Closing the gap between screening and depression prevention: a qualitative study on barriers and facilitators from the perspective of public health professionals in a school-based prevention approach.

BACKGROUND: The prevalence of depression has increased among adolescents in western countries. Prevention is needed to reduce the number of adolescents who experience depression and to avoid negative consequences, including suicide. Several preventive interventions are found to be promising, especially multi-modal approaches, for example combining screening and preventive intervention. However, an important bottleneck arises during the implementation of preventive intervention. Only a small percentage of adolescents who are eligible for participation actually participate in the intervention. To ensure that more adolescents can benefit from prevention, we need to close the gap between detection and preventive intervention. We investigated the barriers and facilitators from the perspective of public health professionals in screening for depressive and suicidal symptoms and depression prevention referral in a school-based setting. METHODS: We conducted 13 semi-structured interviews with public health professionals, who execute screening and depression prevention referral within the Strong Teens and Resilient Minds (STORM) approach. The interviews were recorded, transcribed verbatim, and coded in several cycles using ATLAS.ti Web. RESULTS: Three main themes of barriers and facilitators emerged from the interviews, namely "professional capabilities," "organization and collaboration," and "beliefs about depressive and suicidal symptoms and participation in prevention". The interviews revealed that professionals do not always feel sufficiently equipped in terms of knowledge, skills and supporting networks. Consequently, they do not always feel well able to execute the process of screening and prevention referral. In addition, a lack of knowledge and support in schools and other cooperating organizationorganizations was seen to hinder the process. Last, the beliefs of public health professionals, school staff, adolescents, and parents -especially stigma and taboo-were found to make the screening and prevention referral process more challenging. CONCLUSIONS: To further improve the process of screening and prevention referral in a school-based setting, enhancing professional competence and a holding work environment for professionals, a strong collaboration and a joint approach with schools and other cooperating organizations and society wide education about depressive and suicidal symptoms and preventive intervention are suggested. Future research should determine whether these recommendations actually lead to closing the gap between detection and prevention.

Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis.

BACKGROUND: Suicidal thoughts and behaviors (STBs) among adolescents have hardly decreased despite preventative efforts. School-based prevention programs could have a great reach, yet suicide prevention is not an easy topic to address. To increase acceptability of school-based suicide prevention, it is important to evaluate whether programs that target known risk factors of STBs, such as depression, could be equally effective. METHODS: We conducted a systematic literature search in major electronic databases. Outcomes were suicidal ideation and behaviors. Multivariate random effects meta-regression-analyses were conducted. RESULTS: Eleven primary studies met the inclusion criteria, totalling 23,230 participants. The post-test effect size was small for both suicidal ideation (g = 0.15) and suicidal behaviors (g = 0.30). Meta-regression indicated that targeting known risk factors of STBs was not a significant modifier of effect size for ideation, indicating equal effectiveness. However, it was significant modifier of effect for behaviors, but only one intervention targeted know risk factors. Effects at follow-up (3-12 months) were also significant but small for both outcomes. LIMITATIONS: Substantial heterogeneity between studies was noted. Only few and small sample size studies could be included that targeted known risk factors of STBs. Therefore, these results should be interpreted with caution. CONCLUSIONS: School-based prevention of STBs shows some promise within three months post-test assessments, and potentially also have effects that are sustained over time. More studies are needed to make conclusions regarding school-based interventions that target risk factors of STBs.

Pragmatic Quasi-Experimental Controlled Trial Evaluating the Outcomes of Blended CBT Compared to Face-to-Face CBT and Treatment as Usual for Adolescents with Depressive Disorders.

