Psychological and educational interventions for preventing depression in children and adolescents

278 Pages·2011·2.47 MB·English

Psychological and educational interventions for preventing
depression in children and adolescents (Review)
Merry SN, Hetrick SE, Cox GR, Brudevold-Iversen T, Bir JJ, McDowell H
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
2011,Issue12
http://www.thecochranelibrary.com
Psychologicalandeducationalinterventionsforpreventingdepressioninchildrenandadolescents(Review)
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Figure7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Figure8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Figure9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Figure10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Analysis1.1.Comparison1Psychological/educationalinterventionversusnointervention/wait-list/usualcare,Outcome1
Depressivedisorder(bypopulation). . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Analysis1.2.Comparison1Psychological/educationalinterventionversusnointervention/wait-list/usualcare,Outcome2
Depressivedisorder(byintervention). . . . . . . . . . . . . . . . . . . . . . . . . . 207
Analysis1.3.Comparison1Psychological/educationalinterventionversusnointervention/wait-list/usualcare,Outcome3
Depressivedisorder(bysex). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Analysis1.4.Comparison1Psychological/educationalinterventionversusnointervention/wait-list/usualcare,Outcome4
Depressivedisorders(byrisk). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Analysis1.5.Comparison1Psychological/educationalinterventionversusnointervention/wait-list/usualcare,Outcome5
Depressionscores(bypopulation). . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Analysis1.6.Comparison1Psychological/educationalinterventionversusnointervention/wait-list/usualcare,Outcome6
Depressionscores(byintervention). . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Analysis1.7.Comparison1Psychological/educationalinterventionversusnointervention/wait-list/usualcare,Outcome7
Depressionscores(bysex). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Analysis1.8.Comparison1Psychological/educationalinterventionversusnointervention/wait-list/usualcare,Outcome8
Depressionscores(byrisk). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Analysis2.1.Comparison2Psychological/educationalinterventionversusplacebo/attention/otherintervention,Outcome
1Depressivedisorder(bypopulation). . . . . . . . . . . . . . . . . . . . . . . . . . 221
Analysis2.2.Comparison2Psychological/educationalinterventionversusplacebo/attention/otherintervention,Outcome
2Depressivedisorder(byintervention). . . . . . . . . . . . . . . . . . . . . . . . . . 222
Analysis2.3.Comparison2Psychological/educationalinterventionversusplacebo/attention/otherintervention,Outcome
3Depressionscores(bypopulation). . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Analysis2.4.Comparison2Psychological/educationalinterventionversusplacebo/attention/otherintervention,Outcome
4Depressionscores(byintervention). . . . . . . . . . . . . . . . . . . . . . . . . . 224
Analysis2.5.Comparison2Psychological/educationalinterventionversusplacebo/attention/otherintervention,Outcome
5Depressionscores(bygender). . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Analysis3.1.Comparison3Psychological/educationalinterventionversusnointervention/wait-list/usualcarethreetonine
months,Outcome1Depressivedisorder(bypopulation). . . . . . . . . . . . . . . . . . . . 226
Psychologicalandeducationalinterventionsforpreventingdepressioninchildrenandadolescents(Review) i
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Analysis3.2.Comparison3Psychological/educationalinterventionversusnointervention/wait-list/usualcarethreetonine
months,Outcome2Depressivedisorder(byintervention). . . . . . . . . . . . . . . . . . . 227
Analysis3.3.Comparison3Psychological/educationalinterventionversusnointervention/wait-list/usualcarethreetonine
months,Outcome3Depressivedisorder(bysex). . . . . . . . . . . . . . . . . . . . . . 229
Analysis3.4.Comparison3Psychological/educationalinterventionversusnointervention/wait-list/usualcarethreetonine
months,Outcome4Depressivedisorder(byrisk). . . . . . . . . . . . . . . . . . . . . . 230
Analysis3.5.Comparison3Psychological/educationalinterventionversusnointervention/wait-list/usualcarethreetonine
months,Outcome5Depressionscores(bypopulation). . . . . . . . . . . . . . . . . . . . 231
Analysis3.6.Comparison3Psychological/educationalinterventionversusnointervention/wait-list/usualcarethreetonine
