Preventing Depression in Final Year Secondary Students: School-Based Randomized Controlled Trial

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Abstract

Background

Depression often emerges for the first time during adolescence. There is accumulating evidence that universal depression prevention programs may have the capacity to reduce the impact of depression when delivered in the school environment.

Objective

This trial investigated the effectiveness of SPARX-R, a gamified online cognitive behavior therapy intervention for the prevention of depression relative to an attention-matched control intervention delivered to students prior to facing a significant stressor—final secondary school exams. It was hypothesized that delivering a prevention intervention in advance of a stressor would reduce depressive symptoms relative to the control group.

Methods

A cluster randomized controlled trial was conducted in 10 government schools in Sydney, Australia. Participants were 540 final year secondary students (mean 16.7 [SD 0.51] years), and clusters at the school level were randomly allocated to SPARX-R or the control intervention. Interventions were delivered weekly in 7 modules, each taking approximately 20 to 30 minutes to complete. The primary outcome was symptoms of depression as measured by the Major Depression Inventory. Intention-to-treat analyses were performed.

Results

Compared to controls, participants in the SPARX-R condition (n=242) showed significantly reduced depression symptoms relative to the control (n=298) at post-intervention (Cohen d=0.29) and 6 months post-baseline ( d=0.21) but not at 18 months post-baseline ( d=0.33).

Conclusions

This is the first trial to demonstrate a preventive effect on depressive symptoms prior to a significant and universal stressor in adolescents. It demonstrates that an online intervention delivered in advance of a stressful experience can reduce the impact of such an event on the potential development or exacerbation of depression.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12614000316606; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365986 (Archived by WebCite at http://www.webcitation.org/ 6u7ou1aI9)

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Most cited references 26

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The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial

Sally N. Merry, Karolina Stasiak, Matthew Shepherd … (2012)

Objective To evaluate whether a new computerised cognitive behavioural therapy intervention (SPARX, Smart, Positive, Active, Realistic, X-factor thoughts) could reduce depressive symptoms in help seeking adolescents as much or more than treatment as usual. Design Multicentre randomised controlled non-inferiority trial. Setting 24 primary healthcare sites in New Zealand (youth clinics, general practices, and school based counselling services). Participants 187 adolescents aged 12-19, seeking help for depressive symptoms, with no major risk of self harm and deemed in need of treatment by their primary healthcare clinicians: 94 were allocated to SPARX and 93 to treatment as usual. Interventions Computerised cognitive behavioural therapy (SPARX) comprising seven modules delivered over a period of between four and seven weeks, versus treatment as usual comprising primarily face to face counselling delivered by trained counsellors and clinical psychologists. Outcomes The primary outcome was the change in score on the children’s depression rating scale-revised. Secondary outcomes included response and remission on the children’s depression rating scale-revised, change scores on the Reynolds adolescent depression scale-second edition, the mood and feelings questionnaire, the Kazdin hopelessness scale for children, the Spence children’s anxiety scale, the paediatric quality of life enjoyment and satisfaction questionnaire, and overall satisfaction with treatment ratings. Results 94 participants were allocated to SPARX (mean age 15.6 years, 62.8% female) and 93 to treatment as usual (mean age 15.6 years, 68.8% female). 170 adolescents (91%, SPARX n=85, treatment as usual n=85) were assessed after intervention and 168 (90%, SPARX n=83, treatment as usual n=85) were assessed at the three month follow-up point. Per protocol analyses (n=143) showed that SPARX was not inferior to treatment as usual. Post-intervention, there was a mean reduction of 10.32 in SPARX and 7.59 in treatment as usual in raw scores on the children’s depression rating scale-revised (between group difference 2.73, 95% confidence interval −0.31 to 5.77; P=0.079). Remission rates were significantly higher in the SPARX arm (n=31, 43.7%) than in the treatment as usual arm (n=19, 26.4%) (difference 17.3%, 95% confidence interval 1.6% to 31.8%; P=0.030) and response rates did not differ significantly between the SPARX arm (66.2%, n=47) and treatment as usual arm (58.3%, n=42) (difference 7.9%, −7.9% to 24%; P=0.332). All secondary measures supported non-inferiority. Intention to treat analyses confirmed these findings. Improvements were maintained at follow-up. The frequency of adverse events classified as “possibly” or “probably” related to the intervention did not differ between groups (SPARX n=11; treatment as usual n=11). Conclusions SPARX is a potential alternative to usual care for adolescents presenting with depressive symptoms in primary care settings and could be used to address some of the unmet demand for treatment. Trial registration Australian New Zealand Clinical Trials ACTRN12609000249257.