Depression is a major problem in youth mental health. Current treatment is on average effective, but adolescents are hesitant to seek help. Blended treatment could lower the barriers to seeking treatment. Evidence on effectiveness is, however, scarce. The present pragmatic quasi-experimental controlled trial aimed to compare the outcomes of blended cognitive behavioral therapy (CBT) to face-to-face CBT and treatment as usual. A total of 129 adolescents with clinical depression (82.2% female), aged 13-22 (M = 16.60, SD = 2.03) received blended CBT, face-to-face CBT or treatment as usual. Clinical diagnosis, depressive symptoms, and secondary outcomes were assessed at baseline, post-intervention, and six-months follow-up. Participants receiving blended CBT were, compared to participants receiving face-to-face CBT and treatment as usual, evenly likely to be in remission from their depressive disorder at post-intervention and at six-month follow-up. Depressive symptoms decreased significantly over time in all three conditions, and changes were not significantly different between conditions. Other secondary outcomes (suicide risk, internalizing and externalizing symptoms, severity of depression, and global functioning) did not differ between treatment conditions at post-intervention and six-month follow-up. Since there was no evidence for favorable outcomes for face-to-face therapies above blended CBT, blended CBT may also be an effective treatment format in clinical practice.

Secondary Outcomes of Implemented Depression Prevention in Adolescents: A Randomized Controlled Trial.

Our most recent RCT provides evidence that indicated depression prevention is effective in reducing depressive symptoms in adolescents when implemented in the school community. In the present study we further test the potential effects of this prevention approach on symptoms related to depression: anxiety, suicidality, somatic symptoms, and perfectionism. We conducted exploratory analyses in 130 adolescents with elevated depressive symptoms aged between 12 and 16 years old (M = 13.59; SD = 0.68; 63.8% girls) who were randomly assigned to the experimental (OVK 2.0) or active control condition (psycho-education). Self-reported anxiety, suicidality, somatic symptoms, and perfectionism were assessed at pretest, post intervention, as well as 6- and 12-months follow-up. Latent growth curve analyses revealed that there was a significant decrease in anxiety in both conditions and that this decrease was significantly larger in the intervention condition than in the control condition. Somatic symptoms and socially prescribed perfectionism decreased significantly in the intervention condition and suicidality decreased significantly in the control condition. Yet there was no difference in decrease in suicidality, somatic symptoms, and perfectionism between the two conditions. This study suggest that screening on depressive symptoms and providing a CBT depression prevention program for adolescents with elevated depressive symptoms, can decrease comorbid symptoms of anxiety and therefore ensure better outcomes. We discuss the clinical implications as well suggestions for future research. Clinical Trial Registration: The study is registered in the Dutch Trial Register for RCTs (NTR5725). Date registered: 11th of March 2016.

Suicide ideation as a symptom of adolescent depression. a network analysis.

INTRODUCTION: According to the network perspective, psychopathology is the result of interactions between symptoms. A previous study used network analysis to identify central symptoms of adolescent depression. The aim of the current study was replicate and extend this study by including suicide ideation as a symptom of depression and evaluating which depression symptoms are contributing factors to suicide ideation in adolescents. METHOD: A large community sample (N = 5,888) of adolescents aged 11-16 years completed the Children's Depression Inventory (CDI-2). Network analysis was used to identify the network structure of the CDI-2 and which symptoms were directly related to suicide ideation in the network. Additionally, the network structure of adolescents who did and did not experience suicide ideation were compared. RESULTS: Results pertaining the depression network were highly similar to the study we aimed to replicate. The most central symptoms in the depression network were loneliness, sadness, self-hatred, fatigue, self-deprecation and crying. Loneliness explained most variance of suicide ideation. Adolescents who experience suicide ideation had a similar network structure as those who do not. Adolescents with suicide ideation scored higher on all depression symptoms. LIMITATIONS: The use of cross-sectional data indicates that only undirected networks and results based on between-subject data could be estimated. CONCLUSIONS: Loneliness was a central factor for depression networks and also the most contributing factor of suicide ideation. Preventative efforts should consider taking experiences of loneliness into account as these are especially prevalent in adolescents. Suicide ideation seems more representative of depression symptom severity in adolescents.

Randomized control trial testing the effectiveness of implemented depression prevention in high-risk adolescents.

