enrolled at the time of submission. Baseline assessments are currently underway, and the first results are expected to be submitted for publication in 2022.

Conclusions

The Mind your Mate study will generate vital new knowledge about the effectiveness of a peer support prevention strategy in real-world settings for the most common mental disorders in youth. If effective, this intervention will constitute a scalable, low-cost prevention strategy that has significant potential to reduce the impact of mental and substance use disorders.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620000753954; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379738&isReview=true

International Registered Report Identifier (IRRID)

DERR1-10.2196/26796

Online interventions to prevent mental health problems implemented in school settings: the perspectives from key stakeholders in Austria and Spain

BACKGROUND

Schools are key settings for delivering mental illness prevention in adolescents. Data on stakeholders' attitudes and factors relevant for the implementation of Internet-based prevention programmes are scarce.

METHODS

Stakeholders in the school setting from Austria and Spain were consulted. Potential facilitators (e.g. teachers and school psychologists) completed an online questionnaire (N=50), policy makers (e.g. representatives of the ministry of education and health professional associations) participated in semi-structured interviews (N=9) and pupils (N=29, 14-19 years) participated in focus groups. Thematic analysis was used to identify experiences with, attitudes and needs towards Internet-based prevention programmes, underserved groups, as well as barriers and facilitators for reach, adoption, implementation and maintenance.

RESULTS

Experiences with Internet-based prevention programmes were low across all stakeholder groups. Better reach of the target groups was seen as main advantage whereas lack of personal contact, privacy concerns, risk for misuse and potential stigmatization when implemented during school hours were regarded as disadvantages. Relevant needs towards Internet-based programmes involved attributes of the development process, general requirements for safety and performance, presentation of content, media/tools and contact options of online programmes. Positive attitudes of school staff, low effort for schools and compatibility to schools' curriculum were seen as key factors for successful adoption and implementation. A sound implementation of the programme in the school routine and continued improvement could facilitate maintenance of online prevention initiatives in schools.

CONCLUSIONS

Attitudes towards Internet-based mental illness prevention programmes in school settings are positive across all stakeholder groups. However, especially safety concerns have to be considered.

School-based interventions to prevent anxiety, depression and conduct disorder in children and young people: a systematic review and network meta-analysis

Background

Schools in the UK increasingly have to respond to anxiety, depression and conduct disorder as key causes of morbidity in children and young people.

Objective

The objective was to assess the comparative effectiveness of educational setting-based interventions for the prevention of anxiety, depression and conduct disorder in children and young people.

Design

This study comprised a systematic review, a network meta-analysis and an economic evaluation.

Data sources

The databases MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to 4 April 2018, and the NHS Economic Evaluation Database (NHS EED) was searched on 22 May 2019 for economic evaluations. No language or date filters were applied.

Main outcomes

The main outcomes were post-intervention self-reported anxiety, depression or conduct disorder symptoms.

Review methods

Randomised/quasi-randomised trials of universal or targeted interventions for the prevention of anxiety, depression or conduct disorder in children and young people aged 4–18 years were included. Screening was conducted independently by two reviewers. Data extraction was conducted by one reviewer and checked by a second. Intervention- and component-level network meta-analyses were conducted in OpenBUGS. A review of the economic literature and a cost–consequence analysis were conducted.

Results

A total of 142 studies were included in the review, and 109 contributed to the network meta-analysis. Of the 109 studies, 57 were rated as having an unclear risk of bias for random sequence generation and allocation concealment. Heterogeneity was moderate. In universal secondary school settings, mindfulness/relaxation interventions [standardised mean difference (SMD) –0.65, 95% credible interval (CrI) –1.14 to –0.19] and cognitive–behavioural interventions (SMD –0.15, 95% CrI –0.34 to 0.04) may be effective for anxiety. Cognitive–behavioural interventions incorporating a psychoeducation component may be effective (SMD –0.30, 95% CrI –0.59 to –0.01) at preventing anxiety immediately post intervention. There was evidence that exercise was effective in preventing anxiety in targeted secondary school settings (SMD –0.47, 95% CrI –0.86 to –0.09). There was weak evidence that cognitive–behavioural interventions may prevent anxiety in universal (SMD –0.07, 95% CrI –0.23 to 0.05) and targeted (SMD –0.38, 95% CrI –0.84 to 0.07) primary school settings. There was weak evidence that cognitive–behavioural (SMD –0.04, 95% CrI –0.16 to 0.07) and cognitive–behavioural + interpersonal therapy (SMD –0.18, 95% CrI –0.46 to 0.08) may be effective in preventing depression in universal secondary school settings. Third-wave (SMD –0.35, 95% CrI –0.70 to 0.00) and cognitive–behavioural interventions (SMD –0.11, 95% CrI –0.28 to 0.05) incorporating a psychoeducation component may be effective at preventing depression immediately post intervention. There was no evidence of intervention effectiveness in targeted secondary, targeted primary or universal primary school settings post intervention. The results for university settings were unreliable because of inconsistency in the network meta-analysis. A narrative summary was reported for five conduct disorder prevention studies, all in primary school settings. None reported the primary outcome at the primary post-intervention time point. The economic evidence review reported heterogeneous findings from six studies. Taking the perspective of a single school budget and based on cognitive–behavioural therapy intervention costs in universal secondary school settings, the cost–consequence analysis estimated an intervention cost of £43 per student.

