The efficacy of a universal school-based program to prevent adolescent depression

Evaluated whether a universal school-based program, designed to prevent depression in adolescents, could be effectively implemented within the constraints of the school environment. Participants were 260 Year 9 secondary school students. Students completed measures of depressive symptoms and hopelessness and were then assigned to 1 of 3 groups: (a) Resourceful Adolescent Program-Adolescents (RAP-A), an 11-session school-based resilience building program, as part of the school curriculum; (b) Resourceful Adolescent Program-Family (RAP-F), the same program as in RAP-A, but in which each student's parents were also invited to participate in a 3-session parent program; and (c) Adolescent Watch, a comparison group in which adolescents simply completed the measures. The program was implemented with a high recruitment (88%), low attrition rate (5.8%), and satisfactory adherence to program protocol. Adolescents in either of the RAP programs reported significantly lower levels of depressive symptomatology and hopelessness at post-intervention and 10-month follow-up, compared with those in the comparison group. Adolescents also reported high satisfaction with the program. The study provides evidence for the efficacy of a school-based universal program designed to prevent depression in adolescence.     

Transdiagnostic internet treatment for anxiety and depression: a randomised controlled trial

Disorder-specific cognitive behavioural therapy programs delivered over the internet (iCBT) with clinician guidance are effective at treating specific anxiety disorders and depression. The present study examined the efficacy of a transdiagnostic iCBT protocol to treat three anxiety disorders and/or depression within the same program (the Wellbeing Program). Seventy-seven individuals with a principal diagnosis of major depression, generalised anxiety disorder, panic disorder, and/or social phobia were randomly assigned to a Treatment or Waitlist Control group. Treatment consisted of CBT-based online educational lessons and homework assignments, weekly email or telephone contact from a clinical psychologist, access to a moderated online discussion forum, and automated emails. Eighty one percent of Treatment group participants completed all 8 lessons within the 10 week program. Post-treatment data were collected from 34/37 Treatment group and 35/37 Control group participants, and 3-month follow-up data were collected from 32/37 Treatment group participants. Relative to Controls, Treatment group participants reported significantly reduced symptoms of anxiety and depression as measured by the Depression Anxiety and Stress Scales-21 item, Patient Health Questionnaire-9 item, and Generalised Anxiety Disorder-7 item scales, with corresponding between-groups effect sizes (Cohen’s d) at post treatment of.56,.58, and.52, respectively. The clinician spent a mean time of 84.76 min (SD = 50.37) per person over the program. Participants rated the procedure as highly acceptable, and gains were sustained at follow-up. These results provide preliminary support for the efficacy of transdiagnostic iCBT in the treatment of anxiety and depressive disorders.     

Relation of depression to perceived social support: results from a randomized adolescent depression prevention trial

Theorists posit that certain behaviors exhibited by depressed individuals (e.g., negative self-statements, dependency, reassurance seeking, inappropriate or premature disclosures, passivity, social withdrawal) reduce social support, yet there have been few experimental tests of this hypothesis. Using data from a randomized depression prevention trial (N = 253) involving adolescents (M age = 15.5, SD = 1.2), we tested whether a cognitive behavioral group intervention that significantly reduced depressive symptoms relative to bibliotherapy and educational brochure control conditions through 2-year follow-up produced improvements in perceived parental and friend social support and whether change in depressive symptoms mediated the effect on change in social support. Cognitive behavioral group participants showed significantly greater increases in perceived friend social support through 1-year follow-up relative to bibliotherapy and brochure controls, but there were no significant effects for perceived parental support. Further, change in depressive symptoms appeared to mediate the effects of the intervention on change in perceived friend support. Results provide experimental support for the theory that depressive symptoms are inversely related to perceived social support, but imply that this effect may be specific to friend vs. parental support for adolescents.     

Training school personnel to implement a universal school-based prevention of depression program under real-world conditions

The present study evaluated the impact of a universal prevention of depression program [the Resourceful Adolescent Program (RAP)] when implemented under real-world conditions in a school setting. Prior research has found the RAP program to be beneficial for high-school students when the program was implemented by university staff selected, trained, and supervised by a research team. The present study evaluated the RAP program when implemented by existing school personnel. Separately, we measured the impact of a training program for facilitators, the quality of subsequent program implementation, and the student's response to the RAP Program. Results showed that, in response to the training program, facilitators believed they had acquired the knowledge and confidence to implement the program and that the quality of program implementation was acceptable. The study did not demonstrate a beneficial impact of the RAP program for the students. The results raise important questions regarding the extent of training and ongoing supervision facilitators require if the beneficial outcomes for students are to be maintained when interventions are implemented under real-world conditions in school settings.     