BACKGROUND: Adolescent depression is a global mental health concern. Identification and effective prevention in an early stage are necessary. The present randomized, controlled trial aimed to examine the effectiveness of Cognitive Behavioral Therapy (CBT)-based depression prevention in adolescents with elevated depressive symptoms. This prevention approach is implemented in school communities, which allows to examine effects under real-life circumstances. METHODS: A total of 5222 adolescents were screened for elevated depressive symptoms in the second grade of secondary schools; 130 adolescents aged between 12 and 16 years old (M = 13.59; SD = 0.68; 63.8% girls) were randomly assigned to the experimental (OVK 2.0) or control condition (psycho-education). Self- and parent-reported depressive symptoms were assessed at pretest and post intervention, as well as 6- and 12-months follow-up. Clinical assessment of depression was assessed at pretest and 6-months follow-up. RESULTS: Intent-to-treat analyses revealed that the decrease in adolescent-rated depressive symptoms was significantly larger in the intervention condition than in the control condition. There was no significant difference in decrease of parent-rated depressive symptoms between both conditions. CONCLUSIONS: Based on the findings, we recommend the implementation of screening and prevention in schools, according the basics of this study design. Since this is a new step forward, we discuss the clinical impact and challenges, as well possibilities for future research. TRIAL REGISTRATION: The study is registered in the Dutch Trial Register for RCT's ( NTR5725 ). Date registered: 11 March 2016.

Cross-Lagged Associations between Depressive Symptoms and Response Style in Adolescents.

Depressive disorders are highly prevalent during adolescence and they are a major concern for individuals and society. The Response Style Theory and the Scar Theory both suggest a relationship between response styles and depressive symptoms, but the theories differ in the order of the development of depressive symptoms. Longitudinal reciprocal prospective relationships between depressive symptoms and response styles were examined in a community sample of 1343 adolescents. Additionally, response style was constructed with the traditional approach, which involves examining three response styles separately without considering the possible relations between them, and with the ratio approach, which accounts for all three response styles simultaneously. No reciprocal relationships between depressive symptoms and response style were found over time. Only longitudinal relationships between response style and depressive symptoms were significant. This study found that only depressive symptoms predicted response style, whereas the response style did not emerge as an important underlying mechanism responsible for developing and maintaining depressive symptoms in adolescents. These findings imply that prevention and intervention programs for adolescents with low depressive symptoms should not focus on adaptive and maladaptive response style strategies to decrease depressive symptoms, but should focus more on behavioral interventions.

Depression and Anxiety Symptoms in Female Adolescents: Relations with Parental Psychopathology and Parenting Behavior.

Parental psychopathology and parenting behavior are known to be related to adolescents depression and anxiety, but unique roles of mothers and fathers are not clear. Our aim was to examine the relation of maternal and paternal psychopathology, emotional support, and respect for autonomy, and their interaction to depression and anxiety symptoms in adolescents. In total, 142 female adolescents participated, together with 138 mothers and 113 fathers. Data were analyzed using latent growth curve modeling. Paternal emotional support was negatively related to adolescent baseline level of depression and anxiety symptoms. Further, we found that there was a positive association between respect for autonomy and depression symptoms in adolescents for higher levels of paternal symptoms of psychological problems.

Is Digital Treatment the Holy Grail? Literature Review on Computerized and Blended Treatment for Depressive Disorders in Youth.

Computerized and blended treatments seem to be an attractive treatment for adolescents as an alternative to face-to-face treatment, but mental health professionals seem hesitant to use these treatment modalities. This review provides an overview of factors contributing to and withholding from using computerized or blended treatment in routine care. Three databases were searched with terms related to (1) adolescents, (2) depression, (3) computerized or blended, and (4) treatment. Of the 33 articles identified, 10 focused on unguided computerized treatments, six on guided, two on blended, two compared unguided, blended- and face-to-face treatment to no treatment, and eight studies on games. Further, two articles that were focused on an online monitoring tool and three on intervention characteristics or preferred modes of help-seeking. Evidence for effectiveness, adherence, drop-out, and forming therapeutic relations were suspected to be barriers, but are no reason to reject computerized or blended treatment. Improvement in mental health literacy and the possibility to tailor the intervention are facilitators. However, adolescents' intention to seek help, acceptability of computerized treatment, symptom severity, time spent by therapist, and other facilities are identified as barriers and they need to be taken into account when using computerized or blended interventions. Nevertheless, computerized and blended are promising treatments for depressed youth.