months,Outcome6Depressionscores(byintervention). . . . . . . . . . . . . . . . . . . . 234
Analysis3.7.Comparison3Psychological/educationalinterventionversusnointervention/wait-list/usualcarethreetonine
months,Outcome7Depressionscores(bysex). . . . . . . . . . . . . . . . . . . . . . . 236
Analysis3.8.Comparison3Psychological/educationalinterventionversusnointervention/wait-list/usualcarethreetonine
months,Outcome8Depressionscores(byrisk). . . . . . . . . . . . . . . . . . . . . . . 238
Analysis4.1.Comparison4Psychological/educationalinterventionversusplacebo/attention/otherinterventionthreeto
ninemonths,Outcome1Depressionscores(bypopulation). . . . . . . . . . . . . . . . . . 240
Analysis4.2.Comparison4Psychological/educationalinterventionversusplacebo/attention/otherinterventionthreeto
ninemonths,Outcome2Depressionscores(byintervention). . . . . . . . . . . . . . . . . . 241
Analysis5.1.Comparison5Psychological/educationalinterventionversusnointervention/wait-list/usualcare12months,
Outcome1Depressivedisorder(bypopulation). . . . . . . . . . . . . . . . . . . . . . . 242
Analysis5.2.Comparison5Psychological/educationalinterventionversusnointervention/wait-list/usualcare12months,
Outcome2Depressivedisorder(byintervention). . . . . . . . . . . . . . . . . . . . . . 243
Analysis5.3.Comparison5Psychological/educationalinterventionversusnointervention/wait-list/usualcare12months,
Outcome3Depressivedisorder(bysex). . . . . . . . . . . . . . . . . . . . . . . . . 244
Analysis5.4.Comparison5Psychological/educationalinterventionversusnointervention/wait-list/usualcare12months,
Outcome4Depressivedisorder(byrisk). . . . . . . . . . . . . . . . . . . . . . . . . 245
Analysis5.5.Comparison5Psychological/educationalinterventionversusnointervention/wait-list/usualcare12months,
Outcome5Depressionscores(bypopulation). . . . . . . . . . . . . . . . . . . . . . . 246
Analysis5.6.Comparison5Psychological/educationalinterventionversusnointervention/wait-list/usualcare12months,
Outcome6Depressionscores(byintervention). . . . . . . . . . . . . . . . . . . . . . . 247
Analysis5.7.Comparison5Psychological/educationalinterventionversusnointervention/wait-list/usualcare12months,
Outcome7Depressionscores(bysex). . . . . . . . . . . . . . . . . . . . . . . . . . 249
Analysis5.8.Comparison5Psychological/educationalinterventionversusnointervention/wait-list/usualcare12months,
Outcome8Depressionscores(byrisk). . . . . . . . . . . . . . . . . . . . . . . . . . 251
Analysis6.1.Comparison6Psychological/educationalinterventionversusplacebo/attention/otherintervention12months,
Outcome1Depressionscores(bypopulation). . . . . . . . . . . . . . . . . . . . . . . 252
Analysis6.2.Comparison6Psychological/educationalinterventionversusplacebo/attention/otherintervention12months,
Outcome2Depressionscores(byintervention). . . . . . . . . . . . . . . . . . . . . . . 252
Analysis6.3.Comparison6Psychological/educationalinterventionversusplacebo/attention/otherintervention12months,
Outcome3Depressionscores(bysex). . . . . . . . . . . . . . . . . . . . . . . . . . 253
Analysis7.1.Comparison7Psychological/educationalinterventionversusnointervention/wait-list/usualcare24months,
Outcome1Depressivedisorder(bypopulation). . . . . . . . . . . . . . . . . . . . . . . 254
Analysis7.2.Comparison7Psychological/educationalinterventionversusnointervention/wait-list/usualcare24months,
Outcome2Depressivedisorder(byintervention). . . . . . . . . . . . . . . . . . . . . . 255
Analysis7.3.Comparison7Psychological/educationalinterventionversusnointervention/wait-list/usualcare24months,
Outcome3Depressivedisorder(bysex). . . . . . . . . . . . . . . . . . . . . . . . . 256
Analysis7.4.Comparison7Psychological/educationalinterventionversusnointervention/wait-list/usualcare24months,
Outcome4Depressivedisorder(byrisk). . . . . . . . . . . . . . . . . . . . . . . . . 257
Analysis7.5.Comparison7Psychological/educationalinterventionversusnointervention/wait-list/usualcare24months,
Outcome5Depressionscores(bypopulation). . . . . . . . . . . . . . . . . . . . . . . 258
Analysis7.6.Comparison7Psychological/educationalinterventionversusnointervention/wait-list/usualcare24months,
Outcome6Depressionscores(byintervention). . . . . . . . . . . . . . . . . . . . . . . 259
Psychologicalandeducationalinterventionsforpreventingdepressioninchildrenandadolescents(Review) ii
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Analysis7.7.Comparison7Psychological/educationalinterventionversusnointervention/wait-list/usualcare24months,
