School-based intervention to promote coping in rural teens

School-based depression and anxiety prevention programs: An updated systematic review and meta-analysis

Depression and anxiety are often first experienced during childhood and adolescence, and interest in the prevention of these disorders is growing. The focus of this review was to assess the effectiveness of psychological prevention programs delivered in schools, and to provide an update to our previous review from five years ago (Werner-Seidler, Perry, Calear, Newby, & Christensen, 2017). Three electronic databases were systematically searched for published articles of randomised controlled trials (RCTs) evaluating the efficacy of school-based prevention programs until October 2020. There were 130 articles that met inclusion criteria, representing 118 unique trials and 45,924 participants. Small between-group effect sizes for depression (g = 0.21) and anxiety (g = 0.18) were detected immediately post-intervention. Subgroup analyses suggested that targeted prevention programs (for young people with risk factors or symptoms) were associated with significantly greater effect sizes relative to universal programs for depression, which was confirmed by meta-regression. There was also some evidence that external providers conferred some benefit over school-staff delivered programs. Overall, study quality was moderate and no association between risk of bias and effect size was detected. School-delivered psychological prevention programs have small effects in reducing symptoms of depression and anxiety. Refinement of these programs, and knowledge about how they can be sustainably delivered in schools beyond the trial period is now needed for population-level preventive effects. Systematic Review Registration Number: PROPSERO - CRD42020188323.

Effectiveness of CBT for children and adolescents with depression: A systematic review and meta-regression analysis

Background:

Cognitive-behavioral therapy (CBT) is first choice of treatment for depressive symptoms and disorders in adolescents, however improvements are necessary because overall efficacy is low. Insights on CBT components and contextual and structural characteristics might increase the efficacy. The aim of our approach is to evaluate the efficacy of CBT for youth with depression and investigate the influence of specific components, contextual and structural factors that could improve effects.

Methods:

A systematic review of randomized controlled trials was conducted, searches were undertaken in CINAHL, CENTRAL, EMBASE, MEDLINE/PubMed and PsycINFO. Outcomes were meta-analyzed and confidence in results was assessed using the GRADE-method. Meta-regression was used to pinpoint components or other factors that were associated with an in- or decrease of effects of CBT.

Results:

We included 31 trials with 4335 participants. Moderate-quality evidence was found for CBT reducing depressive symptoms at the end of treatment and at follow-up, and CBT as indicated prevention resulted in 63% less risk of being depressed at follow-up. CBT containing a combination of behavioral activation and challenging thoughts component (as part of cognitive restructuring) or the involvement of caregiver(s) in intervention were associated with better outcomes for youth on the long term.

Conclusions:

There is evidence that CBT is effective for youth with a (subclinical) depression. Our analyses show that effects might improve when CBT contains the components behavioral activation and challenging thoughts and also when the caregiver(s) are involved. However, the influential effects of these three moderators should be further tested in RCTs.

Cognitive behavioural therapy (CBT), third-wave CBT and interpersonal therapy (IPT) based interventions for preventing depression in children and adolescents

BACKGROUND

Depression is common in young people. It has a marked negative impact and is associated with self-harm and suicide. Preventing its onset would be an important advance in public health. This is an update of a Cochrane review that was last updated in 2011.

OBJECTIVES

To determine whether evidence-based psychological interventions (including cognitive behavioural therapy (CBT), interpersonal therapy (IPT) and third wave CBT)) are effective in preventing the onset of depressive disorder in children and adolescents.

SEARCH METHODS

We searched the specialised register of the Cochrane Common Mental Disorders Group (CCMDCTR to 11 September 2015), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We searched conference abstracts and reference lists of included trials and reviews, and contacted experts in the field.

SELECTION CRITERIA

We included randomised controlled trials of an evidence-based psychological prevention programme compared with any comparison control for young people aged 5 to 19 years, who did not currently meet diagnostic criteria for depression.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion and rated their risk of bias. We adjusted sample sizes to take account of cluster designs and multiple comparisons. We contacted trial authors for additional information where needed. We assessed the quality of evidence for the primary outcomes using GRADE.