Limitations

The emphasis on disorder-specific prevention excluded broader mental health interventions and restricted the number of eligible conduct disorder prevention studies. Restricting the study to interventions delivered in the educational setting may have limited the number of eligible university-level interventions.

Conclusions

There was weak evidence of the effectiveness of school-based, disorder-specific prevention interventions, although effects were modest and the evidence not robust. Cognitive–behavioural therapy-based interventions may be more effective if they include a psychoeducation component.

Future work

Future trials for prevention of anxiety and depression should evaluate cognitive–behavioural interventions with and without a psychoeducation component, and include mindfulness/relaxation or exercise comparators, with sufficient follow-up. Cost implications must be adequately measured.

Study registration

This study is registered as PROSPERO CRD42016048184.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Classroom-based cognitive behavioural therapy: a large-scale non-randomised controlled trial of the 'Journey of the Brave'

BACKGROUND

In Japan, 'Journey of the Brave', a cognitive behavioural therapy (CBT)-based anxiety preventive education programme, was previously developed and its effectiveness examined in two small-scale controlled trials. These studies had some limitations, including a small number of participants and not having regular classroom teachers as programme facilitators. Therefore, we conducted a large-scale controlled trial, with teachers as programme implementers.

METHODS

Twenty-seven elementary schools participated: 1622 and 1123 children were allocated to the intervention and control groups, respectively. The intervention group received a programme comprising ten 45-min sessions, while the control group underwent the regular school curriculum. Anxiety symptoms among participants were assessed using the Spence Children's Anxiety Scale (SCAS) at three stages (pre-intervention, post-intervention, and follow-up).

RESULTS

Following primary analysis, estimated mean changes in SCAS from baseline to follow-up were - 4.91 (95% CI - 5.91, - 3.90) in the intervention group and - 2.53 (95% CI - 3.52, - 1.54) in the control group; the group difference was 2.37 (95% CI 1.42, 3.33, p < 0.0001). Children in the intervention group showed significant reduction in their anxiety score versus children in the control group.

CONCLUSIONS

The results showed a statistically significant anxiety score reduction in the intervention group, thus verifying the programme's effectiveness. Trial registration The University Hospital Medical Information Network (UMIN): UMIN000032517. Registered 10 May 2018-Retrospectively registered, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000037083.

Randomised Controlled Trial of Study Without Stress: A Cognitive Behavioural Therapy Program to Reduce Stress in Students in the Final Year of High School

Typically students in their final year of school report high levels of anxiety, depression and stress. This study evaluated Study without Stress, a group cognitive behavioural program to reduce student stress. Fifty-six final year students (77% female) from four Australian secondary schools were randomly allocated to Study without Stress delivered by school staff, or to an 8-week usual care condition. Changes in self-reported stress, anxiety, depression, self-efficacy, and teacher reported emotional problems were assessed pre to post-treatment using intent-to-treat analyses. Maintenance of changes were examined 3-months later. Compared to usual care, Study without Stress led to significant reductions in self-reported stress and distress, and increases in self-efficacy that were maintained over time, with no significant changes in anxiety, depression or teacher reported emotional problems. Study without Stress is beneficial for reducing academic stress and improving self-efficacy in final year students when delivered in a school setting.