Outcome7Depressionscores(bysex). . . . . . . . . . . . . . . . . . . . . . . . . . 260
Analysis7.8.Comparison7Psychological/educationalinterventionversusnointervention/wait-list/usualcare24months,
Outcome8Depressionscores(byrisk). . . . . . . . . . . . . . . . . . . . . . . . . . 261
Analysis8.1.Comparison8Psychological/educationalinterventionversusplacebo/attention/otherintervention24months,
Outcome1Depressionscores(bypopulation). . . . . . . . . . . . . . . . . . . . . . . 262
Analysis8.2.Comparison8Psychological/educationalinterventionversusplacebo/attention/otherintervention24months,
Outcome2Depressionscores(byintervention). . . . . . . . . . . . . . . . . . . . . . . 262
Analysis9.1.Comparison9Psychological/educationalinterventionversusnointervention/wait-list/usualcare36months,
Outcome1Depressivedisorder(bypopulation). . . . . . . . . . . . . . . . . . . . . . . 263
Analysis9.2.Comparison9Psychological/educationalinterventionversusnointervention/wait-list/usualcare36months,
Outcome2Depressivedisorder(byintervention). . . . . . . . . . . . . . . . . . . . . . 264
Analysis9.3.Comparison9Psychological/educationalinterventionversusnointervention/wait-list/usualcare36months,
Outcome3Depressionscores(bypopulation). . . . . . . . . . . . . . . . . . . . . . . 265
Analysis9.4.Comparison9Psychological/educationalinterventionversusnointervention/wait-list/usualcare36months,
Outcome4Depressionscores(byintervention). . . . . . . . . . . . . . . . . . . . . . . 266
Analysis9.5.Comparison9Psychological/educationalinterventionversusnointervention/wait-list/usualcare36months,
Outcome5Depressionscores(bysex). . . . . . . . . . . . . . . . . . . . . . . . . . 267
Analysis9.6.Comparison9Psychological/educationalinterventionversusnointervention/wait-list/usualcare36months,
Outcome6Depressionscores(byrisk). . . . . . . . . . . . . . . . . . . . . . . . . . 268
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 273
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Psychologicalandeducationalinterventionsforpreventingdepressioninchildrenandadolescents(Review) iii
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Psychological and educational interventions for preventing
depression in children and adolescents
SallyNMerry1,SarahEHetrick2,GeorginaRCox2,TessaBrudevold-Iversen1,JullietJBir3,HeatherMcDowell4
1Departmentof Psychological Medicine, University of Auckland,Auckland, NewZealand.2Centreof Excellencein YouthMental
Health,OrygenYouth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia.
3DepartmentofPsychiatry,UniversityofAuckland,Auckland,NewZealand.4ConsultLiaisonTeam,StarshipHospital,Auckland,
NewZealand
Contactaddress:SallyNMerry,DepartmentofPsychologicalMedicine,UniversityofAuckland,PrivateBag92019,Auckland,New
[email protected].
Editorialgroup:CochraneDepression,AnxietyandNeurosisGroup.
Publicationstatusanddate:Newsearchforstudiesandcontentupdated(conclusionschanged),publishedinIssue12,2011.
Reviewcontentassessedasup-to-date: 22July2010.
Citation: MerrySN,HetrickSE,CoxGR,Brudevold-IversenT,BirJJ,McDowellH.Psychologicalandeducationalinterventions
forpreventingdepressioninchildrenandadolescents.CochraneDatabaseofSystematicReviews2011,Issue12.Art.No.:CD003380.
DOI:10.1002/14651858.CD003380.pub3.
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Depressioniscommoninyoungpeople,hasamarkednegativeimpactandisassociatedwithself-harmandsuicide.Preventingitsonset
wouldbeanimportantadvanceinpublichealth.
Objectives
Todeterminewhetherpsychologicaloreducationalinterventions,orboth,areeffectiveinpreventingtheonsetofdepressivedisorder
inchildrenandadolescents.
Searchmethods
TheCochraneDepression,AnxietyandNeurosisReviewGroup’strialsregisters(CCDANCTR)weresearchedattheeditorialbase
inJuly2010. UpdatesearchesofMEDLINE,EMBASE,PsycINFOandERICwereconductedbytheauthorsinSeptember2009.
Conferenceabstracts,referencelistsofincludedstudiesandreviewsweresearchedandexpertsinthefieldcontacted.
Selectioncriteria
Randomisedcontrolledtrialsofpsychologicaloreducationalpreventionprogrammes,orboth,comparedwithplacebo,anycomparison
intervention,ornointerventionforyoungpeopleaged5to19years-old,whodidnotcurrentlymeetdiagnosticcriteriafordepression
orwhowerebelowtheclinicalrangeonstandardised,validated,andreliableratingscalesofdepression,orboth,wereincluded.
Datacollectionandanalysis
Twoauthorsindependentlyassessedstudiesforinclusionandratedtheirquality.Samplesizeswereadjustedtotakeaccountofcluster
designsandmultiplecomparisons.Wecontactedstudyauthorsforadditionalinformationwhereneeded.
