A cluster randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of classroom-based cognitive-behavioural therapy (CBT) in reducing symptoms of depression in high-risk adolescents

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.

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 an evidenced-based cognitive behavioral therapy intervention for adolescents in a school setting

PROBLEM

The adolescent years are a formative time when rapid hormonal and physical changes stimulate the developing mind. Exposure to poverty, abuse, violence, and lack of peer and social support causes an increase in vulnerability to the development of mental health problems. The COVID-19 pandemic has also exacerbated symptoms of depression and anxiety. Regardless of the risk factors, anxiety and depression continue to be significant health problems, affecting thousands of adolescents yearly in the United States. The first-line treatment recommendation for managing anxiety and depression symptoms is cognitive behavioral therapy (CBT). However, access to a provider for CBT treatment is not always an option for many reasons.

METHODS

This pilot evidenced-based practice project aims to increase access to skills acquired through CBT and improve adolescents' mental health by implementing a brief and evidenced-based CBT program in a school setting. The CBT program for this project is the Creating Opportunities for Personal Empowerment (COPE) for Teens program consisting of seven 50-55-min sessions. The COPE program was delivered to 22 students in a 7th-grade health class. The Generalized Anxiety Disorder 7-Item and Patient Health Questionnaire-9 Modified for Adolescents measured anxiety and depression scores at baseline, post-intervention, and 2-month follow-up.

FINDINGS

Results indicate clinically significant improvements in anxiety and depression scores and showed participant satisfaction.

CONCLUSIONS

COPE in the school setting offers a low-risk solution to improving behaviors and emotional intelligence. COPE is a cost-effective solution to the mental health provider shortage.

Review: Interventions to prevent or manage self-harm among students in educational settings - a systematic review

BACKGROUND

At least half of all young people who die by suicide have previously self-harmed and most of those who self-harm will not seek help from health services for self-harming behaviours. By default, schools, colleges and universities necessarily play a key role in identifying those who self-harm and supporting them to access help.

METHODS

We conducted a systematic review (PROSPERO ID: CRD42021243692) of five databases (Medline, PsycINFO, ASSIA, ERIC and BEI) for quantitative studies evaluating interventions to reduce self-harm among students in schools, colleges and universities.

RESULTS

We identified six eligible studies that reported interventions. Two interventions used mindfulness-based approaches and the remaining four interventions focused on in-classroom education. Three interventions reported a significant reduction in self-harm, all three used in-classroom education. Of the six studies, one study was rated methodologically moderate, while the remaining five were weak.

CONCLUSION

In summary, the evidence base is limited in size and quality. Most current interventions to address self-harm in schools focus on training staff in awareness, with a significant gap in direct support for students.

School-based socio-emotional learning programs to prevent depression, anxiety and suicide among adolescents: a global cost-effectiveness analysis

AIMS

Preventing the occurrence of depression/anxiety and suicide during adolescence can lead to substantive health gains over the course of an individual person's life. This study set out to identify the expected population-level costs and health impacts of implementing universal and indicated school-based socio-emotional learning (SEL) programs in different country contexts.

METHODS

A Markov model was developed to examine the effectiveness of delivering universal and indicated school-based SEL programs to prevent the onset of depression/anxiety and suicide deaths among adolescents. Intervention health impacts were measured in healthy life years gained (HLYGs) over a 100-year time horizon. Country-specific intervention costs were calculated and denominated in 2017 international dollars (2017 I$) under a health systems perspective. Cost-effectiveness findings were subsequently expressed in terms of I$ per HLYG. Analyses were conducted on a group of 20 countries from different regions and income levels, with final results aggregated and presented by country income group - that is, low and lower middle income countries (LLMICs) and upper middle and high-income countries (UMHICs). Uncertainty and sensitivity analyses were conducted to test model assumptions.

RESULTS

Implementation costs ranged from an annual per capita investment of I$0.10 in LLMICs to I$0.16 in UMHICs for the universal SEL program and I$0.06 in LLMICs to I$0.09 in UMHICs for the indicated SEL program. The universal SEL program generated 100 HLYGs per 1 million population compared to 5 for the indicated SEL program in LLMICs. The cost per HLYG was I$958 in LLMICS and I$2,006 in UMHICs for the universal SEL program and I$11,123 in LLMICs and I$18,473 in UMHICs for the indicated SEL program. Cost-effectiveness findings were highly sensitive to variations around input parameter values involving the intervention effect sizes and the disability weight used to estimate HLYGs.

CONCLUSIONS

The results of this analysis suggest that universal and indicated SEL programs require a low level of investment (in the range of I$0.05 to I$0.20 per head of population) but that universal SEL programs produce significantly greater health benefits at a population level and therefore better value for money (e.g., less than I$1,000 per HLYG in LLMICs). Despite producing fewer population-level health benefits, the implementation of indicated SEL programs may be justified as a means of reducing population inequalities that affect high-risk populations who would benefit from a more tailored intervention approach.

Non-Positive Experiences Encountered by Pupils During Participation in a Mindfulness-Informed School-Based Intervention

Mindfulness-informed school-based mental health curricula show much promise in cultivating a positive school climate which supports the well-being and mental health of pupils and staff. However, non-positive pupil outcomes and experiences of school-based mental health interventions are often under-recognised and under-reported. This study sought to capture non-positive pupil experiences of a popular mindfulness-informed curriculum. Some pupils across all schools in the study described non-positive experiences, including having troubling thoughts and emotions, and not finding the programme effective. Contexts surrounding these experiences are explored and linked to existing literature, and subsequent recommendations for improvements are made, including the importance of having clear programme structure, definitions and aims, acknowledging and accommodating fidelity issues as best as possible, and better highlighting the potential for non-positive experiences and how they may be reduced.

