A cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of a school-based cognitive–behavioural therapy programme (FRIENDS) in the reduction of anxiety and improvement in mood in children aged 9/10 years

Two universal school-based prevention programs for depression and anxiety: 24-Month follow-up of an RCT

BACKGROUND AND OBJECTIVES

Transdiagnostic approaches have been promoted as a means of maximising preventative effects across multiple problems with depression and anxiety suitable targets as they appear to have highly interconnected systems in pathology development and maintenance. This study investigated long-term effects of two universal school-based programs, Emotion Regulation (ER) and Behavioral Activation (BA), that sought to prevent depression and anxiety by targeting worry (a transdiagnostic feature) to promote resilience.

METHODS

This follow-up study captured data from 162 of 316 initial students (aged 8-13; 52.2% female), from six Australian schools. The original study design cluster randomised students by school into BA, ER, or a usual class control. Intervention conditions consisted of 8 × 50-min weekly sessions. This study measured the effects of these interventions after 24 months on resilience, worry, depression, and anxiety. Resilience was also examined as a potential mediator.

RESULTS

At 24-month follow-up, there was no significant effect of either intervention on depression, anxiety, worry, or resilience levels. Significantly fewer participants in ER and BA met clinical thresholds for separation anxiety disorder (SAD) and obsessive-compulsive disorder (OCD) in the 24-month follow-up compared with baseline. No mediation effects were found.

LIMITATIONS

Although self-report measures are common in universal, school-based research, this represents a study limitation.

CONCLUSIONS

Both interventions may provide limited long-term protective effects on SAD and OCD symptoms, which appear to have a shelf-life shorter than 24 months. To maintain program effects, refresher sessions at shorter intervals may be a consideration for future research.

The cost-effectiveness of school-based interventions for chronic diseases: a systematic review

BACKGROUND

Chronic diseases, or non-communicable diseases (NCD), are conditions of long duration and often influenced and contributed by complex interactions of several variables, including genetic, physiological, environmental, and behavioral factors. These conditions contribute to death, disability, and subsequent health care costs. Primary and secondary school settings provide an opportunity to deliver relatively low cost and effective interventions to improve public health outcomes. However, there lacks systematic evidence on the cost-effectiveness of these interventions.

METHODS

We systematically searched four databases (PubMed/Medline, Cochrane, Embase, and Web of Science) for published studies on the cost-effectiveness of chronic-disease interventions in school settings. Studies were eligible for inclusion if they assessed interventions of any chronic or non-communicable disease, were conducted in a school setting, undertook a full cost-effectiveness analysis and were available in English, Spanish, or French.

RESULTS

Our review identified 1029 articles during our initial search of the databases, and after screening, 33 studies were included in our final analysis. The most used effectiveness outcome measures were summary effectiveness units such as quality-adjusted life years (QALYs) (22 articles; 67%) or disability-adjusted life years (DALYs) (4 articles; 12%). The most common health condition for which an intervention targets is overweight and obesity. Almost all school-based interventions were found to be cost-effective (30 articles; 81%).

CONCLUSION

Our review found evidence to support a number of cost-effective school-based interventions targeting NCDs focused on vaccination, routine physical activity, and supplement delivery interventions. Conversely, many classroom-based cognitive behavioral therapy for mental health and certain multi-component interventions for obesity were not found to be cost-effective.

Review: Economic evidence of preventive interventions for anxiety disorders in children and adolescents - a systematic review

BACKGROUND

Anxiety disorders are common in children and youth. Also, in prevention, be it universal, selective or indicated, economic evaluation supports decision-making in the allocation of scarce resources. This review identified and summarised the existing evidence of economic evaluations for the prevention of anxiety disorders in children and adolescents.

METHODS

A systematic search was conducted on the EBSCO, Scopus, Web of Science, ProQuest, Cochrane and PubMed databases. We included studies that focused on children and adolescents under 18 years of age, aimed to prevent anxiety disorders and presented an incremental analysis of costs and effectiveness. A registered checklist was used that assessed the quality of the included articles.

RESULTS

The search yielded 1697 articles. Five articles were included in this review. Three were RCT-based, and two were model-based studies. Out of five included interventions, one was a universal school-based intervention, two selective interventions and two indicated interventions. Universal school-based prevention of anxiety was not cost-effective compared with usual teaching. Selective parent training and indicative child- and parent-focused CBT prevention were likely cost-effective compared with usual care or doing nothing.