MAIN RESULTS

We included 83 trials in this review. The majority of trials (67) were carried out in school settings with eight in colleges or universities, four in clinical settings, three in the community and four in mixed settings. Twenty-nine trials were carried out in unselected populations and 53 in targeted populations.For the primary outcome of depression diagnosis at medium-term follow-up (up to 12 months), there were 32 trials with 5965 participants and the risk of having a diagnosis of depression was reduced for participants receiving an intervention compared to those receiving no intervention (risk difference (RD) -0.03, 95% confidence interval (CI) -0.05 to -0.01; P value = 0.01). We rated this evidence as moderate quality according to the GRADE criteria. There were 70 trials (73 trial arms) with 13,829 participants that contributed to the analysis for the primary outcome of depression symptoms (self-rated) at the post-intervention time point, with results showing a small but statistically significant effect (standardised mean difference (SMD) -0.21, 95% CI -0.27 to -0.15; P value < 0.0001). This effect persisted to the short-term assessment point (up to three months) (SMD -0.31, 95% CI -0.45 to -0.17; P value < 0.0001; 16 studies; 1558 participants) and medium-term (4 to 12 months) assessment point (SMD -0.12, 95% CI -0.18 to -0.05; P value = 0.0002; 53 studies; 11,913 participants); however, the effect was no longer evident at the long-term follow-up. We rated this evidence as low to moderate quality according to the GRADE criteria.The evidence from this review is unclear with regard to whether the type of population modified the overall effects; there was statistically significant moderation of the overall effect for depression symptoms (P value = 0.0002), but not for depressive disorder (P value = 0.08). For trials implemented in universal populations there was no effect for depression diagnosis (RD -0.01, 95% CI -0.03 to 0.01) and a small effect for depression symptoms (SMD -0.11, 95% CI -0.17 to -0.05). For trials implemented in targeted populations there was a statistically significantly beneficial effect of intervention (depression diagnosis RD -0.04, 95% CI -0.07 to -0.01; depression symptoms SMD -0.32, 95% CI -0.42 to -0.23). Of note were the lack of attention placebo-controlled trials in targeted populations (none for depression diagnosis and four for depression symptoms). Among trials implemented in universal populations a number used an attention placebo comparison in which the intervention consistently showed no effect.

AUTHORS' CONCLUSIONS

Overall the results show small positive benefits of depression prevention, for both the primary outcomes of self-rated depressive symptoms post-intervention and depression diagnosis up to 12 months (but not beyond). Estimates of numbers needed to treat to benefit (NNTB = 11) compare well with other public health interventions. However, the evidence was of moderate to low quality using the GRADE framework and the results were heterogeneous. Prevention programmes delivered to universal populations showed a sobering lack of effect when compared with an attention placebo control. Interventions delivered to targeted populations, particularly those selected on the basis of depression symptoms, had larger effect sizes, but these seldom used an attention placebo comparison and there are practical difficulties inherent in the implementation of targeted programmes. We conclude that there is still not enough evidence to support the implementation of depression prevention programmes.Future research should focus on current gaps in our knowledge. Given the relative lack of evidence for universal interventions compared with attention placebo controls and the poor results from well-conducted effectiveness trials of universal interventions, in our opinion any future such trials should test a depression prevention programme in an indicated targeted population using a credible attention placebo comparison group. Depressive disorder as the primary outcome should be measured over the longer term, as well as clinician-rated depression. Such a trial should consider scalability as well as the potential for the intervention to do harm.

Teachers or psychologists: who should facilitate depression prevention programs in schools?

The current study evaluates a depression prevention program for adolescents led by psychologists vs. teachers in comparison to a control. The universal school-based prevention program has shown its efficacy in several studies when implemented by psychologists. The current study compares the effects of the program as implemented by teachers versus that implemented by psychologists under real-life conditions. A total of 646 vocational track 8th grade students from Germany participated either in a universal prevention program, led by teachers (n = 207) or psychologists (n = 213), or a teaching-as-usual control condition (n = 226). The design includes baseline, post-intervention, and follow-up (at 6 and 12 months post-intervention). The cognitive-behavioral program includes 10 sessions held in a regular school setting in same-gender groups and is based on the social information-processing model of social competence. Positive intervention effects were found on the change in girls’ depressive symptoms up to 12 months after program delivery when the program was implemented by psychologists. No such effects were found on boys or when program was delivered by teachers. The prevention program can successfully be implemented for girls by psychologists. Further research is needed for explanations of these effects.