A hybrid approach to comparing parallel-group and stepped-wedge cluster-randomized trials with a continuous primary outcome when there is uncertainty in the intra-cluster correlation

BACKGROUND/AIMS

To evaluate how uncertainty in the intra-cluster correlation impacts whether a parallel-group or stepped-wedge cluster-randomized trial design is more efficient in terms of the required sample size, in the case of cross-sectional stepped-wedge cluster-randomized trials and continuous outcome data.

METHODS

We motivate our work by reviewing how the intra-cluster correlation and standard deviation were justified in 54 health technology assessment reports on cluster-randomized trials. To enable uncertainty at the design stage to be incorporated into the design specification, we then describe how sample size calculation can be performed for cluster- randomized trials in the 'hybrid' framework, which places priors on design parameters and controls the expected power in place of the conventional frequentist power. Comparison of the parallel-group and stepped-wedge cluster-randomized trial designs is conducted by placing Beta and truncated Normal priors on the intra-cluster correlation, and a Gamma prior on the standard deviation.

RESULTS

Many Health Technology Assessment reports did not adhere to the Consolidated Standards of Reporting Trials guideline of indicating the uncertainty around the assumed intra-cluster correlation, while others did not justify the assumed intra-cluster correlation or standard deviation. Even for a prior intra-cluster correlation distribution with a small mode, moderate prior densities on high intra-cluster correlation values can lead to a stepped-wedge cluster-randomized trial being more efficient because of the degree to which a stepped-wedge cluster-randomized trial is more efficient for high intra-cluster correlations. With careful specification of the priors, the designs in the hybrid framework can become more robust to, for example, an unexpectedly large value of the outcome variance.

CONCLUSION

When there is difficulty obtaining a reliable value for the intra-cluster correlation to assume at the design stage, the proposed methodology offers an appealing approach to sample size calculation. Often, uncertainty in the intra-cluster correlation will mean a stepped-wedge cluster-randomized trial is more efficient than a parallel-group cluster-randomized trial design.

A Systematic Review of School-Based Suicide Prevention Interventions for Adolescents, and Intervention and Contextual Factors in Prevention

Suicide is the fourth leading cause of death among adolescents, globally. Though post-primary, school-based suicide prevention (PSSP) has the potential to be a key strategy for preventing adolescent suicidal thoughts and behaviours (STBs), there are persisting challenges to translating PSSP research to practice. Intervention and contextual factors relevant to PSSP are likely key to both PSSP effectiveness and implementation. As such, this systematic review aimed to summarise the effectiveness of PSSP for adolescent STBs and highlight important intervention and contextual factors with respect to PSSP. PsycINFO, Medline, Education Source, ERIC, Web of Science, and the Cochrane Central Register of Controlled Trials were searched to identify randomised and non-randomised studies evaluating the effectiveness of interventions located in post-primary, school-based settings targeting adolescent STBs. PSSP effectiveness and intervention and contextual factors were synthesised narratively. Twenty-eight studies were retained, containing nearly 47,000 participants. Twelve out of twenty-nine trials comparing intervention and independent control comparators reported statistically significant reductions in STBs postintervention, and 5/7 trials comparing preintervention and postintervention scores demonstrated significant reductions in STBs over time. Reporting and analysis of intervention and contextual factors were lacking across studies, but PSSP effectiveness and intervention acceptability varied across type of school. Although school personnel commonly delivered PSSP interventions, their input and perspectives on PSSP interventions were lacking. Notably, adolescents had little involvement in designing, inputting on, delivering and sharing their perspectives on PSSP interventions. Twenty out of twenty-eight studies were rated as moderate/high risk of bias, with non-randomised trials demonstrating greater risks of bias and trial effectiveness, in comparison to cluster randomised trials. Future research should prioritise complete reporting and analysis of intervention and contextual factors with respect to PSSP, involving key stakeholders (including adolescents and school personnel) in PSSP, and investigating key stakeholders' perspectives on PSSP. Given the inverse associations between both study quality and study design with PSSP effectiveness, particular consideration to study quality and design in PSSP research is needed. Future practice should consider PSSP interventions with universal components and PSSP which supports and involves key stakeholders in engaging with PSSP.

Feasibility of a secondary school-based mental health intervention: Reprezents' On The Level

AIMS

There is a need for innovative school-based mental health interventions to promote good mental health, healthy coping strategies, and engagement with support services. Consequently, Reprezent, a youth development organization, with mental health professionals and young people co-developed an online mental health intervention show, On The Level (OTL). This study assessed the acceptability and feasibility of delivering OTL to young people (aged 11-18 years) in 36 secondary schools across London and Essex, UK.

METHODS

OTL was delivered online as part of the school curriculum, in classrooms at timepoint 1 (T1, 50 min). Follow-up data was collected at timepoint 2 (T2) 4-6 weeks later, during a 20-min OTL review show. For interactive OTL elements and data collection participants logged into an online survey. Measures of acceptability and engagement, mental health and well-being outcomes and intervention evaluation were taken at T1 and T2. We also assessed the feasibility of implementing the OTL intervention in secondary schools.

RESULTS

10,315 participants received the intervention (T1) and 3369 attended the follow-up session (T2), this high attrition, and potential selection bias, was due to only 30% of schools being able to take part in T2. Rates of acceptability were high among young people and school staff. At T1, 88% found OTL engaging, and 84% felt more confident they had the tools to help them better manage stress and anxiety. At T2, 66% viewed mental health in a more positive way, and 71% had better understanding of how to maintain good mental health. Rates of engagement with mental health tools and services were good, and significant reduction in levels of stress were found 4-6 weeks after the OTL show (T2). The low mental health and well-being indices reported by the school children at baseline strongly support the need and use for a mental health intervention such as OTL in secondary schools.

CONCLUSION

These findings indicated good feasibility and acceptability of OTL intervention and support the delivery of the OTL mental health intervention at UK-based secondary schools to educate young people about mental health and well-being and give them the necessary tools to support their mental health.

