A randomized controlled trial of a six-session cognitive behavioral treatment of emotional disorders in adolescents 14-17 years old in child and adolescent mental health services (CAMHS)

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

Background

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

Objectives

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

Search Methods

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

Selection Criteria

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

Data Collection and Analysis

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

Main Results

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

Authors' Conclusions

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

Effectiveness of Psychotherapy for Internalising Symptoms in Children and Adolescents When Delivered in Routine Settings: A Systematic Review and Meta-analysis

This systematic review and meta-analysis aimed to examine the effectiveness of psychological interventions for internalising disorders in youth when delivered in routine settings. Secondary aims were to examine the effectiveness of cognitive behavioural therapy and determine moderators of treatment response. The study was pre-registered (PROSPERO 2020 CRD42020202776). Databases were systematically searched (PsycINFO, Medline, Embase, PubMed, ERIC) in December 2022 and screened according to the PRISMA 2020 statement. Inclusion: School aged participants (4-18 years) with a primary internalising disorder; psychotherapy delivered in a routine setting (e.g. outpatient clinic, school) by setting staff; compared psychotherapy to any control in a randomised controlled trial; reported pre-to-post or pre-to-follow-up comparisons on the primary disorder according to child, parent or independent evaluator report; and was published in English. Risk of bias was assessed using the ROB 2.0 Cochrane tool. Results were synthesised using random effects to pool estimates. Risk ratios were used to analyse dichotomous data and standardised mean differences (SMD) for continuous data. Forty-five studies were included (N = 4901 participants; M = 13 years; range 8-16; SD = 2.5). Nine used waitlist control, 17 treatment as usual, 4 placebo; 15 compared psychotherapy to active control. Psychotherapy was associated with small significant effects pre- to post-treatment compared to non-active controls for anxiety (SMD =  - 0.24 to 0.50) and depression (SMD =  - 0.19 to 0.34) with effects differing by informant. Psychotherapy led to small significant pre-to-post-benefits in youth internalising disorders in routine settings. Results are limited by reporter type and follow-up.

Five-Factor Personality Dimensions Mediated the Relationship between Parents' Parenting Style Differences and Mental Health among Medical University Students

BACKGROUND

Previous studies have identified the relationships between parental parenting style, personality, and mental health. However, the interactive influences between mother's and father's parenting styles on personality have been examined less often. To fill the gaps, the first aim of this study was to build the relationships between parental parenting style differences (PDs) and five-factor personality dimensions. The second aim was to test the mediating effect of five-factor personality dimensions on the relationships between parental parenting style differences and mental health.

METHODS

This is a cross-sectional study conducted among medical university students, and 2583 valid participants were analyzed. Mental health was measured by the Kessler-10 scale. The Chinese Big Five Personality Inventory brief version (CBF-PI-B) was used to access five-factor personality dimensions. PD was calculated by the short form of Egna Minnen av Barndoms Uppfostran. Linear regressions were conducted to analyze the associations between PD and five-factor personality dimensions. The SPSS macros program (PROCESS v3.3) was performed to test the mediating effect of five-factor personality dimensions on the associations between PD and mental health.

RESULTS

Linear regressions found that worse mental health was positively associated with PD (β = 0.15, p < 0.001), higher neuroticism (β = 0.61, p < 0.001), lower conscientiousness (β = -0.11, p < 0.001), lower agreeableness (β = -0.10, p < 0.01), and lower openness (β = -0.05, p < 0.05). The results also supported that PD was positively associated with lower conscientiousness (β = -0.15, p < 0.01), lower agreeableness (β = -0.09, p < 0.001), lower openness (β = -0.15, p < 0.001), and lower extraversion (β = -0.08, p < 0.001), respectively. The mediating effect of agreeableness or openness was supported for the relationships between PD and mental health.

CONCLUSION

These findings remind us of the importance of consistent parenting styles between mother and father, and they also can be translated into practices to improve mental health among medical university students.

Efficient Sufficiency: A qualitative evaluation of a 1 year pilot study of young people and parents accessing a mental health drop-in centre in a paediatric hospital

BACKGROUND

Children and young people with long-term physical health conditions (LTC) are known to have higher levels of co-morbid mental health problems than medically healthy children. Evidence-based treatments for mental health problems are effective in children who also have an LTC. This study aimed to explore the factors associated with participants' perceived acceptability and impact of a transdiagnostic mental health centre offering brief psychological assessment and treatment for children and young people and/or their families with mental health needs in the context of long term physical conditions.