A randomized trial of the Positive Thoughts and Action program for depression among early adolescents

This study was conducted to compare the outcomes of a group-based cognitive-behavioral preventive intervention (Positive Thoughts and Actions [PTA]) tailored to youth in middle school with a brief, individually administered supportive intervention (Individual Support Program [ISP]). A randomized, controlled trial was conducted with 120 early adolescents (72 girls, 48 boys; age = 11-15 years) who had elevated depressive symptoms and were selected from a school-based population. Measures of internalizing problems, externalizing problems, personal adjustment, school problems, and interpersonal relations were obtained from parents, youth, and/or teachers at preintervention (Time 1) and postintervention (Time 2, 5-7 months after preintervention). General linear model repeated measures analyses yielded a significant Group × Time interaction on youth-reported, but not parent-reported, depressive symptoms and internalizing symptoms. Youth in the PTA group showed greater decreases following intervention compared to youth who received ISP, yielding effect sizes (Cohen's d) of 0.36 for depressive symptoms, 95% CI [-.02, .73], and 0.44, 95% CI [.05, .82], for internalizing symptoms. PTA youth also showed improvements in their personal adjustment (sense of inadequacy, self-esteem), and parent-reported social skills, but no differences emerged between groups for externalizing symptoms, school problems, or interpersonal relationships. Cognitive-behavioral preventive interventions in which youth engage in personal goal-setting and practice social-emotional skills, such as PTA, may be beneficial for the reduction of depressive symptoms over and above general support and empathy.

Psychological and educational interventions for preventing depression in children and adolescents

BACKGROUND

Depression is common in young people, has a marked negative impact and is associated with self-harm and suicide. Preventing its onset would be an important advance in public health.  

OBJECTIVES

To determine whether psychological or educational interventions, or both, are effective in preventing the onset of depressive disorder in children and adolescents.

SEARCH METHODS

The Cochrane Depression, Anxiety and Neurosis Review Group's trials registers (CCDANCTR) were searched at the editorial base in July 2010. Update searches of MEDLINE, EMBASE, PsycINFO and ERIC were conducted by the authors in September 2009. Conference abstracts, reference lists of included studies and reviews were searched and experts in the field contacted.

SELECTION CRITERIA

Randomised controlled trials of psychological or educational prevention programmes, or both, compared with placebo, any comparison intervention, or no intervention for young people aged 5 to 19 years-old, who did not currently meet diagnostic criteria for depression or who were below the clinical range on standardised, validated, and reliable rating scales of depression, or both, were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion and rated their quality. Sample sizes were adjusted to take account of cluster designs and multiple comparisons. We contacted study authors for additional information where needed. 

MAIN RESULTS

Fifty-three studies including 14,406 participants were included in the analysis. There were only six studies with clear allocation concealment, participants and assessors were mostly not blind to the intervention or blinding was unclear so that the overall risk of bias was moderately high. Sixteen studies including 3240 participants reported outcomes on depressive diagnosis. The risk of having a depressive disorder post-intervention was reduced immediately compared with no intervention (15 studies; 3115 participants risk difference (RD) -0.09; 95% confidence interval (CI) -0.14 to -0.05; P<0.0003), at three to nine months (14 studies; 1842 participants; RD -0.11; 95% CI -0.16 to -0.06) and at 12 months (10 studies; 1750 participants; RD -0.06; 95% CI -0.11 to -0.01). There was no evidence for continued efficacy at 24 months (eight studies; 2084 participant; RD -0.01; 95% CI -0.04 to 0.03) but limited evidence of efficacy at 36 months (two studies; 464 participants; RD -0.10; 95% CI -0.19 to -0.02). There was significant heterogeneity in all these findings. There was no evidence of efficacy in the few studies that compared intervention with placebo or attention controls.

AUTHORS' CONCLUSIONS

There is some evidence from this review that targeted and universal depression prevention programmes may prevent the onset of depressive disorders compared with no intervention. However, allocation concealment is unclear in most studies, and there is heterogeneity in the findings. The persistence of findings suggests that this is real and not a placebo effect. 