Psychologicalandeducationalinterventionsforpreventingdepressioninchildrenandadolescents(Review) 1
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mainresults
Fifty-three studies including 14,406 participants were included in the analysis. There were only six studies with clear allocation
concealment,participantsandassessorsweremostlynotblindtotheinterventionorblindingwasunclearsothattheoverallriskof
biaswasmoderatelyhigh.Sixteenstudiesincluding3240participantsreportedoutcomesondepressivediagnosis.Theriskofhaving
adepressivedisorderpost-interventionwasreducedimmediatelycomparedwithnointervention(15studies;3115participantsrisk
difference(RD)-0.09;95%confidenceinterval(CI)-0.14to-0.05;P<0.0003),atthreetoninemonths(14studies;1842participants;
RD-0.11;95%CI-0.16to-0.06)andat12months(10studies;1750participants;RD-0.06;95%CI-0.11to-0.01).Therewasno
evidenceforcontinuedefficacyat24months(eightstudies;2084participant;RD-0.01;95%CI-0.04to0.03)butlimitedevidence
ofefficacyat36months(twostudies;464participants;RD-0.10;95%CI-0.19to-0.02).Therewassignificantheterogeneityinall
thesefindings.Therewasnoevidenceofefficacyinthefewstudiesthatcomparedinterventionwithplaceboorattentioncontrols.
Authors’conclusions
Thereissomeevidencefromthisreviewthattargetedanduniversaldepressionpreventionprogrammesmaypreventtheonsetofdepres-
sivedisorderscomparedwithnointervention.However,allocationconcealmentisunclearinmoststudies,andthereisheterogeneity
inthefindings.Thepersistenceoffindingssuggeststhatthisisrealandnotaplaceboeffect.
PLAIN LANGUAGE SUMMARY
Psychologicalandeducationalinterventionsforpreventingdepressioninchildrenandadolescents
Depressivedisorderiscommonandhasamajorimpactonthefunctioningofyoungpeople.Theaimofthisreviewwastoassessthe
effectivenessofprogrammesdesignedtopreventitsonset.
Wefoundthat,comparedwithnointervention,psychologicaldepressionpreventionprogrammeswereeffectiveinpreventingdepression
withanumberofstudiesshowingadecreaseinepisodesofdepressiveillnessoverayear.Thereweresomeproblemswiththewaythe
studiesweredone butdespitethistheresultsareencouraging. Wefounddatatosupportbothtargetedanduniversal programmes,
whichisimportantasuniversalprogrammesarelikelytobeeasiertoimplement.Werecommendthatfurtherresearchbeundertaken
toidentifythemosteffectiveprogrammesandtotesttheseintherealworld.
BACKGROUND
therequestoftheWorldBankandsupportedbytheWorldHealth
Organizationrankeddepressivedisorderfourthintheestimateof
Descriptionofthecondition diseaseburden,aheadofischaemicheartdisease,cerebrovascular
disease and tuberculosis (Murray 1997). The authors predicted
Depressionisacommonprobleminyoungpeople.Overallpreva-
depressionwouldbesecondinthecauseofdisabilitybytheyear
lencerates,measuredfrompointprevalenceupto12monthpe-
2020(Ustun1999;Murray1997a)andin2002theirpredictions
riodprevalence,fromalargemeta-analysiswereestimatedat2.8%
provedtobecorrect,withdepressivedisordersrankedsecond in
forchildrenundertheageof13and5.6%foryoungpeopleaged
developedcountries, andfirst indevelopingcountrieswithlow
13to18years(Costello2006).Ratesrisesteeplyinadolescence
mortality(Mathers2004).Becauseofthistherehasbeeninterest
(Feehan1993;Feehan1994;Fergusson 1993;Fergusson 2001).
inthedevelopmentofprogrammesaimedatpreventingtheonset
By the age of 19, between a fifth and a quarter of young peo-
ofdepression,withanumberofstudiesbeingpublishedinthelast
ple have suffered from a depressive disorder (Lewinsohn 1993;
twodecades.
Lewinsohn1998).Depressioninyoungpeopleisassociatedwith
pooracademicperformance,socialdysfunction,substanceabuse,
andattemptedandcompletedsuicide(Birmaher1996;Birmaher
1996a;Brent1986;Brent2002;Fleming1993;Rao1995;Rhode
Descriptionoftheintervention
1994).TheGlobalBurdenofDiseasestudy,initiatedin1992at
Psychologicalandeducationalinterventionsforpreventingdepressioninchildrenandadolescents(Review) 2
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Prevention can be universal, where the intervention is imple- ders,somepsychologicaltheoriesproposethatindividualfactors
mentedforadesignatedpopulationregardlessofrisk,ortargeted createapredispositiontodevelopingdepressivedisorders,andal-
toapopulation athighriskfor thedisorder. Targetedinterven- ternativelymayprovideamodelforpromotingresilienceinthe
tions can be furtherclassifiedinto selectiveinterventions which faceofstress.Thesetheorieshaveledtothedevelopmentof ef-
focus on populations with a risk factor for disorder e.g. family fectivetreatmentsfordepressivedisorderinyoungpeopleandare
history,andindicatedinterventionswhichfocusonpopulations oftenusedtoprovide atheoreticalbasis forthedevelopmentof
with symptoms or signs suggestive of incipient disorder. Some preventionprogrammes.