The Campbell Collaboration's systematic review of school-based anti-bullying interventions does not meet mandatory methodological standards

BACKGROUND

Many published reviews do not meet the widely accepted PRISMA standards for systematic reviews and meta-analysis. Campbell Collaboration and Cochrane reviews are expected to meet even more rigorous standards, but their adherence to these standards is uneven. For example, a newly updated Campbell systematic review of school-based anti-bullying interventions does not appear to meet many of the Campbell Collaboration's mandatory methodological standards.

ISSUES

In this commentary, we document methodological problems in the Campbell Collaboration's new school-based anti-bullying interventions review, including (1) unexplained deviations from the protocol; (2) inadequate documentation of search strategies; (3) inconsistent reports on the number of included studies; (4) undocumented risk of bias ratings; (5) assessments of selective outcome reporting bias that are not transparent, not replicable, and appear to systematically underestimate risk of bias; (6) unreliable assessments of risk of publication bias; (7) use of a composite scale that conflates distinct risks of bias; and (8) failure to consider issues related to the strength of the evidence and risks of bias in interpreting results and drawing conclusions. Readers who are unaware of these problems may place more confidence in this review than is warranted. Campbell Collaboration editors declined to publish our comments and declined to issue a public statement of concern about this review.

CONCLUSIONS

Systematic reviews are expected to use transparent methods and follow relevant methodological standards. Readers should be concerned when these expectations are not met, because transparency and rigor enhance the trustworthiness of results and conclusions. In the tradition of Donald T. Campbell, there is need for more public debate about the methods and conclusions of systematic reviews, and greater clarity regarding applications of (and adherence to) published standards for systematic reviews.

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.

Effectiveness of school-based programs to reduce bullying perpetration and victimization: An updated systematic review and meta-analysis

Background

Bullying first emerged as an important topic of research in the 1980s in Norway (Olweus), and a recent meta-analysis shows that these forms of aggression remain prevalent among young people globally (Modecki et al.). Prominent researchers in the field have defined bullying as any aggressive behavior that incorporates three key elements, namely: (1) an intention to harm, (2) repetitive in nature, and (3) a clear power imbalance between perpetrator and victim (Centers for Disease Control and Prevention; Farrington). There are many negative outcomes associated with bullying perpetration, such as: suicidal ideation (Holt et al.), weapon carrying (Valdebenito et al.), drug use (Ttofi et al.), and violence and offending in later life (Ttofi et al.). Bullying victimization too is associated with negative outcomes such as: suicidal ideation (Holt et al.), anxiety, low self-esteem and loneliness (Hawker& Boulton). Therefore, school bullying is an important target for effective intervention, and should be considered a matter of public health concern.

Objectives

The objective of this review is to establish whether or not existing school-based antibullying programs are effective in reducing school-bullyng behaviors. This report also updates a previous meta-analysis conducted by Farrington and Ttofi. This earlier review found that antibullying programs are effective in reducing bullying perpetration and victimization and a primary objective of the current report is to update the earlier analysis of 53 evaluations by conducting new searches for evaluations conducted and published since 2009.

Search Methods

Systematic searches were conducted using Boolean combinations of the following keywords: bully*; victim*; bully-victim; school; intervention; prevention; program*; evaluation; effect*; and anti-bullying. Searches were conducted on several online databases including, Web of Science, PscyhINFO, EMBASE, EMBASE, DARE, ERIC, Google Scholar, and Scopus. Databases of unpublished reports, such as masters' and doctoral theses (e.g., Proquest) were also searched.

Selection Criteria

Results from systematic searches were screened thoroughly against the following inclusion criteria. To be included in this review, a study must have: (1) described an evaluation of a school-based antibullying program implemented with school-age participants; (2) utilized an operational definition of school-bullying that coincides with existing definitions; (3) measured school-bullying perpetration and/or victimization using quantitative measures, such as, self-, peer-, or teacher-report questionnaires; and (4) used an experimental or quasi-experimental design, with one group receiving the intervention and another not receiving the intervention.

Data Collection and Analysis

Of the 19,877 search results, 474 were retained for further screening. The majority of these were excluded, and after multiple waves of screening, 100 evaluations were included in our meta-analysis. A total of 103 independent effect sizes were estimated and each effect size was corrected for the impact of including clusters in evaluation designs. Included evaluations were conducted using both randomized (n = 45; i.e., randomized controlled trials/RCTs) and nonrandomized (n = 44; i.e., quasi-experimental designs with before/after measures; BA/EC) methodologies. All of these studies included measures of bullying outcomes before and after implementation of an intervention. The remaining 14 effect sizes were estimated from evaluations that used age cohort designs. Two models of meta-analysis are used to report results in our report. All mean effects computed are presented using both the multivariance adjustment model (MVA) and random effects model (RE). The MVA model assigns weights to primary studies in direct proportion to study level sampling error as with the fixed effects model but adjusts the meta-analytic standard error and confidence intervals for study heterogeneity. The RE model incorporates between-study heterogeneity into the formula for assigning weights to primary studies. The differences and strengths/limitations of both approaches are discussed in the context of the present data.

Results

Our meta-analysis identified that bullying programs significantly reduce bullying perpetration (RE: odds ratio [OR] = 1.309; 95% confidence interval [CI]: 1.24-1.38; z = 9.88; p < .001) and bullying victimization (RE: OR = 1.244; 95% CI: 1.19-1.31; z = 8.92; p < .001), under a random effects model of meta-analysis. Mean effects were similar across both models of meta-analysis for bullying perpetration (i.e., MVA: OR = 1,324; 95% CI: 1.27-1.38; z = 13.4; p < .001) and bullying victimization (i.e., MVA: OR = 1.248; 95% CI: 1.21-1.29; z = 12.06; p < .001). Under both computational models, primary studies were more effective in reducing bullying perpetration than victimization overall. Effect sizes varied across studies, with significant heterogeneity between studies for both bullying perpetration (Q = 323.392; df = 85; p < .001; I 2  = 73.716) and bullying victimization (Q = 387.255; df = 87; p < .001; I 2  = 77.534) outcomes. Analyses suggest that publication bias is unlikely. Between-study heterogeneity was expected, given the large number of studies included, and thus, the number of different programs, methods, measures and samples used.