Impact of a school-based disordered eating prevention program in adolescent girls: general and specific effects depending on adherence to the interactive activities

This study assessed the impact of a school-based program aimed at preventing disordered eating. The program was based on the media-literacy approach and has interactive format. The program was assessed under strong methodological conditions. Seven schools with 263 Spanish adolescent girls in the area of Barcelona, were randomly assigned to either the complete prevention program condition, the partial program condition or the non-treatment control condition, and assessed at pre, post and 6-month follow-up. The program was effective in generating positive changes at follow-up. The effects sizes (ES(d) = 0.29 to ES(d) = 0.38) were greater, on average, than that obtained up to now in selective-universal programs, and similar or greater than that achieved by targeted prevention programs. The results indicate a greater and relevant effect size of the intervention in those participants who completed the inter-session interactive activities (ES(d) = 0.29 to ES(d) = 0.45) although the differences were not significant. These results suggest the importance of monitoring adherence to the activities in all programs defined as "interactive". The implications and limitations of this study are discussed.     

Effects of cancer rehabilitation on problem-solving, anxiety and depression: a RCT comparing physical and cognitive-behavioural training versus physical training

We tested the effects on problem-solving, anxiety and depression of 12-week group-based self-management cancer rehabilitation, combining comprehensive physical training (PT) and cognitive-behavioural problem-solving training (CBT), compared with PT. We expected that PT + CBT would outperform PT in improvements in problem-solving (Social Problem-Solving Inventory-Revised (SPSI-R)), anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), and that more anxious and/or depressed participants would benefit most from adding CBT to PT. Cancer survivors (aged 48.8 ± 10.9 years, all cancer types, medical treatment completed) were randomly assigned to PT + CBT (n = 76) or PT (n = 71). Measurement occasions were: before and post-rehabilitation (12 weeks), 3- and 9-month follow-up. A non-randomised usual care comparison group (UCC) (n = 62) was measured at baseline and after 12 weeks. Longitudinal intention-to-treat analyses showed no differential pattern in change between PT + CBT and PT. Post-rehabilitation, participants in PT and PT + CBT reported within-group improvements in problem-solving (negative problem orientation; p < 0.01), anxiety (p < 0.001) and depression (p < 0.001), which were maintained at 3- and 9-month follow-up (p < 0.05). Compared with UCC post-rehabilitation, PT and PT + CBT only improved in anxiety (p < 0.05). CBT did not add to the effects of PT and had no extra benefits for higher distressed participants. PT was feasible and sufficient for durably reducing cancer survivors' anxiety.     

Effects of cognitive-behavioural therapy on anxiety,depression and condom use in people with HIV in Mexico City: a pilot study

Anxiety and depression in people living with HIV (PLWH) are negatively associated with healthy sexual behaviours. We pilot-tested a Cognitive-Behavioural Therapy (CBT)-based intervention to reduce anxiety and depression, aimed to increase serostatus disclosure to sexual partners, quality of sexual life (QoSL) and condom use. The study had a single-case experimental design (AB) with follow-up measures. Eleven PLWH with moderate/severe anxiety/depression received six-module CBT intervention delivered in ten one-hour individual weekly sessions. Anxiety, depression, consistent/correct condom use and QoSL were measured. Depression and anxiety decreased after the intervention (depression baseline [BL] Mdn = 21, final [F] Mdn = 3, z = -2.934, p = .003; anxiety BL Mdn = 30, F Mdn = 4, z = -2.941, p = .003). QoSL improved (BL Mdn = 28, F Mdn = 13, z = -2.625, p = .009), along with participants’ ability to use condoms (57.14 vs.100, z = -2.937, p = .003). Effect size was large, changes were maintained at follow-up measurements. The CBT intervention had positive effects in reducing anxiety and depression, which could facilitate the acquisition of healthy sexual behaviours. Further studies are important to clarify the benefits of targeting emotional variables to improve wellbeing and prevention behaviours in PLWH.     

A randomized controlled trial of strong minds: A school-based mental health program combining acceptance and commitment therapy and positive psychology

To date, most early intervention programs have been based on emotion regulation strategies that address dysfunctional cognitive appraisals, problem-solving skills, and rumination. Another emotion regulation strategy, ‘acceptance’ training, has largely been overlooked. To examine the efficacy of this strategy, a school-based mental health program combining positive psychology with acceptance and commitment therapy (Strong Minds) was evaluated in a randomized controlled trial with a sample of 267 Year 10 and 11 high-school students in Sydney, Australia. Mixed models for repeated measures examined whether the program led to reductions in symptoms amongst students who commenced the program with high depression, anxiety, and stress scores, and increased wellbeing scores amongst all students. Results demonstrated that compared to controls, participants in the Strong Minds condition with elevated symptom scores (n = 63) reported significant reductions in depression (p = .047), stress (p = .01), and composite depression/anxiety symptoms (p = .02) with medium to strong effect sizes (Cohen's d = 0.53, 0.74, and 0.57, respectively). Increased wellbeing (p = .03) in the total sample and decreased anxiety scores (p = .048) for students with elevated symptoms were significant for Year 10 students with medium effect sizes (Cohen's d = 0.43 and 0.54, respectively). This study tentatively suggests that including the emotion regulation strategy of acceptance in early intervention programs may be effective in reducing symptoms and improving wellbeing in high school students. Further research to investigate the generalizability of these findings is warranted.     