METHODS

One-hundred twenty-eight patients attending the drop-in centre were invited to participate. Overall, 35 participated (31 parents/carers; 4 children and young people) in semi-structured interviews (either in person or by phone) exploring their experience of the centre. Interviews were audio-recorded, transcribed and checked. Framework analysis was then conducted on all transcripts.

RESULTS

Overall, participants found the drop-in centre highly acceptable and reported a positive experience. Reasons for this varied but broadly focused around four themes: (1) efficient sufficiency; (2) autonomy; (3) fusion of process and content factors and (4) (dis)parities of esteems and 'seeing both sides of the coin'.

CONCLUSIONS

Participants found the intervention acceptable. A mental health drop-in centre in a paediatric hospital appears to be a positive and valued adjunct to supplement existing mental health services.

Long-term effectiveness and trajectories of change after treatment with SMART, a transdiagnostic CBT for adolescents with emotional problems

Background

There is a need for long-term effectiveness trials of transdiagnostic treatments. This study investigates the effectiveness and diagnosis-specific trajectories of change in adolescent patients attending SMART, a 6-week transdiagnostic CBT for anxiety and depression, with 6-month follow-up.

Methods

A randomized controlled trial with waiting list control (WLC) was performed at three child and adolescent mental health outpatient services (CAMHS) in Norway. Referred adolescents (N = 163, age = 15.72, 90.3% females) scoring 6 or more on the emotional disorders subscale of the Strengths and Difficulties Questionnaire (SDQ) were randomly assigned to treatment or to WLC. Long-term follow-up (N = 83, baseline age = 15.57, 94% females) was performed 6 months after treatment completion (Mean = 7.1 months, SD = 2.5). Linear mixed model analysis was used to assess time by group effects in patients with no diagnosis, probable anxiety, depressive disorder, and combined anxiety and depressive disorder.

Results

Almost one third (31%) obtained full recovery according to the inclusion criterium (SDQ emotional). There was highly significant change in all outcome variables. Effect sizes (ES) were largest for general functioning, measured with CGAS (ES: d = 2.19), and on emotional problems measured with SDQ (ES: d = 2.10), while CORE-17, BDI-II and CGAS all obtained ES’s close to 1. There were no significant time by diagnostic group interactions for any outcomes, indicating similar trajectories of change, regardless of diagnostic group. Waiting 6 weeks for treatment had no significant impact on long-term treatment effects.

Limitations

Possible regression to the mean. Attrition from baseline to follow-up.

Conclusions

Six weeks of transdiagnostic treatment for adolescents with emotional problems showed highly significant change in emotional symptoms and functioning at 6-month follow-up. Patients with anxiety, depression, combined anxiety and depression, and emotional problems with no specific diagnoses, all had similar trajectories of change. Hence this transdiagnostic SMART treatment can be recommended for adolescent patients with symptoms within the broad spectrum of emotional problems.

Trial registration: ClinicalTrials.gov Identifier: NCT02150265. First registered May 29, 2014.

Association Between Parental Parenting Style Disparities and Mental Health: An Evidence From Chinese Medical College Students

Background

The associations between parental parenting styles and adolescents' development and health problems were also identified in a series of studies. However, the interactive impact of mother's and father's parenting style was less reported, which was implied in previous studies. In this study, we aim to analyze the associations between parental parenting style disparities and mental health among medical college students.

Method

A cross-sectional study was conducted among medical college students in Shandong province, China, and 2,598 medical college students with parents were analyzed in this study. Items in a short form of Egna Minnen av Barndoms Uppfostran (EMBU) were used to calculate the parental parenting style disparities. Mental health was evaluated by the Kessler 10 scale.

Results

The results of linear regressions showed that parental nurture reject disparities (RDs, β = 0.50, p < 0.001), parental emotional warmth disparities (WDs, β = 0.33, p < 0.001), parental overprotective disparities (ODs, β = 0.25, p < 0.001), and total disparities in parenting styles (TDs, β = 0.15, p < 0.001) were associated with mental health among medical college students, respectively. The other associated factors were age, ethnicity, chronic disease, above average family economic status, and good parental relationship.

Conclusion

Our findings supported the positive association between parental parenting style disparities and mental health problems. Further studies can test the mechanism and intervention of the findings about the importance of parental parenting style consistence on mental health.