Authors' Conclusions

We conclude that overall, school-based antibullying programs are effective in reducing bullying perpetration and bullying victimization, although effect sizes are modest. The impact of evaluation methodology on effect size appears to be weak and does not adequately explain the significant heterogeneity between primary studies. Moreover, the issue of the under-/over-estimation of the true treatment effect by different experimental designs and use of self-reported measures is reviewed. The potential explanations for this are discussed, along with recommendations for future primary evaluations. Avenues for future research are discussed, including the need further explain differences across programs by correlating individual effect sizes with varying program components and varying methodological elements available across these 100 evaluations. Initial findings in the variability of effect sizes across different methodological moderators provide some understanding on the issue of heterogeneity, but future analyses based on further moderator variables are needed.

Cost-effectiveness evidence of mental health prevention and promotion interventions: A systematic review of economic evaluations

BACKGROUND

The prevention of mental disorders and promotion of mental health and well-being are growing fields. Whether mental health promotion and prevention interventions provide value for money in children, adolescents, adults, and older adults is unclear. The aim of the current study is to update 2 existing reviews of cost-effectiveness studies in this field in order to determine whether such interventions are cost-effective.

METHODS AND FINDINGS

Electronic databases (including MEDLINE, PsycINFO, CINAHL, and EconLit through EBSCO and Embase) were searched for published cost-effectiveness studies of prevention of mental disorders and promotion of mental health and well-being from 2008 to 2020. The quality of studies was assessed using the Quality of Health Economic Studies Instrument (QHES). The protocol was registered with PROSPERO (# CRD42019127778). The primary outcomes were incremental cost-effectiveness ratio (ICER) or return on investment (ROI) ratio across all studies. A total of 65 studies met the inclusion criteria of a full economic evaluation, of which, 23 targeted children and adolescents, 35 targeted adults, while the remaining targeted older adults. A large number of studies focused on prevention of depression and/or anxiety disorders, followed by promotion of mental health and well-being and other mental disorders. Although there was high heterogeneity in terms of the design among included economic evaluations, most studies consistently found that interventions for mental health prevention and promotion were cost-effective or cost saving. The review found that targeted prevention was likely to be cost-effective compared to universal prevention. Screening plus psychological interventions (e.g., cognitive behavioural therapy [CBT]) at school were the most cost-effective interventions for prevention of mental disorders in children and adolescents, while parenting interventions and workplace interventions had good evidence in mental health promotion. There is inconclusive evidence for preventive interventions for mental disorders or mental health promotion in older adults. While studies were of general high quality, there was limited evidence available from low- and middle-income countries. The review was limited to studies where mental health was the primary outcome and may have missed general health promoting strategies that could also prevent mental disorder or promote mental health. Some ROI studies might not be included given that these studies are commonly published in grey literature rather than in the academic literature.

CONCLUSIONS

Our review found a significant growth of economic evaluations in prevention of mental disorders or promotion of mental health and well-being over the last 10 years. Although several interventions for mental health prevention and promotion provide good value for money, the varied quality as well as methodologies used in economic evaluations limit the generalisability of conclusions about cost-effectiveness. However, the finding that the majority of studies especially in children, adolescents, and adults demonstrated good value for money is promising. Research on cost-effectiveness in low-middle income settings is required.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019127778.

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.

A text mining approach for adapting a school-based sexual health promotion program in Colombia

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We show how to validate a sexual health promotion program.

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The validation estimates the readability of written materials.

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The validation also estimates the word co-occurrence network for topics detection.

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The COMPAS program conducted in Colombia is taken as an example.

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The paper provides the readers with a practical tool for further implementations.

A common practice among clinical psychologists and other health professionals is the use of school-based sexual health promotion programs as a means for preventing sexually transmitted infections. A fundamental criterion for the designing and adaptation of these programs is the age of their target populations because limited education and language are the most relevant factors that limit the efficacy of these programs. The contribution of this paper consists of assessing both the readability of the written materials that accompany the contents of a Spanish-written school-based sexual health promotion program used in Colombia, as well as the words co-occurrence network structure of its contents. The readability of the evaluated program corresponded to its intended target population aged between 14 and 19, with the schooling of 9–13 years of education. The resulting words co-occurrence network structure of the COMPAS program also mirrored its theoretical content. These results all together are deemed as empirical evidence of the adequacy of the program.

Process evaluations of primary care interventions addressing chronic disease: a systematic review

OBJECTIVE

Process evaluations (PEs) alongside randomised controlled trials of complex interventions are valuable because they address questions of for whom, how and why interventions had an impact. We synthesised the methods used in PEs of primary care interventions, and their main findings on implementation barriers and facilitators.

DESIGN

Systematic review using the UK Medical Research Council guidance for PE as a guide.

DATA SOURCES

Academic databases (MEDLINE, SCOPUS, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, EMBASE and Global Health) were searched from 1998 until June 2018.

ELIGIBILITY CRITERIA

We included PE alongside randomised controlled trials of primary care interventions which aimed to improve outcomes for patients with non-communicable diseases.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened and conducted the data extraction and synthesis, with a third reviewer checking a sample for quality assurance.