Longer term outcome of cognitive-behavioural and psychodynamic psychotherapy in routine mental health care: randomised controlled trial

We investigated the comparative effectiveness of cognitive-behavioural (CBT) and psychodynamic therapy (PDT) under clinically representative conditions as a subtrial of a prior study (Watzke et al., 2010, BJP). A consecutive sample of 147 patients with common mental disorders was randomised to either CBT or PDT in routine mental health care. In a primary per-protocol analysis patients randomised to CBT had a significantly better longer term outcome in the primary outcome symptom severity (General Severity Index of the SCL-14; p=.001; partial η(2)=0.073) as well as in health related quality of life (Mental Component Summary of the SF-8; p=.013; partial η(2)=.041) and concerning interpersonal issues (Inventory of Interpersonal Problems, IIP-C; p=.001; partial η(2)=.070) 6 months after treatment than patients randomised to PDT. These results could be confirmed in intention-to-treat analyses (n=180) suggesting that there was no substantial attrition bias due to drop outs at the follow-up assessment. Thus, the so called equivalence outcome paradox was not replicated in this study.     

An open trial of a brief transdiagnostic internet treatment for anxiety and depression

The present study evaluated the efficacy of a brief version of an internet-administered transdiagnostic CBT protocol, the Wellbeing Program (Titov et al., 2011), designed to treat three anxiety disorders and major depression within the same program. This brief version included the same core CBT skills as the original, but condensed the materials from 8 to 5 online lessons, reduced the duration of treatment from 10 to 8 weeks and did not include an online forum. Thirty-two individuals with a principal diagnosis of major depression, generalised anxiety disorder, panic disorder or social phobia received CBT-based online educational lessons, homework assignments, weekly contact from a clinical psychologist and automated emails. Eighty-one percent of participants completed the lessons within the 8 week program. Post-treatment and 3-month follow-up data were collected from 28/32 and 31/32 participants respectively. Participants improved significantly on the Depression Anxiety and Stress Scales – 21 Item, Patient Health Questionnaire – 9 Item, and Generalised Anxiety Disorder – 7 Item scales, with corresponding within-group effect sizes (Cohen’s d) at follow-up of 1.05, .73, and .95, respectively. Participants rated the procedure as highly acceptable with gains of a similar magnitude as those found for the original program, but less time was spent per participant by the clinician in the present trial (mean = 44.61 min, SD = 34.45) compared to the original program (mean = 84.76 min, SD = 50.37). These results provide additional support for the efficacy of transdiagnostic iCBT in the treatment of anxiety and depressive disorders and indicate that a brief version may be of benefit.     

Cognitive vulnerability to depression: a comparison of the weakest link, keystone and additive models

Multiple theories of cognitive vulnerability to depression have been proposed, each focusing on different aspects of negative cognition and utilising different measures of risk. Various methods of integrating such multiple indices of risk have been examined in the literature, and each demonstrates some promise. Yet little is known about the interrelations among these methods, or their incremental validity in predicting changes in depression. The present study compared three integrative models of cognitive vulnerability: the additive, weakest link, and keystone models. Support was found for each model as predictive of depression over time, but only the weakest link model demonstrated incremental utility in predicting changes in depression over the other models. We also explore the correlation between these models and each model's unique contribution to predicting onset of depressive symptoms.     

A family-focused randomized controlled trial to prevent adolescent alcohol and tobacco use: The moderating roles of positive parenting and adolescent gender

Four years of longitudinal data from 2,153 families with a 5th- or 6th-grade preadolescent participating in a family-focused pediatric primary-care-based prevention program were used to examine whether prevention effects were moderated by positive parenting and/or adolescent gender. Alcohol and tobacco use, internalizing problems, and externalizing problems were examined. Although findings revealed no main effect of the prevention program, positive parenting and adolescent gender were moderators of internalizing problems and adolescent gender was a moderator of externalizing problems. Clinical implications and future directions for research are discussed.     