The relationship between search for meaning in life and symptoms of depression and anxiety: Key roles of the presence of meaning in life and life events among Chinese adolescents

BACKGROUND

Meaning in life has been associated with greater mental health. However, previous findings are inconsistent regarding how the search for meaning in life (SML) is related to mental health issues such as symptoms of depression and anxiety. This study proposed and tested a new model to explain how the relationship between SML and symptoms of depression as well as anxiety can be moderated by life events and mediated by the presence of meaning in life (PML).

METHODS

Middle and high school students (N = 1,705, 836 girls and 869 boys; M_age = 14.37, SD = 1.70) were administrated the Meaning in Life Questionnaire, Adolescent Self-Rating Life Events Checklist, Center for Epidemiologic Studies Depression Scale, and the State Anxiety Inventory.

RESULTS

Results showed that the relationship between SML and symptoms of depression (or anxiety) depended on the impact of the life events experienced by the individual. In general, SML served as a beneficial or unrelated factor for those experiencing low impactful life events, but as a harmful factor for those experiencing high impactful life events. For those experiencing middle impactful life events, SML had a positive direct effect, but a negative indirect effect (through PML) on symptoms of depression (or anxiety).

LIMITATIONS

Data are cross-sectional, and the present study examined only middle school students, which may limit generalizability.

CONCLUSIONS

The findings indicate a complex relationship between SML and mental health. Symptoms of depression, anxiety, and other related problems may be diminished by applying training programs and policies aimed at increasing PML and reducing negative life events.

School-Based Approaches to Prevent Depression in Adolescents

Depression is one of the highest prevalent mental illnesses and is one of the common illnesses that can have its onset during childhood or adolescence. It is estimated that up to 20% of children experience mental illness worldwide. Preventing the onset of depression in children and adolescents should be a vital public health goal that will improve public health and decrease health care costs. We reviewed literature that described school-based interventions to prevent the onset of depression, reduce the severity of depressive symptoms, and enhance global functioning in adolescents. Our research also provides strategies for school-based intervention programs that are mainly categorized into three main subtypes. We also discussed each subtype and its advantages and limitations. The goal is to bring the readers an understanding of the importance of preventing depression on a community level, beginning at schools.

Indicated prevention interventions for anxiety in children and adolescents: a review and meta-analysis of school-based programs

Anxiety disorders are among the most common youth mental health disorders. Early intervention can reduce elevated anxiety symptoms. School-based interventions exist but it is unclear how effective targeted approaches are for reducing symptoms of anxiety. This review and meta-analysis aimed to determine the effectiveness of school-based indicated interventions for symptomatic children and adolescents. The study was registered with PROSPERO [CRD42018087628]. We searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Library for randomised-controlled trials comparing indicated programs for child and adolescent (5-18 years) anxiety to active or inactive control groups. Data were extracted from papers up to December 2019. The primary outcome was efficacy (mean change in anxiety symptom scores). Sub-group and sensitivity analyses explored intervention intensity and control type. We identified 20 studies with 2076 participants. Eighteen studies were suitable for meta-analysis. A small positive effect was found for indicated programs compared to controls on self-reported anxiety symptoms at post-test (g = - 0.28, CI = - 0.50, - 0.05, k = 18). This benefit was maintained at 6 (g = - 0.35, CI = - 0.58, - 0.13, k = 9) and 12 months (g = - 0.24, CI = - 0.48, 0.00, k = 4). Based on two studies, > 12 month effects were very small (g = - 0.01, CI = - 0.38, 0.36). No differences were found based on intervention intensity or control type. Risk of bias and variability between studies was high (I² = 78%). Findings show that school-based indicated programs for child and adolescent anxiety can produce small beneficial effects, enduring for up to 12 months. Future studies should include long-term diagnostic assessments.

Personalizing and Optimizing Preventive Intervention Models via a Translational Neuroscience Framework

A new generation of research, building upon developmental psychopathology (Luthar et al. 1997; Luthar et al. (Child Development, 71, 543-562, 2000)), provides evidence that individual differences in risk for behavioral health problems result from intrapersonal and environmental modulation of neurophysiologic and genetic substrates. This transdisciplinary model suggests that, in any given individual, the number of genetic variants implicated in high-risk behavior and the way in which they are assorted and ultimately suppressed or activated in the brain by experiential and contextual factors help to explain behavioral orientations. Implications are that behavioral health problems can be amplified or reduced based on characteristics of an individual and socio-contextual influences on those characteristics. This emerging research has extraordinary implications for the design of prevention programs that more precisely target the malleable mechanisms that underlie behavioral health problems and, hence, more effectively prevent behavioral problems and promote resilience. A detailed, theory-driven examination of all evidence-based interventions is called for to identify the active ingredients that specifically impact these underlying mechanisms. Such an approach will enhance the ability of preventive interventions to achieve effect sizes indicative of beneficial impacts for a greater number of recipients. This paper presents the significant implications of this collective knowledge base for the next generation of precision-based, prevention-focused personalized interventions.