Wirksamkeit von schulbasierten Gruppeninterventionen zur Depressionsprävention

Fünf bis zehn Prozent aller Kinder und Jugendlichen in Deutschland leiden an depressiven Symptomen. Chronische Depressionen gehen regelmäßig mit ersten Erkrankungssymptomen im Kindes- und Jugendalter einher. Der frühen Prävention depressiver Störungen kommt folglich eine hohe Bedeutung zu. Wir untersuchten die Wirksamkeit nichtpharmakologischer schulbasierter Gruppeninterventionen zur Depressionsprävention anhand eines systematischen Literaturreviews. Signifikante Verbesserungen depressiver Störungen konnten in 61 Prozent der eingeschlossenen Studien festgestellt werden. Aufgrund der Heterogenität von Studiendurchführung und –design können keine eindeutigen Aussagen abgeleitet werden, welche Faktoren zu einem Erfolg oder Misserfolg der Programme beitragen. Eine flächendeckende Umsetzung erscheint aufgrund der offenen Fragen zur optimalen Ausgestaltung verfrüht.

Teaching kids to cope with anger: peer education

Anger could be an early warning signal of violent behavior. Early peer education health promotion in relation to anger management could help children before uncontrolled anger becomes a problem in adolescence and adulthood. Peer education has been identified as a viable intervention strategy worldwide with various prevention programs for youth. The purpose of this article is to describe an anger management program (Teaching Kids to Cope with Anger, TKC-A 4th-8th graders) co-led by high school peer educators in an urban school district's summer school enhancement program. A program of five modules will be described. This paper discusses the peer educator implementation and recommendations for future implementation.

A meta-analytic review of depression prevention programs for children and adolescents: factors that predict magnitude of intervention effects

In this meta-analytic review, the authors summarized the effects of depression prevention programs for youth as well as investigated participant, intervention, provider, and research design features associated with larger effects. They identified 47 trials that evaluated 32 prevention programs, producing 60 intervention effect sizes. The average effect for depressive symptoms from pre-to-posttreatment (r = .15) and pretreatment to-follow-up (r = .11) were small, but 13 (41%) prevention programs produced significant reductions in depressive symptoms and 4 (13%) produced significant reductions in risk for future depressive disorder onset relative to control groups. Larger effects emerged for programs targeting high-risk individuals, samples with more females, samples with older adolescents, programs with a shorter duration and with homework assignments, and programs delivered by professional interventionists. Intervention content (e.g., a focus on problem-solving training or reducing negative cognitions) and design features (e.g., use of random assignment and structured interviews) were unrelated to effect sizes. Results suggest that depression prevention efforts produce a higher yield if they incorporate factors associated with larger intervention effects (e.g., selective programs with a shorter duration that include homework).

Systematic review of school-based prevention and early intervention programs for depression

A systematic review was conducted to identify and describe school-based prevention and early intervention programs for depression and to evaluate their effectiveness in reducing depressive symptoms. Forty-two randomised controlled trials, relating to 28 individual school-based programs, were identified through the Cochrane Library, PsycInfo and PubMed databases. A large proportion of the programs identified were based on cognitive behavioural therapy (CBT), and delivered by a mental health professional or graduate student over 8-12 sessions. Indicated programs, which targeted students exhibiting elevated levels of depression, were found to be the most effective, with effect sizes for all programs ranging from 0.21 to 1.40. Teacher program leaders and the employment of attention control conditions were associated with fewer significant effects. Further school-based research is required that involves the use of attention controls, long-term follow-ups and which focuses on the training and evaluation of sustainable program leaders, such as teachers.

Young people and mental health: novel methods for systematic review of research on barriers and facilitators

This paper describes how barriers to, and facilitators of, good mental health amongst young people (11-21 years) were elucidated from a systematic review of studies of young people's views and how these barriers and facilitators were compared with effectiveness studies to identify effective and appropriate interventions, promising interventions needing further evaluation and the need for further intervention. All studies were published before 2000. No clear pattern for effectiveness emerged in terms of mental health promotion focus, the type of intervention, intervention provider or young people. Well-evaluated interventions neither always target what we know young people themselves see as important barriers to their mental health (for instance, loss of friends and family, violence and bullying) nor always build on what they see as key facilitators, particularly their preferred coping strategies. In particular, while young people see material and physical resources as major influences on their mental health, few evaluated interventions targeted these. Rigorously evaluated interventions more often addressed priorities not raised by young people themselves and populations at low risk for mental health problems. These innovative review methods can inform intervention development and evaluation in a new way based on the strengths and needs identified by the target population.

