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  • Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial

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Child and adolescent mental health
Original research
Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial
  1. Willem Kuyken1,
  2. Susan Ball2,
  3. Catherine Crane1,
  4. Poushali Ganguli3,
  5. Benjamin Jones2,
  6. Jesus Montero-Marin1,4,
  7. Elizabeth Nuthall1,
  8. Anam Raja1,
  9. Laura Taylor1,
  10. Kate Tudor1,
  11. Russell M Viner5,
  12. Matthew Allwood1,
  13. Louise Aukland1,
  14. Darren Dunning6,
  15. Tríona Casey1,
  16. Nicola Dalrymple1,
  17. Katherine De Wilde1,
  18. Eleanor-Rose Farley1,
  19. Jennifer Harper1,
  20. Nils Kappelmann1,
  21. Maria Kempnich1,
  22. Liz Lord1,
  23. Emma Medlicott1,
  24. Lucy Palmer1,
  25. Ariane Petit1,
  26. Alice Philips1,
  27. Isobel Pryor-Nitsch1,
  28. Lucy Radley1,
  29. Anna Sonley1,
  30. Jem Shackleford1,
  31. Alice Tickell1,
  32. Sarah-Jayne Blakemore7,8,
  33. The MYRIAD Team1,
  34. Obioha C Ukoumunne2,
  35. Mark T Greenberg9,
  36. Tamsin Ford10,
  37. Tim Dalgleish6,
  38. Sarah Byford3,
  39. J Mark G Williams1
  1. 1 Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
  2. 2 NIHR Applied Research Collaboration South West Peninsula (PenARC), University of Exeter, Exeter, Devon, UK
  3. 3 King’s College London, King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
  4. 4 Teaching, Research and Innovation Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
  5. 5 Population, Policy & Practice research programme, UCL Great Ormond St. Institute of Child Health, London, UK
  6. 6 Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
  7. 7 Department of Psychology, University of Cambridge, Cambridge, UK
  8. 8 UCL Institute of Cognitive Neuroscience, London, UK
  9. 9 Department of Human Development and Family Studies, The Pennsylvania State University, University Park, Pennsylvania, USA
  10. 10 Department of Psychiatry, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
  1. Correspondence to Professor Willem Kuyken, Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK; willem.kuyken{at}psych.ox.ac.uk

Abstract

Background Systematic reviews suggest school-based mindfulness training (SBMT) shows promise in promoting student mental health.

Objective The My Resilience in Adolescence (MYRIAD) Trial evaluated the effectiveness and cost-effectiveness of SBMT compared with teaching-as-usual (TAU).

Methods MYRIAD was a parallel group, cluster-randomised controlled trial. Eighty-five eligible schools consented and were randomised 1:1 to TAU (43 schools, 4232 students) or SBMT (42 schools, 4144 students), stratified by school size, quality, type, deprivation and region. Schools and students (mean (SD); age range=12.2 (0.6); 11–14 years) were broadly UK population-representative. Forty-three schools (n=3678 pupils; 86.9%) delivering SBMT, and 41 schools (n=3572; 86.2%) delivering TAU, provided primary end-point data. SBMT comprised 10 lessons of psychoeducation and mindfulness practices. TAU comprised standard social-emotional teaching. Participant-level risk for depression, social-emotional-behavioural functioning and well-being at 1 year follow-up were the co-primary outcomes. Secondary and economic outcomes were included.

Findings Analysis of 84 schools (n=8376 participants) found no evidence that SBMT was superior to TAU at 1 year. Standardised mean differences (intervention minus control) were: 0.005 (95% CI −0.05 to 0.06) for risk for depression; 0.02 (−0.02 to 0.07) for social-emotional-behavioural functioning; and 0.02 (−0.03 to 0.07) for well-being. SBMT had a high probability of cost-effectiveness (83%) at a willingness-to-pay threshold of £20 000 per quality-adjusted life year. No intervention-related adverse events were observed.

Conclusions Findings do not support the superiority of SBMT over TAU in promoting mental health in adolescence.

Clinical implications There is need to ask what works, for whom and how, as well as considering key contextual and implementation factors.

Trial registration Current controlled trials ISRCTN86619085. This research was funded by the Wellcome Trust (WT104908/Z/14/Z and WT107496/Z/15/Z).