Moving Toward a Precision-Based, Personalized Framework for Prevention Science: Introduction to the Special Issue

The goal of this Special Issue is to introduce prevention scientists to an emerging form of healthcare, called precision medicine. This approach integrates investigation of the mechanisms of disease and health-compromising behaviors with prevention, treatment, and cure resolved at the level of the individual. Precision Medicine and its derivative personalized prevention represents a promising paradigm for prevention science as it accounts for response heterogeneity and guides development of targeted interventions that may enhance program effect sizes. If successfully integrated into prevention science research, personalized prevention is an approach that can inform the development of decision support tools (screening measures, prescriptive algorithms) and enhance the utility of mobile health technologies that will enable practitioners to use personalized consumer data to inform decisions about the best type and/or intensity of a prevention strategy for particular individuals or subgroups of individuals. In this special issue, we present conceptual articles that provide a heuristic framework for precision-based, personalization prevention research and empirical studies that address research questions exemplary of a new generation of precision-based personalized preventive interventions focused on children's mental health, behavioral health, and education.

A Systematic Review and Meta-Analysis of School-Based Stress, Anxiety, and Depression Prevention Programs for Adolescents

Given the recent rise in adolescent mental health issues, many researchers have turned to school-based mental health programs as a way to reduce stress, anxiety, and depressive symptoms among large groups of adolescents. The purpose of the current systematic review and meta-analysis is to identify and evaluate the efficacy of school-based programming aimed at reducing internalizing mental health problems of adolescents. A total of 42 articles, including a total of 7310 adolescents, ages 11-18, met inclusion for the meta-analyses. Meta-analyses were completed for each of the three mental health outcomes (stress, depression, and anxiety) and meta-regression was used to determine the influence of type of program, program dose, sex, race, and age on program effectiveness. Overall, stress interventions did not reduce stress symptoms, although targeted interventions showed greater reductions in stress than universal programs. Overall, anxiety interventions significantly reduced anxiety symptoms, however higher doses may be necessary for universal programs. Lastly, depression interventions significantly reduced depressive symptoms, but this reduction was moderated by a combination of program type, dose, race, and age group. Although, school-based programs aimed at decreasing anxiety and depression were effective, these effects are not long-lasting. Interventions aimed at reducing stress were not effective, however very few programs targeted or included stress as an outcome variable. Implications for practice, policy and research are discussed.

Lessons Learned About Barriers to Implementing School-Based Interventions for Adolescents: Ideas for Enhancing Future Research and Clinical Projects

The majority of youth with mental health problems do not receive treatment, highlighting the critical need to transport evidence-based interventions into community settings, such as schools. Despite being able to reach a large number of adolescents and minority youth, the process of implementing evidence-based interventions to schools is challenging. This paper discusses some expected and unexpected challenges experienced during the implementation of an open trial and a pilot randomized controlled trial examining the acceptability and effectiveness of a school-based preventive intervention for adolescents at risk for internalizing disorders. First, we highlight key programs and findings on preventive interventions for adolescents at risk for depression and anxiety. Next, we provide a brief overview of the preventive intervention we implemented in schools. This provides a context for the section that describes implementation issues and highlights specific challenges and potential solutions for intervention implementation. Finally, the paper offers recommendations for researchers and clinicians interested in implementing school-based mental health services for adolescents.

Impact of a Web Program to Support the Mental Wellbeing of High School Students: A Quasi Experimental Feasibility Study

Little effort has been made to investigate the potential of web programs aimed to support the mental wellbeing of adolescents in school environments in middle-income countries. A quasi-experimental feasibility study was conducted in Thailand with adolescents (N = 180) in three conveniently sampled high schools and with teachers (N = 12) who acted as program tutors. The web program was used in small groups, independently, or it was not used at all. No statistically significant changes were found between the groups regarding depression, stress, or satisfaction. Differences between program users (n = 61) and non-users (n = 48) were not significant. Acceptance was higher among adolescents who used the program independently (n = 40, 73% vs. n = 21, 39%; p = 0.001). Usability feedback did not differ between the groups. Support should be provided in order for programs to be potentially used. More information is needed regarding factors associated with the use of web programs.