selective interventions target risk factors for depression, such as Beckdevelopedcognitivebehaviouraltherapybasedonhiscogni-
trauma, topreventlong-termsequelae.Theprimary targetmay tivemodelofdepression(Beck1976).Heproposedthatindividu-
not be depression, although the effect on depression may have alspronetodepressionhavecognitivedistortionswhichresultina
beenmeasuredalongwithotheroutcomes.Earlyinterventionmay negativeviewofthemselves,theworldandthefuture.Incognitive
beconsideredpreventionortreatment.TheInstituteofMedicine behavioural therapy(CBT), peoplelearntomonitor andevalu-
Report(Mrazek1994)andtheupdatedreport(O’Connell2009) atetheirthoughts,identifydifferentlevelsofmoodinthemselves,
recommendsthatpreventionisdefinedasthoseinterventionsthat recognisethoughtsandbehavioursthathavecontributedtothis
occurpriortotheonsetofaclinicallydiagnoseddisorder. mood, and learnhow to address these.Theassociated concepts
There are many psychological treatments for depression, that of “attributional style”(Abramson 1978) and “learnedhelpless-
include psychodynamic, humanistic and cognitive behavioural ness”(Petersen1993;Seligman1979)havealsocontributed to
strategies.Themostrobustevidenceexistsfortwoparticularpsy- componentsofCBT.Thosewithapessimisticattributionalstyle
chologicalinterventions:cognitivebehaviouraltherapyandinter- see negative events as a stable and enduring part of themselves,
personaltherapy.Thereisevidencethatbothareeffectivetreat- while positive events are seen as transient occurrences in which
mentsfordepressionandthattheymayreducerelapse,hencethe theyhaveplayednopart.Learnedhelplessnessisaphenomenonof
potentialfordepressionprevention. withdrawalanddepressionthatfollowsafailuretocontrolaversive
The depression prevention interventions are often delivered in events.Bothareassociatedwithasenseofhelplessnessandhope-
a group setting, both to reduce cost and because a group may lessness,whichleadstopassivityinthefaceofchallengesandcon-
reinforceeffectivenessbyprovidingpositivepeerexperiences.Both tributestolowmood(McCauley2001).Peoplewhoareproneto
groupandindividualinterventionsusuallytakeplaceonaweekly depressionarethenlesslikelytotakeanactiveapproachtodealing
basisandtypicallylastfor10to15sessions. with difficulties. Cognitive behavioural therapyusuallyincludes
Family-based programmes are based on thepremise thatfamily acomponentofeffectiveproblem-solving.Cognitivebehavioural
memberscaninfluenceoneanother’swell-beingandhaveasignif- therapycanalleviatesymptomsofdepressioninchildrenandado-
icanteffectontheoutcomesofinterventions(Carr2006).Family- lescents(Harrington 1998;Reinecke 1998)and canpreventre-
basedinterventionsoftenincludethecognitivestrategiesoutlined lapse(Paykel1999)althoughlong-termresultsinstudiesinchil-
above.Implementationwithinthefamilysystemisthoughttore- drenandadolescentshavecontradictoryfindings(Fonagy2005).
sultinamorerobustoutcomeasfamilydiscordisariskfactorfor Interpersonalconflict,difficultywithroletransitionsandexperi-
depression. encesoflossareallwellknownasriskfactorsinthedevelopmentof
Thereisevidencesupportingtheimportanceoftheschoolenvi- depressivedisorderinyoungpeople(Birmaher1996;Lewinsohn
ronmentforyoungpeople’swell-being(Carr2006).Youngpeople 1994;McCauley2001;).Interpersonal therapy(IPT)addresses
spendasignificantamountoftimeinschool,anddisseminating someofthesecomponentsandthereisevidenceofefficacyintreat-
a programme within a school or classroom is likely to be cost- mentofteenagedepression(Bolton2003;Mufson1996;Mufson
effectiveasmanyyoungpeoplecanbetaughtatthesametime. 2004).
Inthisreviewwehaveincludedbothpsychologicalandeducational
approachestopreventingdepression.Thekeydifferentiatingpoint
isthateducationalinterventionssimplyprovideinformationabout Whyitisimportanttodothisreview
depression,throughlecturesorfactsheets,whereaspsychological
Since the last review was published in 2004 (Merry 2004b) a
interventionsattempttochangehowpeoplethink,usingavariety
largenumberofstudieshavebeenconducted,andothersareun-
ofdifferentstrategies.
derway. Because of the cost of depression to society, and its re-
lationship to suicide attempts and completedsuicide, this is an
importantpublichealthissue.Previousreviewshaveshownthat
Howtheinterventionmightwork
targeted programmes are potentially effective in preventing de-
Theaetiologyofdepressivedisorderiscomplexandincludesbio- pressionforyoungpeople,withmoremixedresultsfromuniver-
logical,psychologicalandsocialfactors(Davidson2002;Cicchetti salprogrammes(Brunwasser2009;Horowitz2006;Merry2007;
1998;Goodyer2000;McCauley2001;Lewinsohn1994).While Merry2007a).Governmentsarekeentotakeactiontoaddressthe
itisclearthatasingleapproachwillnotreducealldepressivedisor- problem.However,thereisthepotentialforsuchprogrammesto
Psychologicalandeducationalinterventionsforpreventingdepressioninchildrenandadolescents(Review) 3
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
beimplementedintheabsenceofevidenceofeffectiveness.Itis ofMedicineReport(Mrazek1994;O’Connell2009),prevention
timelytore-evaluatetheevidencecurrentlyavailablefortheeffec- wasclassifiedasthoseinterventionsthatoccurredpriortotheini-
tivenessofdepressionpreventionprogrammes. tialonsetofaclinicallydiagnosabledisorderandincludedinter-
ventionsforindividualswhohadelevatedsymptomsofdisorder
butwhodidnotcurrentlymeetthecriteriaforaclinicaldisorder.