Effectiveness and Cost-Effectiveness of Blended Cognitive Behavioral Therapy in Clinically Depressed Adolescents: Protocol for a Pragmatic Quasi-Experimental Controlled Trial.

BACKGROUND: Cognitive behavioral therapy (CBT) is an effective intervention to treat depressive disorders in youth. However, 50% of adolescents still have depressive symptoms after treatment, and 57% drop out during treatment. Online CBT interventions have proven to be effective in reducing depressive symptoms and seem promising as a treatment for depressed adolescents. However, combining online programs with face-to-face sessions seems necessary to increase their effectiveness and monitor for suicide risk. OBJECTIVE: In this study, we examine the effectiveness and cost-effectiveness of a blended CBT treatment protocol, a mixture of online and face-to-face CBT, as a treatment for clinically depressed adolescents. METHODS: A pragmatic quasi-experimental controlled trial will be conducted to study the effectiveness of a blended CBT treatment protocol, in which blended CBT is compared with face-to-face CBT (n=44) and treatment as usual (n=44); the latter two were collected in a previous randomized controlled trial. The same inclusion and exclusion criteria will be used: adolescents aged between 12 and 21 years, with a clinical diagnosis of a depressive disorder, and referred to one of the participating mental health institutions. Assessments will be conducted at the same time points: before the start of the intervention, during the intervention (after 5 and 10 weeks), postintervention, and at 6- and 12-month follow-ups. RESULTS: The primary outcome is the presence of a depression diagnosis at 12-month follow-up. Several secondary outcomes will be measured, such as depressive symptoms, quality of life, and suicide risk. Costs and effects in both conditions will be compared to analyze cost-effectiveness. Further, moderating (age, gender, alcohol and drug use, parental depression, and other psychopathology) and mediating effects (negative automatic thoughts, cognitive emotion regulation, attributional style) will be analyzed. Also, treatment characteristics will be studied, such as characteristics of the therapists, treatment expectancy, and therapeutic alliance. Dropout rates and treatment characteristics will be measured to study the feasibility of blended CBT. CONCLUSIONS: This study will examine the effectiveness and cost-effectiveness of a blended CBT program in which depressed adolescents are treated in mental health care. Results of blended CBT will be compared with face-to-face CBT and treatment as usual, and implications for implementation will be reviewed. TRIAL REGISTRATION: Dutch Trial Register (NTR6759); http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6759. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13434 RR1-10.2196/12654.

Outcomes of a Randomized Controlled Trial on the Effectiveness of Depression and Anxiety Prevention for Adolescents with a High Familial Risk.

A randomized controlled trail was conducted to examine the effectiveness of a depression and anxiety prevention program ‘Een Sprong Vooruit’ (A Leap Forward) among adolescent girls with a high familial risk (N = 142). The results showed neither effects of the prevention program directly after the intervention, nor at 6 or 12 months follow-up on depression and anxiety symptoms. Further, latent growth curve modeling (LGCM) was used to examine whether the growth functions for the intervention and the control condition were different. The slope representing the change in depression symptoms was not significantly different between the intervention and the control condition. For anxiety symptoms, the difference between slopes was also not significant. Based on these results, we suggested that these high-risk adolescent girls might benefit more from a more intensive prevention program.

Evaluation of a multimodal school-based depression and suicide prevention program among Dutch adolescents: design of a cluster-randomized controlled trial.