RESULTS

69 studies were included. There was an overall lack of consistency in how PEs were conducted and reported. The main weakness is that only 30 studies were underpinned by a clear intervention theory often facilitated by the use of existing theoretical frameworks. The main strengths were robust sampling strategies, and the triangulation of qualitative and quantitative data to understand an intervention's mechanisms. Findings were synthesised into three key themes: (1) a fundamental mismatch between what the intervention was designed to achieve and local needs; (2) the required roles and responsibilities of key actors were often not clearly understood; and (3) the health system context-factors such as governance, financing structures and workforce-if unanticipated could adversely impact implementation.

CONCLUSION

Greater consistency is needed in the reporting and the methods of PEs, in particular greater use of theoretical frameworks to inform intervention theory. More emphasis on formative research in designing interventions is needed to align the intervention with the needs of local stakeholders, and to minimise unanticipated consequences due to context-specific barriers.

PROSPERO REGISTRATION NUMBER

CRD42016035572.

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.

Using flawed, uncertain, proximate and sparse (FUPS) data in the context of complexity: learning from the case of child mental health

The use of routinely collected data that are flawed and limited to inform service development in healthcare systems needs to be considered, both theoretically and practically, given the reality in many areas of healthcare that only poor-quality data are available for use in complex adaptive systems. Data may be compromised in a range of ways. They may be flawed, due to missing or erroneously recorded entries; uncertain, due to differences in how data items are rated or conceptualised; proximate, in that data items are a proxy for key issues of concern; and sparse, in that a low volume of cases within key subgroups may limit the possibility of statistical inference. The term 'FUPS' is proposed to describe these flawed, uncertain, proximate and sparse datasets. Many of the systems that seek to use FUPS data may be characterised as dynamic and complex, involving a wide range of agents whose actions impact on each other in reverberating ways, leading to feedback and adaptation. The literature on the use of routinely collected data in healthcare is often implicitly premised on the availability of high-quality data to be used in complicated but not necessarily complex systems. This paper presents an example of the use of a FUPS dataset in the complex system of child mental healthcare. The dataset comprised routinely collected data from services that were part of a national service transformation initiative in child mental health from 2011 to 2015. The paper explores the use of this FUPS dataset to support meaningful dialogue between key stakeholders, including service providers, funders and users, in relation to outcomes of services. There is a particular focus on the potential for service improvement and learning. The issues raised and principles for practice suggested have relevance for other health communities that similarly face the dilemma of how to address the gap between the ideal of comprehensive clear data used in complicated, but not complex, contexts, and the reality of FUPS data in the context of complexity.

Association between School Membership and Substance Use among Adolescents

BACKGROUND

Substance use among adolescents is a major problem worldwide, producing many health and economic consequences. Even though there are well-known personal, familial, and social factors associated with drug use, less is known about the effect of school-related factors. School membership is a recognized variable affecting academic performance among students; however, its effect on substance use is less understood.

AIMS

The primary aim of this study was to explore the association between school membership and cigarette, alcohol, and cannabis use among a representative sample of secondary students from municipal state-funded schools in Santiago of Chile, and secondly, to test the hypothesis that depressive or anxiety symptoms mediate this association.

METHODS

A total of 2,508 students from 22 state-funded schools in Santiago, Chile, answered a questionnaire. This instrument included an abbreviated version of the psychological sense of school membership (PSSM), questions regarding the use of alcohol, tobacco, and cannabis and scales of psychological functioning (depression, anxiety, self-concept, and problem-solving). The association analyses were performed using adjusted regression models for each outcome using all independent variables while controlling for gender and age. For the mediation effect, a combination of ordinary least square and logistic regression analyses was conducted.

RESULTS

There was an association between a strong PSSM and low risk for smoking (OR 0.57; 95% CI 0.46-0.72), drinking (0.65; 95% CI: 0.51-0.83), and cannabis use (0.52; 95% CI 0.37-0.74). We also found that depressive and anxiety symptoms do not fully mediate the association between school membership and any substance use, and 73% of this effect in the case of smoking, 80% in the case of drinking, and 78.5% in the case of cannabis use, was direct.

CONCLUSION

This is the first study in Latin America exploring the association between school membership and substance use among secondary students. School membership seems to be an important and independent factor to be included in preventive interventions. Therefore, these results support future research aiming to test interventions at increasing the sense of school membership to prevent substance use among adolescents.

CLINICAL TRIAL REGISTRATION

ISRCTN19466209. Retrospectively registered.

Cost-effectiveness of a preferred intensity exercise programme for young people with depression compared with treatment as usual: an economic evaluation alongside a clinical trial in the UK

OBJECTIVES

To assess the cost-effectiveness of preferred intensity exercise programme for young people with depression compared with a treatment as usual control group.

DESIGN

A 'within trial' cost-effectiveness and cost-utility analysis conducted alongside a randomised controlled trial. The perspective of the analysis was the UK National Health Service and social services.

SETTING

The intervention was provided in a community leisure centre setting.

PARTICIPANTS

86 young people aged 14-17 years attending Tier 2 and Tier 3 CAMHS (Child and Adolescent Mental Health Services) outpatient services presenting with depression.

INTERVENTIONS

The intervention comprised 12 separate sessions of circuit training over a 6-week period. Sessions were supervised by a qualified exercise therapist. Participants also received treatment as usual. The comparator group received treatment as usual.

RESULTS

We found improvements in the Children's Depression Inventory-2 (CDI-2) and estimated cost-effectiveness at £61 per point improvement in CDI-2 for the exercise group compared with control. We found no evidence that the exercise intervention led to differences in quality-adjusted life years (QALY). QALYs were estimated using the EQ-5D-5L (5-level version of EuroQol-5 dimension).

CONCLUSIONS

There is evidence that exercise can be an effective intervention for adolescents with depression and the current study shows that preferred intensity exercise could also represent a cost-effective intervention in terms of the CDI-2.

TRIAL REGISTRATION NUMBER

NCT01474837.