Meta-analytic review of dissonance-based eating disorder prevention programs: Intervention, participant, and facilitator features that predict larger effects

Many trials have provided support for dissonance-based eating disorder prevention programs. This meta-analytic review characterized the average intervention effects and tested whether various intervention, participant, and facilitator features correlated with larger effects to guide implementation of optimally effective versions of this program. We identified 56 trials that evaluated 68 dissonance-based eating disorder prevention programs (7808 participants). Average intervention effect sizes (d) relative to minimal intervention control conditions and credible alternative interventions (respectively) were 0.57 and 0.31 for thin-ideal internalization, 0.42 and 0.18 for body dissatisfaction, 0.37 and 0.17 for dieting, 0.29 and 0.21 for negative affect, and 0.31 and 0.13 for eating disorder symptoms. As hypothesized, effects were larger for interventions with more dissonance-inducing activities, more group sessions, and larger group sizes, as well as when delivered in-person versus on-line, sessions were recorded, participation was voluntary, body dissatisfaction was required, participants were mid-adolescents or adults (versus older adolescence), there were more ethnic minority participants, groups were led by clinicians versus researchers and at least two facilitators, and when facilitators received more training and supervision. Unexpectedly from a dissonance-induction perspective, effects were larger when participants were compensated. Results offer directions for maximizing the benefits of implementation efforts with dissonance-based eating disorder prevention programs, and may hold lessons for preventing other public health problems with dissonance-based interventions.

Comparison of the performance of the Beck Depression Inventory-II and the Center for Epidemiologic Studies-Depression Scale in Arab adolescents

BACKGROUND AND PURPOSE

Few instruments have been established as valid and reliable to screen for depression among Arab adolescents. The purpose of this study was to examine and compare the performance of two of the most widely used depression screening instruments, the Beck Depression Inventory-II (BDI-II) and the Center for Epidemiologic Studies-Depression scale (CES-D), with Arab adolescents.

METHODS

A nationwide school survey was conducted in Jordan. A total of 3,292 adolescents (1,766 females; 54%) aged 13-17 years completed and returned the survey that included the BDI-II, CES-D, sociodemographics, and health information. Comparisons were made between the BDI-II and CES-D on internal consistency and the reported prevalence of depression in the whole population and subgroups. Multivariate ordinary least squares and logistic regressions were used to assess factors associated with adolescent depression. Agreement regarding recommended cutoffs was also examined using Cohen's k.

RESULTS

Depression prevalence was significantly higher with the CES-D compared to the BDI-II among the same set of sample subgroups. Depression scores from both instruments showed different statistical associations with established risk factors for adolescent depression. The two instruments showed a moderate agreement (kappa = 0.55), indicating that the instruments do not completely identify the same cases. Different cutoff scores of the CES-D seemed to perform better for different age groups.

CONCLUSIONS

Our results varied systematically as a function of the measure used to identify depression prevalence. Caution in the interpretation of associations of depression scores with risk factors is required, as associations may be measurement artifacts. However, given the limited availability of mental health care resources in Arab countries, screening instruments like the BDI-II and CES-D may be a critical first step in preliminarily identifying cases, albeit neither can replace the clinical interview. We cautiously recommend using the CES-D with the risk of over diagnosing, but with the benefit of finding issues which are not typically addressed when there is a lack of mental health services. With the growing social and political unrest in Arab countries, increasing depression rates over time is expected to be a major public health issue. Methodical consideration for how to invest in community-based screening is warranted.

A Digital Game and School-Based Intervention for Students in Hong Kong: Quasi-Experimental Design

Background

In Hong Kong, with an increasing number of children experiencing mental health issues, there is a need to not only develop innovative interventions but also develop comprehensive prevention interventions so as to reduce their anxiety symptoms and enhance their emotional management and interpersonal relationships.

Objective

The aim of this study was to determine the effectiveness of The Adventures of DoReMiFa, an integration model of the cognitive-behavioral approach and positive psychology by using digital game–based and school-based mental health enhancement intervention to magnify the social and emotional health and well-being of the school children in Hong Kong aged 9 to 11 years.