CONCLUSION

Parent education and cognitive behaviour therapy interventions can be cautiously interpreted as being a cost-effective way of preventing anxiety in children and adolescents. However, the evidence is weakly related to cost-effectiveness as there are only a few studies, with relatively small sample sizes and short follow-ups.

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.

Economic Evaluations of Public Health Interventions to Improve Mental Health and Prevent Suicidal Thoughts and Behaviours: A Systematic Literature Review

To review the literature on economic evaluations of public health interventions targeting prevention of mental health problems and suicide, to support evidence based societal resource allocation. A systematic review of economic evaluations within mental health and suicide prevention was conducted including studies published between January 2000 and November 2018. The studies were identified through Medline, PsychINFO, Web of Science, the National Health Service Economic Evaluation Database and Health Technology Assessment. The quality of relevant studies and the transferability of their results were assessed using a criterion set out by the Swedish Agency for Health Technology Assessment. Nineteen studies of moderate to high quality were included in this review, which evaluated 18 interventions in mental health and four interventions in suicide prevention. Fourteen (63%) of all interventions were cost-effective based on the conclusions from original papers. None of the studies that evaluated suicide prevention was of high quality. The interventions largely focused on psychological interventions at school, the workplace and within elderly care as well as screening and brief interventions in primary care. Nine studies (around 50% of included articles) had a high potential for transferability to the Swedish context. Public health interventions aiming to improve mental health have a high potential to be economically beneficial to society, but high-quality evidence on the cost-effectiveness of suicide prevention is limited.

How can adolescent aggression be reduced? A multi-level meta-analysis

Aggressive behaviour among adolescents has significant social and economic costs. Numerous attempts have been made to intervene to reduce aggression in adolescents. However, little is known about what factors enhance or diminish intervention effectiveness. The present systematic review and meta-analysis, therefore, seeks to quantify the effectiveness of interventions to reduce aggressive behaviour in adolescents and to identify when and for whom such interventions work best. Sixteen databases were searched for randomised controlled trials that assessed interventions to reduce aggression among adolescents. After screening 9795 records, 95 studies were included. A multi-level meta-analysis found a significant overall small-to-medium effect size (d = 0.28; 95% CI [0.17, 0.39]). More effective interventions were of shorter duration, were conducted in the Middle East, were targeted at adolescents with higher levels of risk, and were facilitated by intervention professionals. Potentially active ingredients were classified using the Behaviour Change Technique Taxonomy. Behavioural practice and problem solving were components of more effective interventions targeted at the general population. Overall the findings indicate that psychosocial interventions are effective in reducing adolescent aggression. Future trials need to assess the effect of individual techniques and their combination to identify the key components that can reduce aggression in adolescents.

Universal Mental Health Interventions for Children and Adolescents: A Systematic Review of Health Economic Evaluations

BACKGROUND

Effective mental health interventions may reduce the impact that mental health problems have on young people's well-being. Nevertheless, little is known about the cost effectiveness of such interventions for children and adolescents.

OBJECTIVES

The objectives of this systematic review were to summarize and assess recent health economic evaluations of universal mental health interventions for children and adolescents aged 6-18 years.

METHODS

Four electronic databases were searched for relevant health economic studies, using a pre-developed search algorithm. Full health economic evaluations evaluating the cost effectiveness of universal mental health interventions were included, as well as evaluations of anti-bullying and suicide prevention interventions that used a universal approach. Studies on the prevention of substance abuse and those published before 2013 fell outside the scope of this review. Study results were summarised in evidence tables, and each study was subject to a systematic quality appraisal.

RESULTS

Nine studies were included in the review; in six, the economic evaluation was conducted alongside a clinical trial. All studies except one were carried out in the European Union, and all but one evaluated school-based interventions. All evaluated interventions led to positive incremental costs compared to their comparators and most were associated with small increases in quality-adjusted life-years. Almost half of the studies evaluated the cost effectiveness of cognitive behavioural therapy-based interventions aimed at the prevention of depression or anxiety, with mixed results. Cost-effectiveness estimates for a parenting programme, a school-based social and emotional well-being programme and anti-bullying interventions were promising, though the latter were only evaluated for the Swedish context. Drivers of cost effectiveness were implementation costs; intervention effectiveness, delivery mode and duration; baseline prevalence; and the perspective of the evaluation. The overall study quality was reasonable, though most studies only assessed short-term costs and effects.

CONCLUSION

Few studies were found, which limits the possibility of drawing strong conclusions about cost effectiveness. There is some evidence based on decision-analytic modelling that anti-bullying interventions represent value for money. Generally, there is a lack of studies that take into account long-term costs and effects.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42019115882.