Studieswithparticipantswhohadpreviouslymetdiagnosticcrite-
OBJECTIVES riafordepressivedisorder,butdidnotcurrentlymeetthosecriteria
andhadhadnotreatmentfordisorderwereincluded.Although
Todeterminewhetherpsychologicaloreducationalinterventions,
thisisnotapuristdefinitionofprevention,infactthemajority
orboth,areeffectiveinpreventingtheonsetofdepressivedisorders
ofstudieshavenotrigorouslyassessedwhetherornotparticipants
inchildrenandadolescentsincluding:
had ahistory of depressive disorder, while some of the best de-
signedstudiesweidentifieddiddothis.Itwasillogicaltoexclude
1. Universalinterventions;and
thesestudies,giventhattheparticipantsintheotherstudiesare
2. Targetedinterventionsaimedatyoungpeopleatriskof likelyto have also included young people with past episodes of
developingadepressivedisorder(identifiedthroughelevated depressivedisorderthathavebeenunrecognisedanduntreated.
depressivesymptomsorpresenceofknownriskfactors). Weincludedstudiesthattargetedariskfactorfordepressivedis-
order as long as outcomes includeddepressive symptoms or di-
agnosisofdepressivedisorder,orboth,eveniftheywerenotthe
METHODS primaryoutcomevariable(e.g.interventionstoreducetheeffect
oftrauma,wherepost-traumatic stressdisorderwastheprimary
outcomevariable).
Secondary and tertiary interventions, including relapse preven-
Criteriaforconsideringstudiesforthisreview
tion, andpharmacological interventions fordepression wereex-
cluded.
Inthisreviewwehaveincludedbothpsychologicalandeducational
Typesofstudies
preventionprogrammes.Wehavedefinedpsychologicalinterven-
Randomisedcontrolledtrials(RCTs),includingclusterRCTswere tionsbroadlyasthosethattargetpsychologicalprocessesthought
included. tobeinvolvedinthedevelopmentofdepressionandeducational
interventionsarethosethatprovideeducationaboutdepression,
itscausesandwhatcouldbedoneaboutitinabroadsense,for
Typesofparticipants
example lifestyle interventions such as advice to take Omega-3
Studieswereincludedifthesubjectswerechildrenandadolescents
oil.However,thetwocanoverlap,especiallywhenpsychological
(aged5to19years)whodidnotcurrentlymeetthecriteriafor
interventionsincludesomepsycho-education. Earlystudieshave
aclinicaldiagnosisofdepressiveillness,althoughtheymayhave
investigatedpurelyeducationalprogrammesbutthesewerelargely
had sub-clinical symptoms of depression. Studies that included
ineffectiveandtheemphasissincethelastreviewhasbeenonpsy-
participantswithahistoryofdepressionwereincludedifthein-
chologicalinterventions.Themainmodalityemployedbyinvesti-
terventionwasaimedatpreventionofdepressioninanon-clin-
gatorswasbasedoncognitivebehaviouraltherapy,butsomeused
icalsetting,andwheretheparticipantswerenotbeingcurrently
otherapproachessuchasplaytherapy.
treatedfordepression.
The way interventions are delivered varies. In this review most
Studies were excluded if they lacked a clear definition of par-
interventionsaredeliveredingroups,butinthisreviewwehave
ticipants, were on children and adolescents who metDSM-IV-
somestudiesinvestigating theuseofcomputerstodeliverinter-
TR(AmericanPsychiatricAssociation2000)orICD-10(World
ventions.
HealthOrganization2007)criteriafordepressivedisorderorfell
intotheclinicalrangeonstandardised,validated,andreliablerat-
ingscalesofdepressionatthestartofthestudy,orboth,orthere
Typesofoutcomemeasures
wasnoadequateassessmentofparticipants.