Methods

A quasi-experimental design method was used to evaluate this digital game and school-based intervention. The Adventures of DoReMiFa was piloted in 4 primary schools where students were allocated to either an intervention or a control group. The participants were assessed at pre- and postintervention with a 6-month follow-up measuring their mental health knowledge, levels of anxiety symptoms, positive and negative thinking, perspective-taking, and self-esteem.

Results

A total of 459 primary school students from 4 primary schools participated in the study. The response rate on the questionnaires answered on the Web was up to 85.1% (391/459). Compared with the control group, the intervention group was found to have significant association with improved mental health knowledge at the time immediately after the intervention (beta=.46; P=.01) and in the 6-month postintervention period (beta=.66; P<.001); for perspective-taking, the intervention group had exhibited a significant improvement 6 months after the completion of the universal program (beta=1.50; P=.03). The intervention, however, was found not to be effective in reducing the rates of anxiety symptoms and negative thinking among the participating students.

Conclusions

The Adventures of DoReMiFa, an integration of a digital game–based and school-based mental health enhancement intervention, was shown to be effective in elevating the knowledge of mental health and promoting perspective-taking in the primary school students of Hong Kong. Although there was insufficient evidence to support a reduction in symptoms of anxiety and negative automatic thoughts, the overall results were still encouraging in that a preventive effect was found, indicating that the program has the potential to enhance the mental well-being of schoolchildren. It also suggests that knowledge enhancement may not necessarily lead to behavior change, and more focused effort may be needed to achieve the translation. The implications and limitations of this study and suggestions for future research were also discussed.

School-based early intervention for anxiety and depression in older adolescents: A feasibility randomised controlled trial of a self-referral stress management workshop programme ("DISCOVER")

INTRODUCTION

Schools may provide a convenient intervention setting for young people with mental health problems generally, as well as for those who are unwilling or unable to access traditional clinic-based mental health services. However, few studies focus on older adolescents, or those from ethnic minority groups. This study aims to assess the feasibility of a brief school-based psychological intervention for self-referred adolescents aged 16-19 years.

METHODS

A two-arm cluster randomised controlled trial was conducted in 10 inner-city schools with block randomisation of schools. The intervention comprised a one-day CBT Stress management programme with telephone follow-up (DISCOVER) delivered by 3 psychology (2 clinical and 1 assistant) staff. The control was a waitlist condition. Primary outcomes were depression (Mood and Feelings Questionnaire; MFQ) and anxiety (Revised Child Anxiety and Depression Scale; RCADS-anxiety subscale). Data were analysed descriptively and quantitatively to assess feasibility.

RESULTS

155 students were enrolled and 142 (91.6%) followed up after 3 months. Participants were predominantly female (81%) and the mean age was 17.3 years, with equal numbers enrolled from Year 12 and Year 13. Over half (55%) of students were from ethnic minority groups. Intraclass correlations were low. Variance estimates were calculated to estimate the sample size for a full RCT. Preliminary outcomes were encouraging, with reductions in depression (d = 0.27 CI-0.49 to -0.04, p = 0.021) and anxiety (d = 0.25, CI-0.46 to -0.04, p = 0.018) at follow-up.

CONCLUSIONS

Results support the feasibility of a school-based, self-referral intervention with older adolescents in a definitive future full-scale trial (Trial no. ISRCTN88636606).

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.

Evaluation of the effects of a childhood depression prevention program

The study aimed to design and evaluate a program for the prevention of childhood depression ("Pozik-Bizi" [in English, "Live-Happily"]), comparing its effects with a socio-emotional intervention program based on cooperative play. The sample comprised 420 students aged 7 to 10 years from the Basque Country, 51.9% were randomly assigned to the experimental condition ("Pozik-Bizi") program and 48.1% to the control group ("Play program"). Using a pretest-posttest repeated measures experimental design, 7 evaluation instruments were administered. When comparing the two interventions, it was confirmed that those who participated in the "Pozik-Bizi" program significantly decreased their level of clinical maladjustment, school maladjustment, emotional, and behavioral problems, and they increased positive behaviors that inhibit depression. However, the cooperative play program improved self-concept and social skills significantly more than the "Pozik-Bizi" program. The effect size in all the variables was small. The discussion analyzes the effectiveness of specific programs of prevention of childhood depression versus global programs of social-emotional development. This work provides a program to prevent childhood depression that has been shown to be effective in the reduction of clinical variables. In addition, this study confirms the positive potential of programs of cooperative play, to increase self-concept and social skills.