Depression in children and adolescents: linking risk research and prevention

The National Institute of Mental Health has called for translational research linking basic knowledge about vulnerabilities that underlie mood disorders to the development of effective preventive interventions. This paper highlights research about risk factors for depression in children and adolescents and links it to current knowledge about interventions aimed at preventing depression in youth. Basic epidemiologic and clinical research indicates that increased risk for depression is associated with being female; a family history of depression, particularly in a parent; subclinical depressive symptoms; anxiety; stressful life events; neurobiological dysregulation; temperament/personality (e.g., neuroticism); negative cognitions; problems in self-regulation and coping; and interpersonal dysfunction. These vulnerabilities both increase individuals' chances of encountering stress and decrease their ability to deal with the stress once it occurs. Although several existing depression-prevention studies have targeted one or more of these risk factors, the efficacy of these various prevention programs for youth with different combinations of these risk factors needs to be investigated further. Most existing depression-prevention programs in youth have used cognitive-behavioral techniques, with some success. Other depression-prevention strategies have included training in coping, social problem solving, social skills, communication skills, and parenting. A comprehensive prevention program is recommended that includes multiple intervention components, each of which addresses risk and protective factors across different domains and levels of analysis.

Development of a Music Group Psychotherapy Intervention for the Primary Prevention of Adjustment Difficulties in Korean Adolescent Girls

PROBLEM

Traditionally, adolescent mental health in Korea has not been a prime focus for educators, health workers, and politicians, yet a majority of sampled adolescents report interpersonal sensitivity (Kim, 2003).

METHOD

Thirty-five adolescent girls took part in a six-session school-based music group psychotherapy pilot intervention designed to promote relationships and improve self-control skills.

FINDING

Participants identified several outcome benefits that may serve as protective factors in their continued social and emotional development.

CONCLUSIONS

Music is a medium that promotes interpersonal relatedness among Korean adolescent girls. More research is necessary to identify long-term benefits of preventive music group psychotherapy interventions among the adolescent population.

Screening and early psychological intervention for depression in schools : systematic review and meta-analysis

Depression in children and adolescents is considerably undertreated, and the school may be a good setting for identifying and treating depression. We conducted a meta-analysis of studies in which students were screened for depression, and those with depressive symptoms were treated with a psychological intervention. Only randomised controlled trials were included. Eight studies met the inclusion criteria. Five studies focused on younger children (7-14 years) and three studies were aimed at adolescents (12-19 years). In total 5803 students were screened, of whom 7.2% were included in the intervention studies (95% CI: 7.1-7.3). The 'numbers-needed-to-screen' was 31 (95% CI: 27-32), which means that 31 students had to be screened in order to generate one successfully treated case of depression. The effects of the psychological treatments at post-test were compared to control conditions in the 8 studies comprising 12 contrast groups, with a total of 413 students. The mean effect size was 0.55 (95% CI: 0.35-0.76). There were not enough studies to examine whether specific psychotherapies were superior to other psychotherapies. Although the number of studies is small and their quality is limited, screening and early intervention at schools may be an effective strategy to reduce the burden of disease from depression in children and adolescents. More research on the (negative) effects of these interventions is needed.

The prevention of depressive symptoms in children and adolescents: A meta-analytic review

Research on the prevention of depressive symptoms in children and adolescents was reviewed and synthesized with meta-analysis. When all 30 studies were included, selective prevention programs were found to be more effective than universal programs immediately following intervention. Both selective and indicated prevention programs were more effective than universal programs at follow-up, even when the 2 studies with college students were excluded. Effect sizes for selective and indicated prevention programs tended to be small to moderate, both immediately postintervention and at an average follow-up of 6 months. Most effective interventions are more accurately described as treatment rather than prevention. Suggestions for future research include testing potential moderators (e.g., age, gender, anxiety, parental depression) and mechanisms, designing programs that are developmentally appropriate and gender and culturally sensitive, including longer follow-ups, and using multiple measures and methods to assess both symptoms and diagnoses.

A randomized placebo-controlled trial of a school-based depression prevention program

OBJECTIVE

To conduct a placebo-controlled study of the effectiveness of a universal school-based depression prevention program.

METHOD

Three hundred ninety-two students age 13 to 15 from two schools were randomized to intervention (RAP-Kiwi) and placebo programs run by teachers. RAP-Kiwi was an 11-session manual-based program derived from cognitive-behavioral therapy. The placebo was similar but with cognitive components removed. Outcomes were self-rated depression scales, the Reynolds Adolescent Depression Scale (RADS), and the Beck Depression Inventory II (BDI-II). Follow-up was to 18 months. Analysis was done on an intent-to-treat basis.