Depression and Anxiety Prevention Based on Cognitive Behavioral Therapy for At-Risk Adolescents: A Meta-Analytic Review

Depression and anxiety disorders are among the most common mental disorders during adolescence. During this life phase, the incidence of these clinical disorders rises dramatically, and even more adolescents suffer from symptoms of depression or anxiety that are just below the clinical threshold. Both clinical and subclinical levels of depression or anxiety symptoms are related to decreased functioning in various areas, such as social and academic functioning. Prevention of depression and anxiety in adolescents is therefore imperative. We conducted a meta-analytic review of the effects of school-based and community-based prevention programs that are based on cognitive behavioral therapy with the primary goal preventing depression, anxiety, or both in high risk adolescents. Articles were obtained by searching databases and hand searching reference lists of relevant articles and reviews. The selection process yielded 32 articles in the meta-analyses. One article reported on two studies and three articles reported on both depression and anxiety. This resulted in a total of 36 studies, 23 on depression and 13 on anxiety. For depression prevention aimed at high risk adolescents, meta-analysis showed a small effect of prevention programs directly after the intervention, but no effect at 3-6 months and at 12 months follow-up. For anxiety prevention aimed at high risk adolescents, no short-term effect was found, nor at 12 months follow-up. Three to six months after the preventive intervention, symptoms of anxiety were significantly decreased. Although effects on depression and anxiety symptoms were small and temporary, current findings cautiously suggest that depression and anxiety prevention programs based on CBT might have small effects on mental health of adolescents. However, it also indicates that there is still much to be gained for prevention programs. Current findings and possibilities for future research are discussed in order to further improve the effectiveness of targeted prevention on internalizing disorders.

A pilot evaluation of the SPARX-R gaming intervention for preventing depression and improving wellbeing among adolescents in alternative education

AIM

The use of computerized mental health programs with vulnerable youth, such as early school leavers, remains relatively unstudied. This pilot study examined the feasibility of delivering a computerized cognitive behavioral therapy (cCBT) gaming intervention (SPARX-R) for young people (age 15-20 years) who have left school early and are attending Youthreach, an alternative education (AE) program in Ireland.

METHOD

Students (n = 146) from twenty-one Youthreach Centers were randomized to SPARX-R and no-intervention control. All students within the group were included in the study whether or not they were exhibiting heightened levels of depression. Program impact was examined on both negative and positive indicators of mental health, including depression (primary outcome), generalized anxiety, general mental wellbeing, coping and emotion regulation. Assessments were conducted at baseline and post-intervention (7 weeks). Participants that provided data at post-assessment (n = 66) were included in the analysis.

RESULTS

The participants completed on average 5.3 modules of SPARX-R with 30% (n = 9) completing the entire program. A significant improvement in emotion regulation strategies was detected, with expressive suppression decreasing significantly in the SPARX-R group in comparison to the control (- 2.97, 95% CI - 5.48 to - 0.46, p = 0.03).

CONCLUSIONS

Findings suggest that SPARX-R has a positive impact on emotion regulation. The lack of significant findings on other outcome measures may be attributed to inadequate sample size, and therefore, further research with larger samples are required to establish the effectiveness of the program in reducing depression and anxiety and improving psychological wellbeing among young people attending AE.

The effectiveness and cost-effectiveness of a mindfulness training programme in schools compared with normal school provision (MYRIAD): study protocol for a randomised controlled trial

BACKGROUND

Mindfulness-based approaches for adults are effective at enhancing mental health, but few controlled trials have evaluated their effectiveness or cost-effectiveness for young people. The primary aim of this trial is to evaluate the effectiveness and cost-effectiveness of a mindfulness training (MT) programme to enhance mental health, wellbeing and social-emotional behavioural functioning in adolescence.

METHODS/DESIGN

To address this aim, the design will be a superiority, cluster randomised controlled, parallel-group trial in which schools offering social and emotional provision in line with good practice (Formby et al., Personal, Social, Health and Economic (PSHE) Education: A mapping study of the prevalent models of delivery and their effectiveness, 2010; OFSTED, Not Yet Good Enough: Personal, Social, Health and Economic Education in schools, 2013) will be randomised to either continue this provision (control) or include MT in this provision (intervention). The study will recruit and randomise 76 schools (clusters) and 5700 school students aged 12 to 14 years, followed up for 2 years.

DISCUSSION

The study will contribute to establishing if MT is an effective and cost-effective approach to promoting mental health in adolescence.

TRIALS REGISTRATION

International Standard Randomised Controlled Trials, identifier: ISRCTN86619085 . Registered on 3 June 2016.

Practitioner Review: School-based interventions in child mental health

BACKGROUND

School-based interventions (SBIs) are well-established and effective treatments for improving child mental health. Specific school-based topics include prevention (Tier I-III) and interventions (e.g. cognitive-behavioural programmes and daily report cards).

METHODS

We performed a systematic literature search in five commonly used online databases (ERIC, MEDLINE, PsycARTICLES, PsycINFO and PSYNDEX) for English-language articles published between 1993 and 2015. Additional sources included reference lists of relevant articles and book chapters.

RESULTS

We identified a number of successful behavioural or cognitive-behavioural programmes yielding moderate to strong effects for a range of emotional and behavioural problems. The implementation of these programmes and the collaboration of the involved settings (school and home) and persons are important factors for their effectiveness under real-life conditions.

CONCLUSIONS

Effective SBIs are valuable tools for students with mental health problems if evidence-based cognitive-behavioural interventions are applied and rules of translational algorithms and implementation science are respected.

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.

Indicated school-based intervention to improve depressive symptoms among at risk Chilean adolescents: a randomized controlled trial

BACKGROUND

Depression is a disabling condition affecting people of all ages, but generally starting during adolescence. Schools seem to be an excellent setting where preventive interventions may be delivered. This study aimed to test the effectiveness of an indicated school-based intervention to reduce depressive symptoms among at-risk adolescents from low-income families.