Evaluating the Long-Term Effectiveness of School-Based Depression, Anxiety, and Substance Use Prevention Into Young Adulthood: Protocol for the Climate School Combined Study

Background

Mental health and substance use disorders are the leading causes of global disability in children and youth. Both tend to first onset or escalate in adolescence and young adulthood, calling for effective prevention during this time. The Climate Schools Combined (CSC) study was the first trial of a Web-based combined universal approach, delivered through school classes, to prevent both mental health and substance use problems in adolescence. There is also limited evidence for the cost-effectiveness of school-based prevention programs.

Objective

The aim of this protocol paper is to describe the CSC follow-up study, which aims to determine the long-term efficacy and cost-effectiveness of the CSC prevention program for depression, anxiety, and substance use (alcohol and cannabis use) up to 7 years post intervention.

Methods

A cluster randomized controlled trial (the CSC study) was conducted with 6386 participants aged approximately 13.5 years at baseline from 2014 to 2016. Participating schools were randomized to 1 of 4 conditions: (1) control (health education as usual), (2) Climate Substance Use (universal substance use prevention), (3) Climate Mental Health (universal mental health prevention), or (4) CSC (universal substance use and mental health prevention). It was hypothesized that the CSC program would be more effective than conditions (1) to (3) in reducing alcohol and cannabis use (and related harms), anxiety, and depression symptoms as well as increasing knowledge related to alcohol, cannabis, anxiety, and depression. This long-term study will invite follow-up participants to complete 3 additional Web-based assessments at approximately 5, 6, and 7 years post baseline using multiple sources of locator information already provided to the research team. The primary outcomes include alcohol and cannabis use (and related harms) and mental health symptoms. An economic evaluation of the program will also be conducted using both data linkage as well as self-report resource use and quality of life measures. Secondary outcomes include self-efficacy, social networks, peer substance use, emotion regulation, and perfectionism. Analyses will be conducted using multilevel mixed-effects models within an intention-to-treat framework.

Results

The CSC long-term follow-up study is funded from 2018 to 2022 by the Australian National Health and Medical Research Council (APP1143555). The first follow-up wave commences in August 2018, and the results are expected to be submitted for publication in 2022.

Conclusions

This is the first study to provide a long-term evaluation of combined universal substance use and mental health prevention up to 7 years post intervention. Evidence of sustained benefits into early adulthood would provide a scalable, easy-to-implement prevention strategy with the potential for widespread dissemination to reduce the considerable harms, burden of disease, injury, and social costs associated with youth substance use and mental disorders.

International Registered Report Identifier (IRRID)

PRR1-10.2196/11372

Universal, school-based interventions to promote mental and emotional well-being: what is being done in the UK and does it work? A systematic review

OBJECTIVES

The present review aimed to assess the quality, content and evidence of efficacy of universally delivered (to all pupils aged 5-16 years), school-based, mental health interventions designed to promote mental health/well-being and resilience, using a validated outcome measure and provided within the UK in order to inform UK schools-based well-being implementation.

DESIGN

A systematic review of published literature set within UK mainstream school settings.

DATA SOURCES

Embase, CINAHL, MEDLINE, PsycINFO, PsychArticles, ASSIA and Psychological and Behavioural Sciences published between 2000 and April 2016.

ELIGIBILITY CRITERIA

Published in English; universal interventions that aimed to improve mental health/emotional well-being in a mainstream school environment; school pupils were the direct recipients of the intervention; pre-post design utilised allowing comparison using a validated outcome measure.

DATA EXTRACTION AND SYNTHESIS

12 studies were identified including RCTs and non-controlled pre-post designs (5 primary school based, 7 secondary school based). A narrative synthesis was applied with study quality check. 1 RESULTS: Effectiveness of school-based universal interventions was found to be neutral or small with more positive effects found for poorer quality studies and those based in primary schools (pupils aged 9-12 years). Studies varied widely in their use of measures and study design. Only four studies were rated 'excellent' quality. Methodological issues such as small sample size, varying course fidelity and lack of randomisation reduced overall study quality. Where there were several positive outcomes, effect sizes were small, and methodological issues rendered many results to be interpreted with caution. Overall, results suggested a trend whereby higher quality studies reported less positive effects. The only study that conducted a health economic analysis suggested the intervention was not cost-effective.