RESULTS

Immediately after the intervention, depression scores were reduced significantly more by RAP-Kiwi than by placebo, with a mean difference in change from baseline between groups of 1.5 on BDI-II (CI > 0.38, p =.01) and 2.24 on RADS (CI > 0.22, p =.04). Categorical analysis confirmed significant clinical benefit with an absolute risk reduction of 3% (95% CI, 1-11%, McNemar chi, p =.03), with the "number needed to treat" for short-term benefit of 33. Group differences in depression scores averaged across time to 18 months were significant on RADS but not on BDI-II. Retention rates were 91% at 6 months and 72% at 18 months.

CONCLUSIONS

The RAP-Kiwi program is a potentially effective public health measure. Confirmation of effectiveness measuring episodes of depressive illness and broader measures of adjustment is warranted.

Psychological and/or educational interventions for the prevention of depression in children and adolescents

BACKGROUND

Depression is the fourth most important disease in the estimation of the burden of disease Murray 1996 and is a common problem with prevalence rates estimated to be as high as 8% in young people. Depression in young people is associated with poor academic performance, social dysfunction, substance abuse, suicide attempts, and completed suicide (NHMRC 1997). This has precipitated the development of programmes aimed at preventing the onset of depression. This review evaluates evidence for the effectiveness of these prevention programmes.

OBJECTIVES

To determine whether psychological and/or educational interventions (both universal and targeted) are effective in reducing risk of depressive disorder by reducing depressive symptoms immediately after intervention or by preventing the onset of depressive disorder in children and adolescents over the next one to three years.

SEARCH STRATEGY

The Cochrane Depression, Anxiety and Neurosis Group trials register (August 2002), MEDLINE (1966 to December Week 3 2002), EMBASE (1980 to January Week 2 2003), PsychInfo (1886 to January Week 2 2003) and ERIC (1985 to December 2002) were searched. In addition, conference abstracts, the reference lists of included studies, and other reviews were searched and experts in the field were contacted.

SELECTION CRITERIA

Each identified study was assessed for possible inclusion by two independent reviewers based on the methods sections. The determinants for inclusion were that the trial include a psychological and/or educational prevention programme for young people aged 5 to 19 years-old, who did not meet DSM or ICD criteria for depression and/or did not fall into the clinical range on standardised, validated, and reliable rating scales of depression.

DATA COLLECTION AND ANALYSIS

The methodological quality of the included trials was assessed by two independent reviewers according to a list of pre-determined criteria, which were based on quality ratings devised by Moncrieff and colleagues (Moncrieff 2001). Outcome data was extracted and entered into Revman 4.2. Means and standard deviations for continuous outcomes and number of events for dichotomous outcomes were extracted where available. For trials where the required data were not reported or could not be calculated, further details were requested from first authors. If no further details were provided, the trial was included in the review and described, but not included in the meta-analysis. Results were presented for each type of intervention: targeted or universal interventions; and educational or psychological interventions and if data were provided, by gender. Where possible data were combined in meta-analyses to give a treatment effect across all trials. Sensitivity analysis were conducted on studies rated as "adequate" or "high" quality, that is with a score over 22, based on the scale by Moncrieff et al (Moncrieff 2001). The presence of publication bias was assessed using funnel plots.

MAIN RESULTS

Studies were divided into those that compared intervention with an active comparison or placebo (i.e. a control condition that resembles the intervention being investigated but which lacks the elements thought to be active in preventing depression) and those that used a "wait-list" or no intervention comparison group. Only two studies fell into the former category and neither showed effectiveness although one study was inadequately powered to show a difference and in the other the "placebo" contained active therapeutic elements, reducing the ability to demonstrate a difference from intervention. Psychological interventions were effective compared with non-intervention immediately after the programmes were delivered with a significant reduction in scores on depression rating scales for targeted (standardised mean difference (SMD) of -0.26 and a 95% confidence interval (CI) of -0.40 to -0.13 ) but not universal interventions (SMD -0.21, 95% CI -0.48, 0.06), with a significant effect maintained on pooling data (SMD -0.26, 95% CI -0.36, -0.15). While small effect sizes were reported, these were associated with a significant reduction in depressive episodes. The overall risk difference after intervention translates to "numbers needed to treat" (NNT) of 10. The most effective study is the targeted programme by Clarke (Clarke 2001) where the initial effect size of -0.46 is associated with an initial risk difference of -0.22 and NNT 5. There was no evidence of effectiveness for educational interventions. Reports of effectiveness for boys and girls were contradictory. The quality of many studies was poor, and only two studies made allocation concealment explicit. Sensitivity analysis of only high quality studies did not alter the results significantly. The only analysis in which there was significant statistical heterogeneity was the sub-group analysis by gender where there was variability in the response to different programmes for both girls and boys. For the most part funnel plots indicate findings are robust for short term effects with no publication bias evident. There are too few studies to comment on whether there is publication bias for studies reporting long-term (12-36 month) follow-up.