Serotonergic function, two-mode models of self-regulation, and vulnerability to depression: what depression has in common with impulsive aggression

Evidence from diverse literatures supports the viewpoint that two modes of self-regulation exist, a lower-order system that responds quickly to associative cues of the moment and a higher-order system that responds more reflectively and planfully; that low serotonergic function is linked to relative dominance of the lower-order system; that how dominance of the lower-order system is manifested depends on additional variables; and that low serotonergic function therefore can promote behavioral patterns as divergent as impulsive aggression and lethargic depression. Literatures reviewed include work on two-mode models; studies of brain function supporting the biological plausibility of the two-mode view and the involvement of serotonergic pathways in functions pertaining to it; and studies relating low serotonergic function to impulsiveness, aggression (including extreme violence), aspects of personality, and depression vulnerability. Substantial differences between depression and other phenomena reviewed are interpreted by proposing that depression reflects both low serotonergic function and low reward sensitivity. The article closes with brief consideration of the idea that low serotonergic function relates to even more diverse phenomena, whose natures depend in part on sensitivities of other systems.     

Internet-based treatment of depression: a randomized controlled trial comparing guided with unguided self-help

Internet-delivered self-help for depression with therapist guidance has shown efficacy in several trials. Results from meta-analyses suggest that guidance is important and that self-help programs without support are less effective. However, there are no direct experimental comparisons between guided and unguided internet-based treatments for depression. The present study compared the benefits of a 10-week web-based unguided self-help treatment with the same intervention complemented with weekly therapist support via e-mail. A waiting-list control group was also included. Seventy-six individuals meeting the diagnostic criteria of major depression or dysthymia were randomly assigned to one of the three conditions. The Beck Depression Inventory (BDI-II) was used as the primary outcome measure. Secondary outcomes included general psychopathology, interpersonal problems, and quality of life. Sixty-nine participants (91%) completed the assessment at posttreatment and 59 (78%) at 6-month follow-up. Results showed significant symptom reductions in both treatment groups compared to the waiting-list control group. At posttreatment, between-group effect sizes on the BDI-II were d = .66 for unguided self-help versus waiting-list and d = 1.14 for guided self-help versus waiting-list controls. In the comparison of the two active treatments, small-to-moderate, but not statistically significant effects in favor of the guided condition were found on all measured dimensions. In both groups, treatment gains were maintained at 6-month follow-up. The findings provide evidence that internet-delivered treatments for depression can be effective whether support is added or not. However, all participants were interviewed in a structured diagnostic telephone interview before inclusion, which prohibits conclusions regarding unguided treatments that are without any human contact.     

Efficacy of guided self-help behavioural activation and physical activity for depression: a randomized controlled trial

Behavioural activation and physical activity have received empirical support that highlight their efficacy in reducing depression. Even though both behavioural activation and physical activity share the common goal of reactivating the individual, limited research has directly compared these interventions, and more research is required to evaluate their efficacy when offered in low-intensity formats. The present study involves a randomized controlled clinical trial comparing the efficacy of two guided self-help interventions for the treatment of depression: behavioural activation and physical activity. Fifty-nine participants presenting mild-to-moderate symptoms of depression were randomized either to a behavioural activation intervention (n = 20), a physical activity intervention (n = 19) or a wait-list control group (n = 20). All participants completed symptom measure pre-, mid- and post-intervention, as well as at a two-month follow-up. Mixed-model analyses of variance revealed that both interventions were significantly more efficacious in reducing depressive symptoms in comparison with the control group. Physical activity involved significantly less time-investment compared to the behavioural activation condition (less than half the amount of time). These results indicate that physical activity and behavioural activation both effectively reduce depressive symptoms and are favourably applicable in low-intensity formats. Implications of these results and avenues for future research are discussed.     

Acute pain in a clinical setting: Effects of cognitive-behavioural skills training

The present study evaluated the efficacy of cognitive-behavioural skills training, patterned after stress-inoculation training, as a preventive intervention for the attenuation of acute clinical pain during a noxious X-ray procedure—the knee arthrogram. Thirty-six adult male outpatients were randomly assigned to one of three groups: Skills Training. Attention-Placebo, and No-Treatment Control. An experimental pain test was administered before and after the interventions, as a generalization measure. Arthrogram pain was assessed by three dependent measures: patient's ratings, radiologist's ratings and videotape ratings completed by two‘blind’ raters. The results failed to support the efficacy of skills training for the attenuation of acute clinical pain, or its generalization to the experimental pain test. Although Skills Training subjects reported using significantly more coping strategies during the arthrogram. many subjects in the two control groups also reported using their own spontaneous strategies. Equivocal data were obtained on the role of ‘self-efficacy’ expectancies in mediating pain behaviour and experience. Experimental pain threshold but not pain tolerance was significantly related to acute clinical pain experienced during the arthrogram.