Review ArticleIndicated preventive interventions for depression in children and adolescents: A meta-analysis and meta-regression
Introduction
Depression is a common disorder with a lifetime prevalence between 10 and 15% (Lepine and Briley, 2011), contributing to 1.84% (1.38%–2.33%) of the total global burden of disease (Disability Adjusted Life Years) (Institute for Health Metrics and Evaluation (IHME), 2016; Whiteford et al., 2013). The disorder is characterized by persistent low mood and loss of interest in previously pleasurable activities (Kasper et al., 2015; American Psychiatric Association, 2013), and is associated with decreased productivity (Lepine and Briley, 2011; Rost et al., 2014), diminished health related quality of life (HRQoL), strains in relationships, poor educational outcomes, unemployment as well as increased utilization of healthcare services (OECD, 2015), and an increased risk of all-cause mortality (Cuijpers et al., 2014), including suicide (Osby et al., 2001; Wulsin et al., 1999).
A significant proportion (over 25%) report that their first episode occurs during adolescence (Kessler et al., 2005), making this a vulnerable time. A substantial proportion of adolescents also have subsyndromal symptoms and go undiagnosed or unmanaged (Bertha and Balazs, 2013; Cameron et al., 2011). Depression with an adolescent onset is associated with an increased risk of depression in adulthood (Jonsson et al., 2011; Copeland et al., 2013). In addition, there is a large cost burden associated with depressive disorders (Hu, 2006; Gustavsson et al., 2011). In view of the early occurrence of depressive symptoms and the poor prognosis later in life, prevention has received considerable attention (Cuijpers et al., 2012). Specifically, preventive interventions have shown to be less costly than treatment and have a potential to reduce symptom severity (Hetrick et al., 2015; Garber et al., 2016; Crowe and McKay, 2017; Werner-Seidler et al., 2017; Yang et al., 2017), thus being cost-effective (Mihalopoulos and Vos, 2013). This is especially true for indicated preventive interventions for depression in adolescents (Garber, 2006; Rasing et al., 2017). Indicated preventive interventions are preventive measures targeted to people with symptoms that are either too few or not severe enough to warrant a diagnosis of e.g. Major Depressive Disorder (MDD). Indicated preventive interventions for depression in children and adolescents have demonstrated moderate effects, showing relative risks between 0.29 and 0.78 in comparison to all controls (Horowitz and Garber, 2006; Stice et al., 2009; Stockings et al., 2016). There is a range of indicated preventive interventions based on different theoretical grounds e.g. cognitive behavioral therapy, interpersonal therapy, problem solving based therapy, and psychodynamic therapy approaches. Out of these interventions, group-based cognitive behavioral therapy (GB-CBT) is the one that has been most extensively studied. It has been shown to be effective at reducing depressive symptoms when delivered in routine practice and schools (Hetrick et al., 2015; Rasing et al., 2017; Stockings et al., 2016; Bellón et al., 2015; Mendelson and Eaton, 2018). However, some research in the area has found GB-CBT interventions to have inconsistencies, such as low to no effect and that evidence is insufficient to draw generalizable conclusions on effectiveness (Rasing et al., 2017; Merry and Spence, 2007; Brent et al., 2015; Corrieri et al., 2013; Holmes et al., 2018). Most research has also expressed results as continuous outcome measures e.g. Cohen's d, which are not suitable for assessing cost-effectiveness as compared to relative risks. Relative risks can be directly used in health economics modelling to adjust the transition probabilities from one health state to another as opposed to Cohen's d. Furthermore, the effectiveness estimates are regarded the same irrespective of type of comparator (active or passive controls) and presence or absence of booster sessions, which may limit the clinical relevance of the results since earlier research, Gearing et al., demonstrates this difference for booster sessions (Gearing et al., 2013). These distinctions are relevant from both a clinical and economic perspective. Firstly, it is of importance to know if GB-CBT outperforms interventions based on non-specific components related to provision of support and counselling that might be less costly or more practical to implement. Secondly, it is also essential to ascertain if booster sessions have any additional health benefit since its inclusion increases the costs. In addition, to conduct cost-effectiveness evaluations of GB-CBT interventions for children and adolescents, it would require a more definitive evidence synthesis of the effectiveness. Stockings et al. (2016), and Rasing et al. (2017), published the most recent reviews and meta-analyses on the effects of preventive interventions on depression and anxiety in children and adolescents. Stockings' work focused on all types of preventive interventions while Rasing's work focused on targeted (selective and indicated) CBT based interventions but expressed outcomes as continuous outcomes (Cohen's d) rather than RRs. Both studies did not explore the impact of booster sessions and type of comparator (active or passive).
We hypothesized that GB-CBT indicated preventive interventions for depression in children and adolescents would demonstrate to be effective when compared to passive comparators, but that the results would differ for active comparators. We also presumed that inclusion of booster sessions would improve the results.