BACKGROUND: Since 2010, suicide has been the most important cause of mortality in youth aged 15 to 29 years in the Netherlands. Depression is an important risk factor for suicidal behaviors (i.e., suicide ideation, deliberate self-harm, planning, and suicide attempts) in adolescents. Adolescents who develop depressive symptoms, are also at risk for adult depression. This developmental continuity is especially noticeable in adolescents compared to other age groups; therefore, it is necessary to develop preventive strategies for teens. This study will test a multimodal school-based approach to suicide and depression prevention, which integrates universal and targeted approaches and includes various stakeholders (schools, adolescents, parents, and mental health professionals) simultaneously. METHODS: We will perform a cluster randomized controlled trial (RCT) with an intervention and control condition to test the effectiveness of a school-based multimodal stepped-prevention program for depression and suicidal behaviors in adolescents. Adolescents in their second year of secondary education will participate in the study. The participants in the intervention condition will receive the entire multimodal stepped-preventive program comprising early screening and detection of suicidal behaviors and depressive symptoms, a safety net consisting of gatekeepers at school, followed by universal and indicated prevention. The participants in the control condition will undergo only the screening and the safety net of gatekeepers at schools. They will complete assessments at baseline, post-intervention, and 6, 12, and 24-month follow-up. Primary outcome will be suicidal behaviors measured at 12-months follow-up. Additionally, the present study will identify mechanisms that mediate and moderate the program effects and test the effect of the program on various secondary outcomes. DISCUSSION: If the school-based multimodal stepped-prevention program proves to be effective, it could be implemented in schools on a large scale. TRIAL REGISTRATION: The study is registered in the Dutch Trial Register ( NTR6622 ).

Depression and Anxiety Prevention Based on Cognitive Behavioral Therapy for At-Risk Adolescents: A Meta-Analytic Review.

Depression and anxiety disorders are among the most common mental disorders during adolescence. During this life phase, the incidence of these clinical disorders rises dramatically, and even more adolescents suffer from symptoms of depression or anxiety that are just below the clinical threshold. Both clinical and subclinical levels of depression or anxiety symptoms are related to decreased functioning in various areas, such as social and academic functioning. Prevention of depression and anxiety in adolescents is therefore imperative. We conducted a meta-analytic review of the effects of school-based and community-based prevention programs that are based on cognitive behavioral therapy with the primary goal preventing depression, anxiety, or both in high risk adolescents. Articles were obtained by searching databases and hand searching reference lists of relevant articles and reviews. The selection process yielded 32 articles in the meta-analyses. One article reported on two studies and three articles reported on both depression and anxiety. This resulted in a total of 36 studies, 23 on depression and 13 on anxiety. For depression prevention aimed at high risk adolescents, meta-analysis showed a small effect of prevention programs directly after the intervention, but no effect at 3-6 months and at 12 months follow-up. For anxiety prevention aimed at high risk adolescents, no short-term effect was found, nor at 12 months follow-up. Three to six months after the preventive intervention, symptoms of anxiety were significantly decreased. Although effects on depression and anxiety symptoms were small and temporary, current findings cautiously suggest that depression and anxiety prevention programs based on CBT might have small effects on mental health of adolescents. However, it also indicates that there is still much to be gained for prevention programs. Current findings and possibilities for future research are discussed in order to further improve the effectiveness of targeted prevention on internalizing disorders.

Evaluation of a school-based depression prevention program among adolescents with elevated depressive symptoms: study protocol of a randomized controlled trial.