CONCLUSIONS

The current evidence suggests there are neutral to small effects of universal, school-based interventions in the UK that aim to promote emotional or mental well-being or the prevention of mental health difficulties. Robust, long-term methodologies need to be pursued ensuring adequate recording of fidelity, the use of validated measures sensitive to mechanisms of change, reporting of those lost to follow-up and any adverse effects. Further high-quality and large-scale research is required across the UK in order to robustly test any long-term benefits for pupils or on the wider educational or health system.

Exploring the feasibility and acceptability of a school-based self-referral intervention for emotional difficulties in older adolescents: qualitative perspectives from students and school staff

BACKGROUND

Adolescents with emotional difficulties need accessible, acceptable and evidence-based mental health interventions. Self-referral workshops (DISCOVER workshops) were offered to stressed 16- to 19-year olds in 10 Inner London schools.

METHOD

Semistructured interviews were conducted with three groups of participants: students who attended a 1-day workshop (n = 15); students who initially showed interest in the DISCOVER workshop programme, but decided not to take part (n = 9); and school staff who helped organise the programme in their schools (n = 10). Students were purposively sampled to ensure that those from Black and minority ethnic (BME) backgrounds were represented. Data were analysed using thematic analysis.

RESULTS

The accounts generally indicate that the delivery and evaluation of this intervention is perceived as feasible and acceptable. Students, including those from BME backgrounds, described the setting as suitable and reported that the workshop helped them develop new understandings of stress and how to handle it. They expressed a preference for engaging and interactive activities, and valued a personalised approach to workshop provision. School staff felt that the workshop was in line with school values. They described some logistical barriers to providing the workshops in school settings, and expressed a desire for more information about the workshop in order to provide follow-up support. The main reason students gave for nonparticipation was limited time.

CONCLUSIONS

Findings are discussed in relation to increasing the feasibility of implementing school-based psychological interventions and the value of providing access to mental health support in schools.

Effectiveness of a cognitive behavioural therapy-based anxiety prevention programme at an elementary school in Japan: a quasi-experimental study

BACKGROUND

The efficacy of cognitive behavioural therapy (CBT) for anxiety related problems in children is empirically supported. In addition, universal anxiety prevention programmes based on CBT have been demonstrated in recent years. The purpose of this study was to verify the effectiveness of a CBT based original programme 'Journey of the Brave,' aiming to prevent anxiety disorders and anxiety-related problems for Japanese children aged 10-12 years old.

METHODS

Intervention groups from two classes of 5th grade elementary students (n = 41) received ten 45-min programme sessions. The control group was drawn from one class of 5th grade children (n = 31) from a nearby school. All participants completed the Spence Children's Anxiety Scale (SCAS) at pre, post, and 3 months follow-up. Mixed-effects model for repeated measures analysis was conducted.

RESULTS

The mean anxiety score on the SCAS for the intervention group was significantly reduced at both post intervention and 3 months follow-up compared with the control group. The group differences on the SCAS from baseline to post-test were - 5.321 (95% CI - 10.12 to - 0.523, p = 0.030), and at the 3-month follow-up were - 7.104 (95% CI - 11.90 to - 2.306, p = 0.004).

CONCLUSIONS

The effectiveness of the anxiety prevention programme 'Journey of the Brave' was verified though this study using a quasi-experimental design on a small sample.Trial registration: UMIN000009021.

Changes in Depression and Positive Mental Health Among Youth in a Healthy Relationships Program

Mental health promotion programming in schools and community settings is an important part of a comprehensive mental health strategy. The goal of this study was to identify and explore meaningful classes of youth based on their pre- and post-intervention depression symptoms scores with 722 youth involved in a 15-week healthy relationships and mental health promotion program. We utilized latent class growth analysis to identify depression class trajectories, controlling for group clustering effects. A three-class solution identified high decreasing, moderate stable, and low stable trajectories. Gender, age, and reported experience of bullying victimization predicted trajectory class membership. The low stable class trajectory was associated with the highest positive mental health, followed by the moderate stable and the high decreasing trajectories. These results suggest that youth with the highest depression scores showed significant improvement in symptomatology over the course of the program.