The aim of this study was to synthesize evidence on GB-CBT indicated preventive interventions for depression in children and adolescents with particular focus on:
- 1)
Addressing the inconsistencies in effectiveness of GB-CBT indicated interventions for the prevention of depression in children and adolescents.
- 2)
The effectiveness of GB-CBT indicated preventive interventions in relation to an active or passive comparator and the impact of booster sessions on intervention effectiveness.
- 3)
Synthesizing and reporting effect sizes in a useful form for inputs in cost-effectiveness assessments and decision-analytic modelling of these interventions.
Addressing the above aims will provide a better base for decision making concerning optimal resource allocation for adoption and implementation of these interventions.
Section snippets
Methods
This study was a systematic literature review with a meta-analysis based on the Cochrane Handbook for Systematic Reviews of Interventions (Higgins and Green, 2011), and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines (Moher et al., 2009). This work stems from meta-analyses conducted by Stockings et al. (2016), and Rasing et al. (2017), which were assessed to be of good quality according to the Assessing the Methodological Quality of
Study selection
A total of 36 articles, excluding duplicates, were obtained from Stockings' (n = 28) and Rasing's (n = 20) work. An additional 1351 articles were retrieved from the electronic search and 8 articles from the reference lists of the selected literature, thus a total of 1407 articles. Of the 1407 articles, 1275 were eliminated based on the title and abstract irrelevance and an additional 67 papers were duplicates. The remaining 65 articles were read in full text and assessed for eligibility. Twenty
Summary of evidence
This study aimed to investigate the effectiveness of GB-CBT indicated preventive interventions for depression in children and adolescents. The analyses contribute essentially to existing literature by focusing on the intervention effectiveness when compared to active and/or passive comparators, as well as on the impact of bias and booster sessions on effectiveness. In comparison to all control conditions, there was a reduction in the incidence of depressive disorder(s) at post-test (RR 0.43,
Conclusion
Group based CBT indicated preventive interventions for depression in children and adolescents are effective but the effect seems to decay over time. There is a need to further explore the benefit of booster sessions and the appropriate timing for them to be offered. Our results also underscore the value of making a clear distinction between active and passive comparators in order to guide decision-making.
Author contribution
All authors (RS, CN, IF, AS, SL and UJ) were involved in the development of the idea, (RS, CN and IF) did the data collection and analysis, all the authors then worked with the interpretation of results and discussion of this work. They have all agreed to this being the current version of the manuscript.
Funding
The study was supported by the Swedish Research Council (grant number 2014-10092), in collaboration with three other government agencies; Forte, Formas and Vinnova.
Ethical concerns
This study was a systematic literature review using existing published studies and the information from other researchers' work has been well referenced and acknowledged.
References (82)
- et al.
Prevention of depression among Icelandic adolescents
Behav. Res. Ther.
(2009) - et al.
Prevention of depression among Icelandic adolescents: a 12-month follow-up
Behav. Res. Ther.
(2011) - et al.
Effectiveness of psychological and/or educational interventions to prevent the onset of episodes of depression: a systematic review of systematic reviews and meta-analyses
Prev. Med.
(2015) - et al.
Evaluation of an intervention program for anxious adolescent boys who are bullied at school
J. Adolesc. Health
(2009) - et al.
Recognition and subsequent treatment of patients with sub-threshold symptoms of depression in primary care
J. Affect. Disord.
(2011) - et al.
The clinical effectiveness of cognitive behavior therapy and an alternative medicine approach in reducing symptoms of depression in adolescents
Psychiatry Res.
(2016) - et al.
Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents: a randomized trial of a group cognitive intervention
J. Am. Acad. Child Adolesc. Psychiatry
(1995) - et al.
Efficacy of cognitive-behavioral therapy for childhood anxiety and depression
J. Anxiety Disord.
(2017) Depression in children and adolescents
Am. J. Prev. Med.
(2006)- et al.
Cost of disorders of the brain in Europe 2010
Eur. Neuropsychopharmacol.
(2011)
The Lancet Psychiatry Commission on psychological treatments research in tomorrow's science
Lancet Psychiatry
The effect of cognitive–behavioral group therapy on the self-esteem, depression, and self-efficacy of runaway adolescents in a shelter in South Korea
Appl. Nurs. Res.
Mental health outcome of long-term and episodic adolescent depression: 15-year follow-up of a community sample
J. Affect. Disord.
Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data
J. Am. Acad. Child Adolesc. Psychiatry
A randomized controlled trial comparing two cognitive-behavioral programs for adolescent girls with subclinical depression: a school-based program (Op Volle Kracht) and a computerized program (SPARX)
Behav. Res. Ther.
Group prevention of depression and anxiety symptoms
Behav. Res. Ther.
Development of a school-based program for adolescents at-risk for depression in India: results from a pilot study
Asian J. Psychiatr.
Randomized trial of a brief depression prevention program: an elusive search for a psychosocial placebo control condition
Behav. Res. Ther.