The Relationship Between Mental Health Problems and Systemic Family Dynamics Among High School and University Students in Shaanxi Province, China

Objectives: The present study aimed to correlate relationships between systemic family dynamics and mental health and to explore family factors that influence adolescent mental health in Shaanxi Province, China.

Methods: A cross-sectional survey was conducted to sample adolescents aged 12–23 using a questionnaire including Self-rating Scale of Systemic Family Dynamics, Symptom Checklist-90 Revised, and general demographic.

Results: More educated parents in white-collar employment and higher family income were associated with better mental health and better family dynamic scores. The total score of family dynamics was positively correlated with mental health scores. The generalized linear mixed model found that poorer mental health was associated with increased age, being in senior high school, having a father in a blue-collar profession, and SSFD square. The structural equation modelling suggested that this is largely a mediated effect via those characteristics impacting family dynamics, which in turn affect mental health.

Conclusion: Family dynamics may be an important contributor to adolescent mental health. Education and interventions aimed at improving family dynamics may be useful for reducing the prevalence of mental health problems amongst adolescents.

Evaluation of a mental health drop-in centre offering brief transdiagnostic psychological assessment and treatment for children and adolescents with long-term physical conditions and their families: a single-arm, open, non-randomised trial

BACKGROUND

Children and young people with long-term physical conditions have significantly elevated mental health needs. Transdiagnostic, brief psychological interventions have the potential to increase access to evidence-based psychological treatments for patients who attend health services primarily for physical health needs.

OBJECTIVE

A non-randomised study was conducted to assess the impact of brief, transdiagnostic psychological interventions in children and young people presenting at a drop-in mental health centre in the reception area of a paediatric hospital.

METHODS

186 participants attending a transdiagnostic mental health drop-in centre were allocated to assessment and psychological intervention based on a clinical decision-making algorithm. Interventions included signposting, guided self-help based on a modular psychological treatment and referral to the hospital's paediatric psychology service. The primary transdiagnostic mental health outcome measure was the parent-reported Strengths and Difficulties Questionnaire (SDQ), which was given at baseline and 6 months post-baseline.

FINDINGS

There was a significant positive impact of attending the drop-in mental health centre on the SDQ (Cohen's d=0.22) and on the secondary outcome measure of Paediatric Quality of life (Cohen's d=0.55).

CONCLUSIONS

A mental health drop-in centre offering brief, transdiagnostic assessment and treatment may reduce emotional and behavioural symptoms and improve quality of life in children and young people with mental health needs in the context of long-term physical conditions. A randomised controlled trial to investigate the specificity of any effects is warranted.

CLINICAL IMPLICATIONS

Drop-in centres for mental health needs may increase access and have beneficial effects for children and young people with physical conditions.

CORE-OM as a routine outcome measure for adolescents with emotional disorders: factor structure and psychometric properties

Background

Instruments for monitoring the clinical status of adolescents with emotional problems are needed. The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) according to theory measures problems/symptoms, well-being, functioning and risk. Documentation of whether the theoretical factor structure for CORE-OM is applicable for adolescents is lacking.

Methods

This study examined the factor structure and psychometric properties of the CORE-OM based on two samples of adolescents (age 14–18): youths seeking treatment for emotional problems (N = 140) and high school students (N = 531). A split half approach was chosen. An exploratory factor analysis (EFA) was performed on the first half of the stratified samples to establish the suitability of the model. A Confirmatory Factor Analysis (CFA) with the chosen model from the EFA was performed on the second half. Internal consistency and clinical cut-off scores of the CORE-OM were investigated.

Results

The best fitting model only partially confirmed the theoretical model for the CORE-OM. The model consisted of five factors: 1) General problems, 2) risk to self, 3) positive resources 4) risk to others and 5) problems with others. The clinical cut-off score based on the all-item total was higher than in an adult sample. Both the all-item total and general problems cut-off scores showed gender differences.

Conclusion

The factor analysis on CORE-OM for adolescents resulted in a five-factor solution, and opens up for new subscales concerning positive resources and problems with others. A 17-item solution for the general problems/symptoms scale is suggested. We advise developers of self-report instruments not to reverse items, if they do not intend to measure a separate factor, since these seem to affect the dimensionality of the scales. Comparing means for gender in non-clinical samples should not be done without modification of the general emotional problem and the positive resources scales. Slightly elevated CORE-OM scores (up to 1.3) in adolescents may be normal fluctuations.