METHODS

A two-arm, parallel, randomized controlled trial was conducted in 11 secondary schools in vulnerable socioeconomic areas in Santiago, Chile. High-risk students in year 10 (2° Medio) were invited to a baseline assessment (n = 1048). Those who scored ≥10 (boys) and ≥15 (girls) in the BDI-II were invited to the trial (n = 376). A total of 342 students consented and were randomly allocated into an intervention or a control arm in a ratio of 2:1. The intervention consisted of 8 group sessions of 45 min each, based on cognitive-behavioural models and delivered by two trained psychologists in the schools. Primary (BDI-II) and secondary outcomes (measures of anxiety, automatic thoughts and problem-solving skills) were administered before and at 3 months post intervention. The primary outcome was the recovery rate, defined as the proportion of participants who scored in the BDI-II <10 (among boys) and <15 (among girls) at 3 months after completing the intervention.

RESULTS

There were 229 participants in the intervention group and 113 in the control group. At 3-month follow-up 81.4 % in the intervention and 81.7 % in the control group provided outcome data. The recovery rate was 10 % higher in the intervention (50.3 %) than in the control (40.2 %) group; with an adjusted OR = 1.62 (95 % CI: 0.95 to 2.77) (p = 0.08). No difference between groups was found in any of the secondary outcomes. Secondary analyses revealed an interaction between group and baseline BDI-II score.

CONCLUSIONS

We found no clear evidence of the effectiveness of a brief, indicated school-based intervention based on cognitive-behavioural models on reducing depressive symptoms among Chilean adolescents from low-income families. More research is needed in order to find better solutions to prevent depression among adolescents.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN33871591 . Retrospectively registered 29 June 2011.

Electronic interventions for depression in adolescents: hot idea or hot air?

Depressive disorders frequently onset in adolescence, and although effective treatments for these disorders are known, many youth have difficulty accessing care when needed. Electronic interventions and mobile applications have been posited as a possible solution for increasing access to affordable care. This narrative review explores the state of the evidence for their effectiveness, safety, and acceptability with teenagers. Although many electronic interventions and mobile applications have received widespread attention, minimal rigorous independent research has been conducted, and their use with teenagers who have depression cannot be recommended at this time.

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

Background

Anxiety in children is common, impairs everyday functioning and increases the risk of severe mental health disorders in adulthood, yet few children with anxiety are identified and referred for treatment.

Objective

To investigate the clinical effectiveness and cost-effectiveness of a universal school-based preventative programme (FRIENDS) in reducing symptoms of anxiety and low mood.

Design

Cluster randomised controlled trial. Schools (n = 41) were randomly assigned after recruitment on a 1 : 1 : 1 basis to health-led FRIENDS, school-led FRIENDS and usual school provision.

Setting

Primary schools in three local education authorities in the south-west of England.

Participants

Children (n = 1362) aged 9–10 years attending school and participating in personal, social and health education (PSHE).

Interventions

The FRIENDS programme is a cognitive–behavioural therapy programme that develops skills to counter the cognitive, emotional and behavioural aspects of anxiety. The FRIENDS programme was led by either a trained member of the school or a health leader external to the school and was delivered over 9 consecutive weeks. The comparison group received usual school PSHE lessons. Interventions were delivered in the academic year September 2011–July 2012.

Main outcome measures

Clinical effectiveness assessed by child report of symptoms of anxiety (Revised Child Anxiety and Depression Scale, RCADS); cost-effectiveness based on RCADS and quality-adjusted life-years (Child Health Utility 9 Dimensions, CHU-9D) between baseline and 6 months; process evaluation, evaluation of reach and attrition and qualitative feedback from children, school staff and parents.

Results

At 12 months there was a difference in the adjusted mean RCADS scores for health-led FRIENDS compared with school-led FRIENDS [–3.91, 95% confidence interval (CI) –6.48 to –1.35] and for health-led FRIENDS compared with usual school provision (–2.66, 95% CI –5.22 to –0.09). At 24 months we were able to assess only 43.6% of our cohort. There were few differences in baseline characteristics between completers and non-completers. Child-reported anxiety in all three groups had reduced by 24 months and there were no longer any group effects. There were no between-group effects for any parent- or child-completed secondary outcomes at 12 or 24 months. The cost of the FRIENDS programme was £52–56 per child. We found no evidence that the FRIENDS programme was cost-effective over a 6-month period; however, our subgroup for the economic analysis differed significantly from our main trial cohort.

Conclusions

Although greater reductions in anxiety were noted at 12 months when the FRIENDS programme was delivered by health leaders, these additional benefits were not maintained at 24 months. Children’s anxiety levels improved irrespective of the intervention that they received. Our economic evaluation and 24-month assessment had significant shortcomings. However, the universal delivery of specific anxiety prevention programmes will result in additional costs that may be beyond the finances available to most schools. Future work should identify the active ingredients and potential moderators of universal anxiety programmes to determine whether programme length can be reduced, short-term effectiveness maintained and cost-effectiveness improved. At present, our results find limited evidence to support the universal provision of specific anxiety prevention programmes in UK primary schools.

Trial registration

Current Controlled Trials ISRCTN23563048.

Funding

The National Institute for Health Research Public Health Research programme.

Trial for the Prevention of Depression (TriPoD) in final-year secondary students: study protocol for a cluster randomised controlled trial

BACKGROUND

Evidence suggests that current treatments cannot fully alleviate the burden of disease associated with depression but that prevention approaches offer a promising opportunity to further reduce this burden. Adolescence is a critical period in the development of mental illness, and final school examinations are a significant and nearly universal stressor that may act as a trigger for mental health difficulties such as depression. The aim of the present trial is to investigate the impact of SPARX-R, an online, gamified intervention based on cognitive behavioural principles, on the prevention of depression in secondary school students before their final examinations.

