Elsevier

Preventive Medicine

Volume 118, January 2019, Pages 7-15
Preventive Medicine

Review Article
Indicated preventive interventions for depression in children and adolescents: A meta-analysis and meta-regression

https://doi.org/10.1016/j.ypmed.2018.09.021Get rights and content

Highlights

  • Indicated GB-CBT interventions appear to prevent or postpone onset of a depressive disorder.

  • The preventive effect demonstrated by GB-CBT interventions lasts for ≥12 months

  • Intervention effect decays over time, but lasts longer than for active comparators

  • Future research needs to clarify how and when booster sessions should be provided

Abstract

Depression contributes about 2% to the global burden of disease. A first onset of depressive disorder or subsyndromal depressive symptoms is common in adolescence, indicating that early prevention is a priority. However, trials of preventive interventions for depression in youths show conflicting results. This systematic review and meta-analysis investigated the effectiveness of group-based cognitive behavioral therapy (GB-CBT) as a preventive intervention targeting subsyndromal depression in children and adolescents. In addition, the impact of different covariates (type of comparator and use of booster sessions) was assessed. Relevant articles were identified from previous systematic reviews, and supplemented with an electronic search spanning from 01/09/2014 to 28/02/2018. The retrieved articles were assessed for eligibility and risk of bias. Relevant data were extracted. Intervention effectiveness was pooled using a random-effects model and the impact of covariates assessed using meta-regression. 38 eligible articles (34 trials) were obtained. The analysis showed GB-CBT to significantly reduce the incidence (relative risk 0.43, 95% CI 0.21–0.87) and symptoms (Cohen's d −0.22, 95% CI −0.32 to −0.11) of depression at post-test compared to all controls. Comparisons with passive comparators suggested that the effect decayed over time. However, compared to active controls, a significant intervention effect was evident only after 12 month or more. Our results suggest that the preventive effect of GB-CBT wears off, but still lasts longer than the effect of active comparators. Only a few studies included booster sessions, precluding firm conclusions. Future studies should clarify to what extent maintenance strategies can prolong the preventive effect of GB-CBT.

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.

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