BACKGROUND: Adolescents are at risk of developing depressive symptoms. Given the prevalence, recurrence and negative consequences of adolescent depression, it is crucial to implement prevention programs for high-risk adolescents. Prevention programs at an indicated level have shown to be successful in reducing depressive symptoms in adolescents. This study will evaluate the (cost)effectiveness of the prevention program 'Op Volle Kracht (OVK 2.0)' for adolescents with elevated depressive symptoms. METHODS: We will perform a Randomized Controlled Trial (RCT) with an intervention and control condition to test the effectiveness of an indicated prevention program aimed at depression in adolescents. Adolescents in their second year of secondary education (11-15 year) will be screened for depressive symptoms. Those with heightened levels of depressive symptoms (CDI-2 ≥ 14) will be randomly assigned to the intervention (N = 80) or control group (N = 80). The participants in the intervention condition will receive a prevention program comprising eight meetings of 60 min each. The participants in the control condition will receive psycho-educational information. All participants and their parents will complete assessment at baseline, post-intervention, and 6-, 12- and 24- month follow-up. Primary outcome will be depressive symptoms. Additionally, the present study will identify mechanisms that mediate and moderate the program effects and test the effect of OVK 2.0 on secondary outcomes. DISCUSSION: This paper describes a study designed to screen adolescents for depressive symptoms and offer them a prevention program to prevent the onset of depressive symptomatology. Adolescents in the intervention condition are expected to show lower levels of depressive symptoms at 12 month follow-up compared to adolescents in the control condition. If OVK 2.0 proves to be effective, the screening and intervention program could be implemented in schools on a large scale. TRIAL REGISTRATION: Dutch Trial Register NTR5725 . Date registered: 11th of March 2016.

The association between perceived maternal and paternal psychopathology and depression and anxiety symptoms in adolescent girls.

Exposure to parental depression and anxiety is known to heighten the risk of internalizing symptoms and disorders in children and adolescents. Ample research has focused on the influence of maternal depression and anxiety, but the contribution of psychopathology in fathers remains unclear. We studied the relationships of perceived maternal and paternal psychopathology with adolescents' depression and anxiety symptoms in a general population sample of 862 adolescent girls (age M = 12.39, SD = 0.79). Assessments included adolescents' self-reports of their own depression and anxiety as well as their reports of maternal and paternal psychopathology. We found that perceived maternal and paternal psychopathology were both related to depression and anxiety symptoms in adolescent girls. A combination of higher maternal and paternal psychopathology was related to even higher levels of depression and anxiety in adolescent girls. Our findings showed that adolescents' perceptions of their parents' psychopathology are significantly related to their own emotional problems.

Effectiveness of depression and anxiety prevention in adolescents with high familial risk: study protocol for a randomized controlled trial.

BACKGROUND: Depression and anxiety disorders during adolescence can have detrimental consequences. Both disorders are related to negative outcome in various areas during adolescence and are also predictive of depression and anxiety disorders later in life. Especially parental psychopathology and being female are risk factors that increase the probability of developing one of these disorders during adolescence. Research has shown that prevention programs have promising results, especially for adolescents who have these risk factors. Therefore, in this study, we will focus on the effectiveness of a prevention program 'A jump forward' that has been developed for adolescent girls with a familial risk of depression and/or anxiety. METHODS/DESIGN: We designed a randomized controlled trial to test the effectiveness of an indicated and selective prevention program aimed at depression and anxiety in adolescent girls. Adolescents aged between 11 and 15 years old with depressive and/or anxiety symptoms and with parents who show indicators of parental psychopathology will be randomly assigned to the experimental (N = 80) or control groups (N = 80). Participants in the experimental group will follow a preventive intervention, consisting of six sessions of 90 minutes each. All participants will complete baseline, intervention phase 1 (after session 2), intervention phase 2 (after session 4), post-intervention, 6 month follow-up, and 12 month follow-up assessments. Furthermore, parents will be asked to complete assessments at baseline, post-intervention, and 12-month follow-up. Primary outcome will be depressive symptoms. Secondary outcomes will be anxiety symptoms, suicidal ideation, response style, negative cognitive errors, parental emotional support and parental control, parental psychopathology, parenting stress and adolescents' depression and anxiety symptoms according to the parents. DISCUSSION: This paper described the study designed to evaluate a program for preventing depression and/or anxiety in high-risk adolescents over a 12-month follow-up period. If the program showed to be effective in reducing symptoms of depression and anxiety and preventing adolescents from developing clinical levels of these disorders, our results would be relevant to practice. Thus, the intervention could be used on a large scale. Moreover, this study aims to contribute to the evidence-based prevention of depression and anxiety of adolescents. TRIAL REGISTRATION: Dutch Trial Register NTR3720.