Evaluating the effectiveness of a universal eHealth school-based prevention program for depression and anxiety, and the moderating role of friendship network characteristics

Abstract

Background. Lifetime trajectories of mental ill health are often established during adolescence. Effective interventions to prevent the emergence of mental health problems are needed. In the current study we assessed the efficacy of the CBT informed Climate Schools universal eHealth preventive mental health program, relative to a control. We also explored whether the intervention had differential effects on students with varying degrees of social connectedness. Method. We evaluated the efficacy of the Climate Schools mental health program (19 participating schools; average age at baseline was 13.6) versus an active control group (18 participating schools; average age at baseline was 13.5) which formed part of a large cluster randomised controlled trial in Australian schools. Measures of internalising problems, depression and anxiety were collected at baseline, immediately following the intervention and at 6-, 12- and 18-months post intervention. Immediately following the intervention, 2539 students provided data on at least one outcome of interest (2065 students at 18 months post intervention). Results. We found no evidence that the stand-alone mental health intervention improved outcomes, on any measure, relative to a control. Across all participants we observed small, but significant, increases in internalising problems, depression, and anxiety at 18 months post intervention, relative to baseline. Student’s social connectedness did not influence intervention outcomes. Conclusion. These results are consistent with recent findings that universal school-based, CBT informed, preventive interventions for mental health have limited efficacy when delivered alone. We highlight the potential for combined intervention approaches, and more targeted interventions, to better improve outcomes.

Measuring and reporting potential harm from universal school-based mental health interventions: Research recommendations for an ethical issue

“…These effects might equate to a relaKvely small number of young people deterioraKng in one trial, parKcularly if the effect is only found in a subgroup of parKcipants 16 , but the same effect size can be very impachul when intervenKons are scaled up to reach large proporKons of young people, as is the goal with universal school intervenKons 11,23 . For example, if delivered to all the 3.6m students at state-funded secondary schools in the UK 24 , an intervenKon with a negaKve effect size of d=0.1 (comparable to that found in a recent study 12 ) could lead to 62,765 addiKonal young people scoring above threshold for high levels of internalising problems (see Box 1 for simulated data).…”

“…In addiKon, we recommend that researchers familiarise themselves with qualitaKve research that has asked young people for detailed insights into their experience of school-based mental health intervenKons 11,20,32 . Based on the exisKng literature, we recommend that depressive symptoms, anxiety and prosocial behaviour are always included as outcomes that can show potenKally harmful effects [12][13][14][15][16] .…”

“…To illustrate the potenKal scale of the issue of harm from universal school-based mental health intervenKons, we simulated data using a small negaKve effect size of d=0.1 (comparable to that found in a recent study 12 ) to envisage the impact of delivering such an intervenKon to all state-funded secondary school pupils in the UK. In this hypotheKcal example, we simulated scores for the combined emo&onal problems and peer problems subscales of the Strengths and DifficulKes QuesKonnaire (SDQ), a commonly used measure of internalising symptoms in adolescents 55 .…”

“…However, there is evidence that universal school-based mental health intervenKons may indeed cause harm: these trials someKmes report negaKve effects in their primary or secondary outcome measures, indicaKng that at least some young people may experience some degree of harm from these intervenKons 11 . In one school-based trial, a universal CBT-based intervenKon taught to adolescents was found to increase internalising symptoms in the intervenKon group, but not in the control group, at six and 12 months post intervenKon 12 . A CBT-based depression prevenKon programme led to a decrease in prosocial behaviour in adolescents; there was no change in prosocial behaviour in the control group that received their usual lessons 13 .…”

Scoping review: Potential harm from school-based group mental health interventions

“…We define potential harm as any negative outcomes/outcome or adverse event that could plausibly be linked to the school intervention itself . For example, one universal CBT-based intervention was found to increase internalising symptoms in the intervention group, but not in the control group, at six and 12 months post intervention (Andrews et al, 2021). Other studies have found negative outcomes for specific subgroups.…”