The PATHS curriculum for promoting social and emotional well-being among children aged 7–9 years: a cluster RCT

Background

Universal social and emotional learning interventions can produce significant practical improvements in children’s social skills and other outcomes. However, the UK evidence base remains limited.

Objectives

To investigate the implementation, impact and cost-effectiveness of the Promoting Alternative THinking Strategies (PATHS) curriculum.

Design

Cluster randomised controlled trial. Primary schools (n = 45) were randomly assigned to implement PATHS or to continue with their usual provision for 2 years.

Setting

Primary schools in seven local authorities in Greater Manchester.

Participants

Children (n = 5218) in Years 3–5 (aged 7–9 years) attending participating schools.

Intervention

PATHS aims to promote children’s social skills via a taught curriculum, which is delivered by the class teacher, generalisation activities and techniques, and supplementary materials for parents. Schools in the usual provision group delivered the Social and Emotional Aspects of Learning programme and related interventions.

Main outcome measures

Children’s social skills (primary outcome, assessed by the Social Skills Improvement System); pro-social behaviour and mental health difficulties (Strengths and Difficulties Questionnaire); psychological well-being, perceptions of peer and social support, and school environment (Kidscreen-27); exclusions, attendance and attainment (National Pupil Database records); and quality-adjusted life-years (QALYs) (Child Health Utility 9 Dimensions). A comprehensive implementation and process evaluation was undertaken, involving usual provision surveys, structured observations of PATHS lessons, interviews with school staff and parents, and focus groups with children.

Results

There was tentative evidence (at ap-value of  < 0.10) that PATHS led to very small improvements in children’s social skills, perceptions of peer and social support, and reductions in exclusions immediately following implementation. A very small but statistically significant improvement in children’s psychological well-being [d = 0.12, 95% confidence interval (CI) –0.02 to 0.25;p < 0.05) was also found. No lasting improvements in any outcomes were observed at 12- or 24-month post-intervention follow-up. PATHS was implemented well, but not at the recommended frequency; our qualitative analysis revealed that this was primarily due to competing priorities and pressure to focus on the core academic curriculum. Higher levels of implementation quality and participant responsiveness were associated with significant improvements in psychological well-being. Finally, the mean incremental cost of PATHS compared with usual provision was determined to be £29.93 per child. Mean incremental QALYs were positive and statistically significant (adjusted mean 0.0019, 95% CI 0.0009 to 0.0029;p < 0.05), and the incremental net benefit of introducing PATHS was determined to be £7.64. The probability of cost-effectiveness in our base-case scenario was 88%.

Limitations

Moderate attrition through the course of the main trial, and significant attrition thereafter (although this was mitigated by the use of multiple imputation of missing data); suboptimal frequency of delivery of PATHS lessons.

Conclusions

The impact of PATHS was modest and limited, although that which was observed may still represent value for money. Future work should examine the possibility of further modifications to the intervention to improve goodness of fit with the English school context without compromising its efficacy, and identify whether or not particular subgroups benefit differentially from PATHS.

Trial registration

Current Controlled Trials ISRCTN85087674 (the study protocol can be found at:www.journalslibrary.nihr.ac.uk/programmes/phr/10300601/#/).

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol 6, No. 10. See the NIHR Journals Library website for further project information.

Effect of a universal anxiety prevention programme (FRIENDS) on children's academic performance: results from a randomised controlled trial

BACKGROUND

Evaluations of school-based anxiety prevention programmes have reported improvements in psychological functioning although little is known about their effect upon educational outcomes.

METHODS

One thousand three hundred and sixty-two children from 40 primary schools in England took part in the randomised controlled trial, Preventing Anxiety in Children through Education in Schools. The trial investigated the effectiveness of a universal school-based cognitive behaviour therapy prevention programme, FRIENDS, delivered by health care staff or school staff compared with usual personal, social, health and education (PSHE) lessons. Self-report psychological outcomes and educational attainment on national standardised attainment tests in reading, writing and maths were collected 12 months postintervention. Analysis was performed at individual level using multivariable mixed effect models controlling for gender, type of intervention and school effect. Registered trial: ISRCTN: 23563048.

RESULTS

At 12 months, anxiety reduced in the health-led FRIENDS group compared to school-led FRIENDS and PSHE. There were no between-group differences in academic performance regardless of gender, deprivation, ethnicity and additional educational needs.

CONCLUSIONS

School-based mental health interventions should assess psychological and educational outcomes. Further research should directly compare the effects of interventions led by health and school staff.