Dichotomousoutcomemeasuresincludedstructuredclinicalin-
terviews,yieldingdiagnosisofdepressivedisorderusingmeasures
Typesofinterventions such as the Kiddie Schedule for Affective Disorders Scale (K-
Studiesondepressionpreventionwereincludediftheycompared SADS)(Kaufman1997).Otheroutcomemeasuresusedapredes-
theefficacyofeducationalorpsychologicalinterventionswiththe ignatedcut-offpointonacontinuousmeasurelikelytobecorre-
efficacyofplacebo,anycomparisonintervention,ornointerven- latedwithpresenceofadepressivedisorder,suchastheReynolds
tioninchildrenandadolescents.AsrecommendedintheInstitute Adolescent Depression Scale (Reynolds 1986) and rating scales
Psychologicalandeducationalinterventionsforpreventingdepressioninchildrenandadolescents(Review) 4
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
providing continuous measures of depressive symptoms such as searchesofMEDLINE(1950-),EMBASE(1974-)andPsycINFO
theChildren’sDepressionInventory(CDI)(Kovacs1992). (1967-); quarterly searchesof the Cochrane Central Register of
ControlledTrials(CENTRAL)andreview-specificsearchesofad-
ditional databases. Reportsof trialsare also sourcedfrominter-
Primaryoutcomes nationaltrialsregistersc/otheWorldHealthOrganization’strials
Ourprimaryoutcomeswere: portal (ICTRP) (http://apps.who.int/trialsearch/), drug compa-
• prevalenceofdepressivedisorderintheinterventiongroup nies, thehandsearching of key journals, conference proceedings
comparedwiththecontrolgrouppost-interventionandat andother(non-Cochrane)systematicreviewsandmeta-analyses.
follow-up,measuredoneitheravalidatedmeasureofdepressive DetailsofCCDAN’sgenericsearchstrategiescanbefoundonthe
disorder,oraboveacut-offonavalidated,reliable,continuous Group’swebsite.
measureofdepressionindicating’caseness’;and
• depressivesymptomsintheinterventiongroupcompared
withthecontrolgrouppost-interventionandatfollow-up. Electronicsearches
1.TheCochraneDepression,AnxietyandNeurosisGrouptrials
Themeasurementtoolsincluded:
registersweresearched(toJuly2010)usingthefollowingupdated
1. ArecogniseddiagnosticsystemsuchasDSM-IV-TR
searchstrategy:
(AmericanPsychiatricAssociation2000)orICD-10(World
CCDANCTR-StudiesRegister
HealthOrganization2007);
Diagnosis=(depress*ordysthymi*)and
2. Standardised,validated,andreliabledepressionratingscales
AgeGroup=(child*oradolescen*orunclearor“notstated”)and
suitableforchildrenandadolescents.Wheremorethanone
Free-Text=(prevent*or“earlyintervention*”orriskorat-riskor
outcomemeasurewasused,thehighestqualityoutcomemeasure
vulnerab*or(healthandpromot*)or“healthliteracy”oreducat*
wasenteredintotheanalyses.Forthisweusedahierarchybased
or psychoeducat* or training or “life skill*”or school* or class-
onpsychometricpropertiesandappropriatenessforusewith
room*orinternet*ordivorce*ordeathorbereave*)
childrenandadolescents,followingthemethoddescribedby
Hazell2002,seeAppendix5.
CCDANCTR-ReferencesRegister
Outcomesareorganisedbyfollow-uptimepoints,includingpost
Title/Abstract= (depression or depressive or dysthymi* or “de-
intervention,shortertermfollow-up,whichwedefinedas3to9
pressedmood“or“mentalhealth”)and
months,andlongertermfollow-upincluding12months,24and
Free-text= (adolesc* or preadolesc* or pre-adolesc* or child* or
36months.
boysorgirlsorjuvenil*orminorsorpre-schoolorpreschoolor
paediatric* or pediatric* or pubescen* or puberty or school* or
high-schoolorteen*oryoungoryouth*or(student*and(college
Secondaryoutcomes
oruniversit*))orundergraduate*)and
Given the size of the review and variability of the data, other
Free-text=(prevent*or”earlyintervention*“orriskorat-riskor
secondaryoutcomes(suchasgeneral/socialadjustment,academic
vulnerab*or(healthandpromot*)or”healthliteracy“oreducat*
functioning, cognitive style, anxiety and suicidal ideation) were
or psychoeducat* or training or ”life skill*“or school* or class-
notincludedintheupdateofthereview.
room*orinternet*ordivorce*ordeathorbereave*)
2.TheoriginalsearchofMEDLINE,EMBASE,PsycINFOand
ERIC was in 2005. The original search terms for all databases
Searchmethodsforidentificationofstudies havebeenupdated(September2009),(seeAppendix1;Appendix
2;Appendix3;Appendix4)andsearchesofthesedatabaseswere
CCDAN’sSpecialisedRegister(CCDANCTR)
updatedatthistime.