METHODS/DESIGN

Government, independent and Catholic secondary schools in New South Wales, Australia, will be recruited to participate in the trial. All students enrolled in their final year of high school (year 12) in participating schools will be invited to participate. To account for possible attrition, the target sample size was set at 1600 participants across 30 schools. Participating schools will be cluster randomised at the school level to receive either SPARX-R or lifeSTYLE, an attention-controlled placebo comparator. The control intervention is an online program aimed at maintaining a healthy lifestyle. The primary outcome will be symptoms of depression, and secondary outcomes will include symptoms of anxiety, suicidal ideation and behaviours, stigma and academic performance. Additional measures of cost-effectiveness, as well as process variables (e.g., adherence, acceptability) and potential predictors of response to treatment, will be collected. Consenting parents will be invited to complete measures regarding their own mental health and expectations for their child. Assessments will be conducted pre- and post-intervention and at 6- and 18-month follow-up. Primary analyses will compare changes in levels of depressive symptomatology for the intervention group relative to the attention control condition using mixed-effects model repeated-measures analyses to account for clustering within schools.

DISCUSSION

This is the first trial of a universal depression prevention intervention delivered to school students in advance of a specific, significant stressor. If found to be effective, this program may offer schools a new approach to preparing students for their final year of schooling.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry identifier: ACTRN12614000316606 . Registered 25 March 2014.

Measuring Health Utilities in Children and Adolescents: A Systematic Review of the Literature

Background

The objective of this review was to evaluate the use of all direct and indirect methods used to estimate health utilities in both children and adolescents. Utilities measured pre- and post-intervention are combined with the time over which health states are experienced to calculate quality-adjusted life years (QALYs). Cost-utility analyses (CUAs) estimate the cost-effectiveness of health technologies based on their costs and benefits using QALYs as a measure of benefit. The accurate measurement of QALYs is dependent on using appropriate methods to elicit health utilities.

Objective

We sought studies that measured health utilities directly from patients or their proxies. We did not exclude those studies that also included adults in the analysis, but excluded those studies focused only on adults.

Methods and Findings

We evaluated 90 studies from a total of 1,780 selected from the databases. 47 (52%) studies were CUAs incorporated into randomised clinical trials; 23 (26%) were health-state utility assessments; 8 (9%) validated methods and 12 (13%) compared existing or new methods. 22 unique direct or indirect calculation methods were used a total of 137 times. Direct calculation through standard gamble, time trade-off and visual analogue scale was used 32 times. The EuroQol EQ-5D was the most frequently-used single method, selected for 41 studies. 15 of the methods used were generic methods and the remaining 7 were disease-specific. 48 of the 90 studies (53%) used some form of proxy, with 26 (29%) using proxies exclusively to estimate health utilities.

Conclusions

Several child- and adolescent-specific methods are still being developed and validated, leaving many studies using methods that have not been designed or validated for use in children or adolescents. Several studies failed to justify using proxy respondents rather than administering the methods directly to the patients. Only two studies examined missing responses to the methods administered with respect to the patients’ ages.

Integrating children with psychiatric disorders in the classroom: a systematic review

BACKGROUND

The school setting may be the optimal context for early screening of and intervention on child mental health problems, because of its large reach and intertwinement with various participants (child, teacher, parent, other community services). But this setting also exposes children to the risk of stigma, peer rejection and social exclusion. This systematic literature review investigates the efficacy of mental health interventions addressed to children and adolescents in school settings, and it evaluates which programs explicitly take into account social inclusion indicators.

METHOD

Only randomized controlled trials conducted on clinical populations of students and carried out in school settings were selected: 27 studies overall. Most studies applied group Cognitive Behavioural Therapy or Interpersonal Psychotherapy.

RESULTS

Findings were suggestive of the effectiveness of school-based intervention programs in reducing symptoms of most mental disorders. Some evidence was found about the idea that effective studies on clinical populations may promote the social inclusion of children with an ongoing mental disorder and avoid the risk of being highly stigmatized.

CONCLUSION

School programs are still needed that implement standardized models with verifiable and evidence-based practices involving the whole school community.

Cost-effectiveness of classroom-based cognitive behaviour therapy in reducing symptoms of depression in adolescents: a trial-based analysis

BACKGROUND

A substantial minority of adolescents suffer from depression and it is associated with increased risk of suicide, social and educational impairment, and mental health problems in adulthood. A recently conducted randomized controlled trial in England evaluated the effectiveness of a manualized universally delivered age-appropriate CBT programme in school classrooms. The cost-effectiveness of the programme for preventing low mood and depression for all participants from a health and social care sector perspective needs to be determined.

METHODS

A trial-based cost-effectiveness analysis based on a cluster-randomized controlled trial (trial registration--ISRCTN 19083628) comparing classroom-based CBT with usual school provision of Personal Social and Health Education. Per-student cost of intervention was estimated from programme records. The study was undertaken in eight mixed-sex U.K. secondary schools, and included 3,357 school children aged 12 to 16 years (in the two trial arms evaluated in the cost-effectiveness analysis). The main outcome measures were individual self-reported data on care costs, Quality-Adjusted Life-Years (QALYs, based on the EQ-5D health-related quality-of-life instrument) and symptoms of depression (Short Mood and Feelings Questionnaire) at baseline, 6 and 12 months.

RESULTS

Although there was lower quality-adjusted life-years over 12 months (-.05 QALYs per person, 95% confidence interval -.09 to -.005, p = .03) with CBT, this is a 'clinically' negligible difference, which was not found in the complete case analyses. There was little evidence of any between-arm differences in SMFQ scores (0.19, 95% CI -0.57 to 0.95, p = .62), or costs (£142, 95% CI -£132 to £415, p = .31) per person for CBT versus usual school provision.

CONCLUSIONS

Our analysis suggests that the universal provision of classroom-based CBT is unlikely to be either more effective or less costly than usual school provision.