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Self-monitoring Using Mobile Phones in the Early Stages of Adolescent Depression: Randomized Controlled Trial

Sylvia Kauer, Sophie Caroline Reid, Alexander Hew Dale Crooke … (2012)

Background The stepped-care approach, where people with early symptoms of depression are stepped up from low-intensity interventions to higher-level interventions as needed, has the potential to assist many people with mild depressive symptoms. Self-monitoring techniques assist people to understand their mental health symptoms by increasing their emotional self-awareness (ESA) and can be easily distributed on mobile phones at low cost. Increasing ESA is an important first step in psychotherapy and has the potential to intervene before mild depressive symptoms progress to major depressive disorder. In this secondary analysis we examined a mobile phone self-monitoring tool used by young people experiencing mild or more depressive symptoms to investigate the relationships between self-monitoring, ESA, and depression. Objectives We tested two main hypotheses: (1) people who monitored their mood, stress, and coping strategies would have increased ESA from pretest to 6-week follow-up compared with an attention comparison group, and (2) an increase in ESA would predict a decrease in depressive symptoms. Methods We recruited patients aged 14 to 24 years from rural and metropolitan general practices. Eligible participants were identified as having mild or more mental health concerns by their general practitioner. Participants were randomly assigned to either the intervention group (where mood, stress, and daily activities were monitored) or the attention comparison group (where only daily activities were monitored), and both groups self-monitored for 2 to 4 weeks. Randomization was carried out electronically via random seed generation, by an in-house computer programmer; therefore, general practitioners, participants, and researchers were blinded to group allocation at randomization. Participants completed pretest, posttest, and 6-week follow-up measures of the Depression Anxiety Stress Scale and the ESA Scale. We estimated a parallel process latent growth curve model (LGCM) using Mplus to test the indirect effect of the intervention on depressive symptoms via the mediator ESA, and calculated 95% bias-corrected bootstrapping confidence intervals (CIs). Results Of the 163 participants assessed for eligibility, 118 were randomly assigned and 114 were included in analyses (68 in the intervention group and 46 in the comparison group). A parallel process LGCM estimated the indirect effect of the intervention on depressive symptoms via ESA and was shown to be statistically significant based on the 95% bias-corrected bootstrapping CIs not containing zero (–6.366 to –0.029). The proportion of the maximum possible indirect effect estimated was κ2 =.54 (95% CI .426–.640). Conclusions This study supported the hypothesis that self-monitoring increases ESA, which in turn decreases depressive symptoms for young people with mild or more depressive symptoms. Mobile phone self-monitoring programs are ideally suited to first-step intervention programs for depression in the stepped-care approach, particularly when ESA is targeted as a mediating factor. Trial Registration ClinicalTrials.gov NCT00794222; http://clinicaltrials.gov/ct2/show/NCT00794222 (Archived by WebCite at http://www.webcitation.org/65lldW34k)

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Author and article information

Contributors

Helen Christensen:

Black Dog InstituteUniversity of New South WalesHospital RoadRandwick,Australia61 2 9382 8208h.christensen@blackdog.org.au

ORCID: http://orcid.org/0000-0003-0435-2065

Journal

Journal ID (nlm-ta): J Med Internet Res

Journal ID (iso-abbrev): J. Med. Internet Res

Journal ID (publisher-id): JMIR

Title: Journal of Medical Internet Research

Publisher: JMIR Publications (Toronto, Canada )

ISSN (Print): 1439-4456

ISSN (Electronic): 1438-8871

Publication date Collection: November 2017

Publication date (Electronic): 02 November 2017

Volume: 19

Issue: 11

Electronic Location Identifier: e369

Affiliations

[1] ¹ Black Dog Institute University of New South Wales Randwick Australia

[2] ² National Institute for Mental Health Research The Australian National University Canberra Australia

[3] ³ Institute of Neuroscience University of Newcastle Newcastle upon Tyne United Kingdom

[4] ⁴ Department of Psychological Medicine University of Auckland Grafton New Zealand

Author notes

Corresponding Author: Helen Christensen h.christensen@ 123456blackdog.org.au

Author information

Yael Perry http://orcid.org/0000-0002-7974-3434

Aliza Werner-Seidler http://orcid.org/0000-0002-9046-6159

Alison Calear http://orcid.org/0000-0002-7028-725X

Andrew Mackinnon http://orcid.org/0000-0003-0831-9801

Catherine King http://orcid.org/0000-0002-3075-7819

Jan Scott http://orcid.org/0000-0002-7203-8601

Sally Merry http://orcid.org/0000-0002-8281-1573

Theresa Fleming http://orcid.org/0000-0002-5174-9359

Karolina Stasiak http://orcid.org/0000-0002-1153-3123

Helen Christensen http://orcid.org/0000-0003-0435-2065

Philip J Batterham http://orcid.org/0000-0002-4547-6876

Article

Publisher ID: v19i11e369

DOI: 10.2196/jmir.8241

PMC ID: 5691241

PubMed ID: 29097357

SO-VID: dd0e3287-f811-4e8f-a4f9-132f409bf317

Copyright © ©Yael Perry, Aliza Werner-Seidler, Alison Calear, Andrew Mackinnon, Catherine King, Jan Scott, Sally Merry, Theresa Fleming, Karolina Stasiak, Helen Christensen, Philip J Batterham. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 02.11.2017.

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

History

Date received : 19 June 2017

Date revision requested : 27 July 2017

Date revision received : 8 August 2017

Date accepted : 20 September 2017

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