REVIEWER'S CONCLUSIONS

Although there is insufficient evidence to warrant the introduction of depression prevention programmes currently, results to date indicate that further study would be worthwhile. There is a need to compare interventions with a placebo or some sort of active comparison so that study participants do not know whether they are in the intervention group or not, to investigate the impact of booster sessions to see if effectiveness immediately after intervention can be prolonged, ideally for a year or longer, and to consider practical implementation of prevention programmes when choosing target populations. Until now most studies have focussed on psychological interventions. The potential effectiveness of educational interventions has not been fully investigated. Given the gender differences in prevalence, and the change in these that occurs in adolescence with a disproportionate increase in prevalence rates for girls, it is likely that girls and boys will respond differently to interventions. Although differences have been reported in studies in this review the findings are contradictory and a more definitive delineation of gender specific responses to interventions would be helpful.

The impact of school nursing on school performance: a research synthesis

School nurses work in an educational setting. Due to budget cuts, different goals, and confusion between educators and nurses regarding the school nurse role, school nurses are being asked to demonstrate their effectiveness and justify their presence in elementary and secondary schools. Although school nursing was first initiated 100 years ago, a review of the literature published since 1965 indicates that 15 studies have been conducted that examine the impact of school nurses on academic performance. However, today many articles have recommended more research linking school nursing to educational outcomes. This article synthesizes the results of 15 research articles. Findings from these studies indicate that nursing interventions targeted at specific populations, including parents, have had significant effects. A relationship between school nurses' interventions and absenteeism is also suggested. Limitations of these studies are discussed, along with suggestions for future research.

Anger assessment in rural high school students

Anger and aggression in school children are a major concern in American society today. Students with high anger levels and poor cognitive processing skills are at risk for poor relationships, underachievement in school, and health problems. This article describes characteristics of children who are at risk for high anger levels and aggression as well as those who are able to modulate their anger. Results of a survey are reported which describe levels of anger in 624 rural high school students. This sample reported lower levels of anger, compared to the normative group. Differences among the sample include higher internal anger expression in girls, higher trait anger in boys ages 15-16, and higher trait anger in girls ages 16-17. Recommendations are made for future research and specific steps that school nurses can take.

Health concerns and risk behaviors of rural adolescents

Although much has been written about the health status of adolescents, little is known about adolescents' perception of their own health. The purpose of this article is to describe the health concerns of rural adolescents. Two national studies, the Youth Risk Behavior Survey and the National Longitudinal Study of Adolescent Health (Add Health Project), are used as comparisons. Data from the rural survey represent 624 community adolescents attending 4 rural Pennsylvania schools. The students were in the 9th, 10th, and 11th grades. The Adolescent Health Inventory was used to report concerns related to general health, psychosocial issues, and risk behaviors. Overall, rural adolescents in the study reported an average of 6.5 (SD = 3.2) health concerns with frequencies of occurrence being always or often and reported an average involvement in 1 (SD = 1.3) risk behavior. Psychosocial issues were reported by 28%, and 23% worried about their general health. Frequently reported risk behaviors included alcohol use, drug use, and a lack of exercise. There was minimal concern expressed regarding venereal disease or AIDS, whereas 12% expressed concern about the possibility of pregnancy. These results suggest the likelihood that adolescents perceive health from a holistic perspective and that health promotion programs should consider involving adolescents in planning, both (a) to ensure congruence of the plan of care with adolescents' concerns and (b) to clarify the interpretation and meaning of their concerns. We present implications for the community health nurse.