TheCochraneDepression,AnxietyandNeurosisReviewGroup
BecausetheCCDANregistersnowincluderegularsearchesofall
(CCDAN)maintaintwoclinicaltrialsregistersattheireditorial
thesedatabases,wedidnotundertakeanyfurthersearchesofthese
baseinBristol,UK,areferencesregisterandastudies-basedregis-
databasesinJuly2010.
ter.TheCCDANCTR-ReferencesRegistercontainsover27,500
reportsoftrialsindepression,anxietyandneurosis.Approximately
60%ofthesereferenceshavebeentaggedtoindividual,codedtri-
Searchingotherresources
als.ThecodedtrialsareheldintheCCDANCTR-StudiesRegis-
terandrecordsarelinkedbetweenthetworegistersthroughthe 1. Thereferencelistsofarticlesandotherreviewsretrievedin
use of unique Study ID tags. Coding of trials is based on the thesearchweresearched;
EU-Psicodingmanual.PleasecontacttheCCDANTrialsSearch 2. Conferenceabstracts,1994,1996,and1998-2001,forthe
Co-ordinatorforfurtherdetails.Reportsoftrialsforinclusionin AmericanAcademyofChildandAdolescentPsychiatrywere
theGroup’sregisters arecollatedfromroutine (weekly),generic searched;
Psychologicalandeducationalinterventionsforpreventingdepressioninchildrenandadolescents(Review) 5
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
3. Personalcommunication:inordertoensurethatasmanyas 3. Descriptionofintervention,includingtypee.g.CBT,
possibleRCTswereidentified,theauthorsoftheincludedstudies educational;durationandintensity,whetheritwasmanualised
wereconsultedtofindoutiftheyknewofanypublishedor andwhodeliveredtheintervention;
unpublishedRCTsinthearea,whichhadnotyetbeenidentified. 4. Typeofplacebo/control/comparison,e.g.wait-list,no
intervention,placebo.
Datacollectionandanalysis
Measures
1. Assessmentinstruments;
Selectionofstudies 2. Assessmentintervals.
Theselectionoftrialsforinclusionintheupdateofthereviewwas
performedindependently by at leasttwo of the review authors.
Whereatitleor abstractappearedtodescribeatrialeligiblefor Outcomes
inclusion,weobtainedthefullarticleandinspectedittoassessrel-
1. Diagnosisofdepressivedisorder;
evancetothisreviewbasedontheinclusioncriteria.Anydiscrep-
2. Depressivesymptoms.
anciesbetweenthetworeviewerswereresolvedbyathirdreview
Whenaspectsofmethodologywereunclear,orwhenthedatawere
author.
inaformunsuitableformeta-analysisandtrialsappearedtomeet
theeligibilitycriteria,additionalinformationwassoughtfromthe
principal author. We have indicated in the notes section of the
Dataextractionandmanagement
Characteristicsofincludedstudiesifanauthorsuppliedadditional
Datawereindependentlyextractedbyfourofthereviewauthors
data.
(SM,JB,GCorTB)anddiscrepancieswereresolvedbySH.To
ensureaccuratedataentry,thedataweredouble-checkedafteren-
tryforanalysis.Thefollowingdetailswereextractedfromthein- Assessmentofriskofbiasinincludedstudies
cludedtrialsandtheinformationispresentedintheCharacteristics Fortheoriginalversionofthisreview,weassessedmethodological
ofincludedstudies: qualityusingthequalityratingscaledevisedbyMoncrieffandcol-
leagues(Moncrieff2006).Allstudieswerescoredindependently
bytwooftheauthorsandthosescoring30ormoreweredeemed
’high’quality,thosescoring23ormoreweredeemed’adequate’.
Methods
Asensitivityanalysiswasundertakenincludingonlythosestudies
1. StudyDesigni.e.RCTorclusterRCT; thatscoredinthe’high’or’adequate’qualityrange.
2. Whetherapowercalculationwasdone; Forthecurrentupdate(2011),weupdatedourmethodstocon-
3. Thesourceofsubjectse.g.school; formtothecurrentversionoftheCochraneHandbook(Higgins
4. Whethertherewasrepresentativesamplerecruitment; 2008a)andmorespecifically,the’RiskofBias’toolitrecommends
5. Whetherdiagnosticcriteriaorclearinclusioncriteriawere (Higgins 2008b). We examined each study for randomised se-
used. quence generation method, allocation concealment, blinding of
participantsandassessors,themethodsofaddressingincomplete
outcomedata,potentialselectivereporting,andanyotherpossible
biasthatmightaffecttheoutcomeofthestudy.
Characteristicsofthestudyparticipants
Allassessmentsof thequality of trialswereperformedindepen-
1. Ageandsexofparticipants;
dentlybytworeviewauthors(SMandHM)forpreviousversions
2. Methodsusedtodefineanddiagnosestudyparticipants;
of this review and by one of SM, JB, GC, TB, or HM for the
3. Otherinclusioncriteria,e.g.thosewithahighriskfactor;
currentversionofthisreview.Anydiscrepancieswereresolvedby
4. Exclusioncriteria;
SH.
5. Country.
Adescription oftheassessmentofriskofbiasisinRiskofBias
TablesintheCharacteristicsofincludedstudies.
Interventionsused Measuresoftreatmenteffect
1. Locationofinterventionprogrammee.g.schoolor
community;
Depressivediagnosis
2. Focusofintervention,i.e.TargetedorUniversal;
Psychologicalandeducationalinterventionsforpreventingdepressioninchildrenandadolescents(Review) 6
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.