  • Child & adolescent psychiatry
  • Depression & mood disorders

Data availability statement

Data are available upon reasonable request. The baseline data and codebook from the MYRIAD Trial are available from Prof Kuyken (willem.kuyken@psych.ox.ac.uk) upon request (release of data is subject to an approved proposal and a signed data access agreement).

https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/ebmental-2021-300396

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    Data availability statement

    Data are available upon reasonable request. The baseline data and codebook from the MYRIAD Trial are available from Prof Kuyken (willem.kuyken@psych.ox.ac.uk) upon request (release of data is subject to an approved proposal and a signed data access agreement).

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    Footnotes

    • OCU, MTG, TF, TD, SB and JMGW are joint senior authors.

    • Collaborators The MYRIAD Team Group Authorship comprises Saz Ahmed, Ball, Marc Bennett, Katie Fletcher, Lucy Foulkes, Kirsty Griffiths, Cait Griffin, Konstantina Komninidou, Rachel Knight, Suzannah Laws, Jovita Leung, Jenna Parker, Blanca Piera Pi-Sunyer, Ashok Sakhardande, Elise Sellars, Maris Vainre, Lucy Warriner and Brian Wainman, These individuals have worked across the MYRIAD strategic award ‘Promoting Mental Health and Building Resilience in Adolescence: Investigating Mindfulness and Attentional Control’, they are acknowledged as group authors in this paper for their substantial contributions to the project in accordance with the MYRIAD Dissemination Protocol. The authors would like to acknowledge the wider MYRIAD Team for their contribution to this work: The MYRIAD Trial Team at the University of Oxford: Ruth Baer, Daniel Brett, Katie Fletcher, Verena Hinze, Konstantina Komnindou, Suzannah Laws, Elsie Sellars, and Lucy Warriner. Co-Investigators: Sarah Byford (KCL), Mark Greenberg (Penn State), Tamsin Ford (Cambridge), Susan Gathercole (MRC CBU), Obi Ukoumunne (Exeter), Phil Zelazo (Minnesota). Cambridge research team: Marc Bennett, Kirsty Griffiths, Rachel Knight, Jenna Parker, Marie Vainre. UCL research team: Saz Ahmed, Lucy Foulkes, Cait Griffin, Jovita Leung, Blanca Piera Pi-Sunyer, Ashok Sakhardande, Kirsten Thomas. Exeter research team: Ben Jones. Last but not least, the authors are very grateful of all the participating schools, teachers and young people for giving their time so generously to participate in this project. We are grateful to the members of the Trial Steering Committee (Nick Axford (Chair), Chris Bonnell, Sam Cartwright-Hatton, Cathy Creswell (previous Chair), Steve Hollon, Lucinda Powell, Paul Ramchandani (previous member), Paul Stallard, Una Sookun), Data Monitoring and Ethics Committee (Ruth Baer (previous member), Jan R Boehnke, Mike Campbell (Chair), Sona Dimidjian, Judy Kidger, Obi Ukoumunne) and Scientific Advisory Board for the programme as a whole (Nick Allen, Susan Bogels, Pim Cuijpers, Celene Domitrovich, Uta Frith (Chair), Terrie Moffitt, Vikram Patel).

    • Contributors WK, JMGW, TD, OU, TF, SBy & MTG were responsible for the original proposal and securing funding for the trial. WK, OU, JMM, MA, SBa and BJ have verified the underlying data. WK as chief investigator is the guarantor and therefore had overall responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. Besides senior authors, authors are listed alphabetically in two blocks, major contributors (SBy-RV) and contributors (MA-AT). Major contributors were members of the study team who had, normally over a period of 6 months or more, made a major scientific and/or strategic contribution. Contributors were members of the study team who made a major contribution, normally over 6 months or more to one or more of the following: (1) development and implementation of the study protocols; (2) acquisition of data, and; (3) preparation of data. However, normally a scientific or strategic contribution was not an essential part of their duties. All authors read and approved the final manuscript.

    • Funding This research was funded in whole, or in part, by the Wellcome Trust (WT104908/Z/14/Z and WT107496/Z/15/Z) and supported by the National Institute for Health Research Clinical Research Network (NIHR CRN). For the purposes of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. Susan Ball, Ben Jones and Obi Ukoumunne were supported by the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula. JMM has a “Miguel Servet” research contract from the ISCIII (CP21/00080). The funders of the study had no role in study design, data collection, analysis or interpretation nor in writing the paper. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. The views expressed are those of the author(s) and not necessarily those of the funders.

    • Competing interests WK is the Director of the Oxford Mindfulness Centre and receives royalties for several books on mindfulness. JMGW is former Director of the Oxford Mindfulness Centre and receives royalties for several books on mindfulness.

    • Provenance and peer review Not commissioned; internally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.