School-based depression and anxiety prevention programs for young people: a systematic review and meta-analysis
Clin. Psychol. Rev.
Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010
Lancet
Efficacy and acceptability of cognitive behavioral therapy for depression in children: a systematic review and meta-analysis
Acad. Pediatr.
Diagnostic and Statistical Manual of Mental Disorders
Efficacy of a brief school-based program for selective prevention of childhood anxiety
Anxiety Stress Coping
Beck Depression Inventory-II
Subthreshold depression in adolescence: a systematic review
Eur. Child Adolesc. Psychiatry
How a meta-analysis works
Intro. Meta Anal.
Effect of a cognitive-behavioral prevention program on depression 6 years after implementation among at-risk adolescents: a randomized clinical trial
JAMA psychiatry
A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents
Arch. Gen. Psychiatry
Diagnostic transitions from childhood to adolescence to early adulthood
J. Child Psychol. Psychiatry
School-based prevention programs for depression and anxiety in adolescence: a systematic review
Health Promot. Int.
Preventing depression: a global priority
JAMA
Comprehensive meta-analysis of excess mortality in depression in the general community versus patients with specific illnesses
Am. J. Psychiatry
The prevention of depression and anxiety in a sample of high-risk adolescents: a randomized controlled trial
Can. J. Sch. Psychol.
Twelve-month outcomes of a randomized trial of the positive thoughts and action program for depression among early adolescents
Prev. Sci.
Treatment and prevention of depression and anxiety in youth: test of cross-over effects
Depress. Anxiety
The effectiveness of booster sessions in CBT treatment for child and adolescent mood and anxiety disorders
Depress. Anxiety
Prevention of depressive symptoms in schoolchildren: two-year follow-up
Psychol. Sci.
Preventing depression among early adolescents in the primary care setting: a randomized controlled study of the Penn Resiliency Program
J. Abnorm. Child Psychol.
School-based prevention of depression and anxiety symptoms in early adolescence: a pilot of a parent intervention component
Sch. Psychol. Q.
School-based prevention of depressive symptoms: a randomized controlled study of the effectiveness and specificity of the Penn Resiliency Program
J. Consult. Clin. Psychol.
Where to go from here? An exploratory meta-analysis of the most promising approaches to depression prevention programs for children and adolescents
Int. J. Environ. Res. Public Health
Cited by (27)
Adolescents accept digital mental health support in schools: A co-design and feasibility study of a school-based app for UK adolescents
2022, Mental Health and PreventionPublic mental health: required actions to address implementation failure in the context of COVID-19
2022, The Lancet PsychiatryPrimary prevention of depression: An umbrella review of controlled interventions
2021, Journal of Affective DisordersSchool-based intervention for depressive symptoms in upper secondary education: A focused review and meta-analysis of the effect of CBT-based prevention
2021, Mental Health and PreventionCitation Excerpt :In summary, school-based interventions have particular benefits in an upper secondary school setting. Cognitive-behavioral therapy (CBT) is an effective psychological treatment for depression, and this therapeutic technique is often included in school-based interventions (Feiss et al., 2019; Hetrick, Cox, Witt, Bir & Merry, 2016; Ssegonja et al., 2019). CBT addresses patients’ behavioral and cognitive skills that are helpful in problem-solving, and appropriate school-based intervention enables students to learn these valuable skills.
Further Evidence that Subsyndromal Manifestations of Depression in Childhood Predict the Subsequent Development of Major Depression: A Replication Study in a 10 Year Longitudinally Assessed Sample
2021, Journal of Affective DisordersCitation Excerpt :Considering the morbidity and dysfunction associated with pediatric MDD, efforts aimed at the identification of children at high risk for MDD early on in their development are of high clinical, scientific, and public health relevance. Despite the large availability of studies that discuss intervention strategies (Szigethy et al., 2007; Brent et al., 2001; Ssegonja et al., 2019; Baldofski et al., 2019), very little research exists that examines the identification of these subthreshold symptoms in youth. Of the scant literature available, research has shown that depression onset can be identified by increased levels of self-reported hopelessness and lower levels of functioning (Weersing et al., 2016) or through specialized clinician interviews (Patra, 2019).
Multiple domains of risk factors for first onset of depression in adolescent girls
2021, Journal of Affective DisordersCitation Excerpt :Yet, these predictors explained a modest amount of variance in first-onset DD, suggesting that additional factors are likely to play a role. Furthermore, these results have clinical implications for indicated or selective preventive interventions for adolescent-onset depression (Ssegonja et al., 2019), which could test whether targeting a combination of adolescents’ depressive symptomatology and rumination, as well as their parents’ mood and tendency to be critical of their daughters, reduces the incidence of depression. Our study further sheds new light on the risk factors that, in early adolescence, predict first-onset DD with a subsequent chronic/recurrent course vs. no onset.