Is behavioural activation an effective treatment for depression in children and adolescents? An updated systematic review and meta-analysis

Behavioural Activation (BA)-a brief therapy based on the scheduling of enjoyable, purposeful and rewarding activities-is an effective and cost-effective treatment for depression in adults that shows promise for children and adolescents. We provide an update on a previous systematic review of evidence on BA-delivered in-person, telephone, or online-for depression and comorbid anxiety in children and adolescents. We conducted systematic literature searches in 6 databases up to February 2024. We included all study designs evaluating BA with participants up to 18 years old with diagnosable depression, as established by a validated screening tool or diagnostic manual. We used the Moncrieff Scale and the Cochrane Risk of Bias tool to assess study quality. We summarised the findings of all study types with a narrative synthesis and of randomised controlled trials (RCTs) with a meta-analysis. Overall, 24 studies (6 RCTs, 18 pre-post evaluations, n = 2,758) met our inclusion criteria. A meta-analysis of 4 RCTs (n = 156) showed that BA has a small effect of 0.24 (Hedge's adjusted g) in reducing depression symptoms compared to a waiting-list control, usual care and other therapies. Online and telephone-facilitated BA was shown to be feasible in 3 studies and effective in 1. Outcomes on comorbid anxiety were mixed. No economic evaluations met our inclusion criteria. BA shows sufficient promise as an intervention for reducing depression symptoms in children and adolescents to justify the need for further RCTs, providing that five conditions are met: studies are powered to detect a minimal clinically important difference; BA materials are fit-for-purpose to produce clinically meaningful change; follow-ups are longer than 6 months; primary outcomes are child-reported; and intervention costs, resource use and adverse events are reported.

Cross-culturally adapted psychological interventions for the treatment of depression and/or anxiety among young people: A scoping review

BACKGROUND

Mental health problems among young people are a major global public health challenge. Psychological interventions may improve mental health, yet most are developed in western cultures, and it is unclear whether they are applicable to other geographical settings and can be delivered successfully to diverse populations. We identified empirical studies focusing upon cross-culturally adapted psychological interventions and examined the cultural adaptation process used and the effectiveness of the interventions in the treatment of depression and/or anxiety disorders among young people (defined here as children and adolescents aged between 8-18 years).

METHOD

We conducted a scoping review aligning to the guidelines reported in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) Statement. Stakeholder engagement enabled us to discuss the findings of the review and obtain feedback.

RESULTS

We identified 17 studies of cross-culturally adapted psychological interventions that considered the appropriate language, metaphors, culturally appropriate terms, and cultural values of young people. Most studies (n = 11) adopted a randomised control trial (RCT) methodology. Six studies used the ecological validity and cultural sensitivity framework. Planned adaptation, cultural adaptation of content, and surface and deep structure level adaptations were used in other studies. Apart from one pilot study, all studies reported that culturally adapted interventions resulted in improvements in depression and/or anxiety symptoms in young people. The results suggest the potential effectiveness of cross-culturally adapted interventions within this context. Our stakeholder consultations demonstrated that engaging different community-level stakeholders in the adaptation process was highly recommended.

CONCLUSIONS

Whilst most included studies indicated improvements in depression and/or anxiety symptoms in young people following a cross-culturally adapted intervention, more work is needed in this area. In particular, focus should be placed upon identifying the dimensions of interventions that should be culturally adapted to make them acceptable, engaging and effective.