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Question
Question: Are brief, teacher-delivered, personality-targeted cognitive behavioural therapy (CBT) interventions effective for the treatment of mental health symptoms in high-risk adolescents?
Patients: A total of 1210 year 9 students (age 13–14 years) who scored 1 SD above the school mean on at least one of the four subscales of the Substance Use Risk Profile Scale (SURPS). SURPS assesses variation in personality risk for substance abuse/dependence along four dimensions: sensation seeking, impulsivity, anxiety sensitivity and hopelessness.
Setting: 19 London schools; 2008–2010.
Intervention: Two, 90 min CBT group sessions led by a trained teacher, school counsellor or pastoral member of staff (11 schools) or no intervention (8 schools). CBT sessions were delivered to personality-matched groups according to elevated SURPS subscale (average six adolescents per group). If a child had elevated scores on several subscales, they were assigned to the personality group that most deviated from the norm.
Outcomes: Self-reported depression, anxiety and conduct disorder symptoms. Depression and anxiety were measured using subscales from the Brief Symptoms Inventory, and classified as severe when scores exceeded published guidelines. Conduct disorder symptoms were assessed using the conduct subscale of the Strengths and Difficulties Questionnaire, and classified as severe according to bandings provided from a large sample of UK adolescents.
Patient follow-up: 84.6% (significantly higher retention in the intervention than control groups: 81.4% vs 74.8% of adolescents).
Methods
Design: Cluster randomised controlled trial.
Allocation: Unclear.
Blinding: Unblinded.
Follow-up period: 2 years.
Main results
The intervention reduced the risk of severe depressive symptoms by 26% (OR 0.74, 95% CI 0.58 to 0.96) and the risk of severe conduct disorder symptoms by 21% (OR 0.79, 95% CI 0.65 to 0.96), but did not significantly reduce the risk of severe anxiety symptoms (OR 0.79, 95% CI 0.59 to 1.05). Subgroup analysis by personality type found that the intervention significantly reduced the risk of severe conduct disorder in adolescents with impulsivity, but not in other personality groups combined. The intervention did not reduce the risk of severe depressive symptoms in adolescents with hopelessness, but it did significantly reduce risk in the other personality groups combined. The intervention had no significant effect on the risk of severe anxiety in either adolescents with the anxiety sensitivity subtype, or other personality groups combined (see the WebExtra tables for subanalysis according to subtype).
Conclusions
A brief, personality-targeted CBT intervention delivered by teachers and school-based professionals can reduce depression, anxiety and conduct disorder symptoms in high-risk adolescents.
Notes
Mental health symptoms were secondary outcomes of this trial. The primary outcome of the trial was substance use.
Commentary
This paper highlights the importance of mental health prevention for at-risk youths. Prevention services may be more acceptable than treatment because they can be rendered in settings not explicitly designated for mental health, and because adolescents do not have to identify themselves as ill. This school-based intervention allows for universal screening, and provides at-risk adolescents with access to behavioural health support in a comfortable and familiar setting. Similar mental health prevention efforts also are being evaluated in primary care settings.1
It is noteworthy that this study reports sustained benefits after short-term intervention. Other mental health prevention efforts have yielded short-term benefits, but effects have attenuated over time. A recent group cognitive-behavioural depression prevention trial targeting at-risk adolescents revealed sustained benefits over a 33-month follow-up, but the intervention was much more intensive than the programme discussed here.2 From a public health perspective, it is exciting to see evidence that a short-term, teacher-delivered intervention can produce clinically significant reductions in symptoms.
Although this intervention was associated with significant effects on impulsive behaviour and severe anxiety, there were no significant effects on hopelessness-specific severe depression. Kennard et al3 note that both an adequate dose of intervention (9 sessions), and specific components of the intervention (training in social skills and problem-solving) are associated with more favourable intervention outcomes for depressed youths. It may be that the hopelessness-prone youths in the present study did not display an adequate response because they did not receive an adequate intervention dose.
This paper provides crucial support for the development of preventive efforts to address the needs of adolescents at risk for behavioural health concerns.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online references
Footnotes
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Sources of funding: Action on Addiction.
Footnotes
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Competing interests None.