Final CAT

Kiran Kazmi

Final CAT – School based intervention for the prevention for childhood depression

Brief description of patient problem/setting

There are many pediatric patients that are admitted to EELOS (a psychiatric emergency room for adolescents) for suicidal ideations secondary to depression. Most of the children that were interviewed had access to public schooling. Considering that school is a large part of the adolescent life, I wanted to know if there was any research that showed depression prevention or decreased symptoms of depression in children though the help of school based interventions.

Search Question:

In the pediatric population, does school-based intervention help prevent childhood depression?

Question Type: What kind of question is this? (boxes now checkable in Word)

☐Prevalence ☐Screening ☐Diagnosis

☒Prognosis ☒Treatment ☐Harms

PICO search terms:

P	I	C	O
Adolescent	School-based	No intervention	Depression prevention
Children	Early intervention		Mental health
School-aged children			Depression symptoms
Youth

Search tools and strategy used:

Database	Terms	Filter	Articles
PubMed	adolescent school-based intervention depression	Review; Full Text	28
PubMed	adolescent school-based intervention depression prevention	Review; Full Text; 10 years; Humans	11
Cochrane	Children adolescent school-based intervention depression prevention	None	1
Trip Data Base	adolescent school-based intervention depression prevention	Review	103

Explain how you narrow your choices to the few selected articles.

I first looked into Cochrane considering that it is known to have systematic reviews. However, when I put in my search terms in to the database, only one systematic review returned and even then that systematic review was not relevant to my PICO question, showing a result for school based intervention for alcohol use prevention.

I then searched TRIP database, which gave me an extensive return. However, many of the articles that returned, just based off of their titles, they were irrelevant to my PICO question. The few articles that were relevant to my PICO question, either the I did not have access to the full article or there was only a small portion of the study that was relevant to my PICO, which I did not consider appropriate to incorporate.

I lastly searched my articles on PubMed, putting in my search terms and filters. I had a decent number of articles return, which I had to narrow down. I narrowed the articles based off of their introductions and abstracts. Of the 28 articles, 15 of them did not answer my specific PICO question, instead focused on other school-based interventions, such has school-based suicide prevention or school-based alcohol and drug use prevention programs. The rest of the eight articles were either not the highest level of evidence or did not satisfy my criteria for being a recent study.

Results found:

CITATION	Neil, Alison L, and Helen Christensen. “Australian School-Based Prevention and Early Intervention Programs for Anxiety and Depression: a Systematic Review.” The Medical Journal of Australia, Centre for Reviews and Dissemination (UK), 19 Mar. 2007, https://www.ncbi.nlm.nih.gov/pubmed/17371212.
ABSTRACT	Abstract OBJECTIVE: To establish the nature and efficacy of Australian school-based prevention and early intervention programs for anxiety and depression. DATA SOURCES: Cochrane, PsychInfo and PubMed databases, and the Primary Mental Health Care Australian Resource Centre database, were searched in June 2006. Additional materials were obtained from program websites, reference lists and authors. STUDY SELECTION: Programs that were developed in Australia or trialled in Australia and addressed anxiety, depression, or resilience were included. DATA SYNTHESIS: 24 efficacy or effectiveness trials of 9 intervention programs were identified. Most were based on cognitive behaviour therapy, interpersonal therapy or psychoeducation. Six were universal interventions, two were indicated programs and one was a treatment program. Most were associated with short-term improvements or symptom reduction at follow-up. CONCLUSIONS: A number of schools programs produce positive outcomes. However, even well established programs require further evaluation to establish readiness for broad dissemination as outlined in the standards of the Society for Prevention Research.
STUDY	Systemic Review
LINK/PDF	https://www.ncbi.nlm.nih.gov/pubmed/?term=Australian+School-Based+Prevention+and+Early+Intervention+Programs+for+Anxiety+and+Depression%3A+a+Systematic+Review.%E2%80%9D

CITATION	Dray, J., Bowman, J., Campbell, E., Freund, M., Wolfenden, L., Hodder, R. K., … Wiggers, J. (2017, October). Systematic Review of Universal Resilience-Focused Interventions Targeting Child and Adolescent Mental Health in the School Setting. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28942803.
ABSTRACT	Abstract OBJECTIVE: To examine the effect of universal, school-based, resilience-focused interventions on mental health problems in children and adolescents. METHOD: Eligible studies were randomized controlled trials (RCTs) of universal, school-based interventions that included strategies to strengthen a minimum of 3 internal resilience protective factors, and included an outcome measure of mental health problems in children and adolescents aged 5 to 18 years. Six databases were searched from 1995 to 2015. Results were pooled in meta-analyses by mental health outcome (anxiety symptoms, depressive symptoms, hyperactivity, conduct problems, internalizing problems, externalizing problems, and general psychological distress), for all trials (5-18 years). Subgroup analyses were conducted by age (child: 5-10 years; adolescent: 11-18 years), length of follow-up (short: post-≤12 months; long: >12 months), and gender (narrative). RESULTS: A total of 57 included trials were identified from 5,984 records, with 49 contributing to meta-analyses. For all trials, resilience-focused interventions were effective relative to a control in reducing 4 of 7 outcomes: depressive symptoms, internalizing problems, externalizing problems, and general psychological distress. For child trials (meta-analyses for 6 outcomes), interventions were effective for anxiety symptoms and general psychological distress. For adolescent trials (meta-analyses for 5 outcomes), interventions were effective for internalizing problems. For short-term follow-up, interventions were effective for 2 of 7 outcomes: depressive symptoms and anxiety symptoms. For long-term follow-up (meta-analyses for 5 outcomes), interventions were effective for internalizing problems. CONCLUSION: The findings may suggest most promise for using universal resilience-focused interventions at least for short-term reductions in depressive and anxiety symptoms for children and adolescents, particularly if a cognitive-behavioral therapy-based approach is used. The limited number of trials providing data amenable for meta-analysis for some outcomes and subgroups, the variability of interventions, study quality, and bias mean that it is not possible to draw more specific conclusions. Identifying what intervention qualities (such as number and type of protective factor) achieve the greatest positive effect per mental health problem outcome remains an important area for future research. SYSTEMATIC REVIEW PROTOCOL AND REGISTRATION: Systematic Review of Universal Resilience Interventions Targeting Child and Adolescent Mental Health in the School Setting; http://dx.doi.org/10.1186/s13643-015-0172-6; PROSPERO CRD42015025908. Copyright © 2017 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved. KEYWORDS: mental health; meta-analysis; resilience; school; universal intervention
STUDY	Systematic Review and Meta-Analysis
LINK/PDF	https://www.ncbi.nlm.nih.gov/pubmed/?term=Systematic+Review+of+Universal+Resilience-Focused+Interventions+Targeting+Child+and+Adolescent+Mental+Health+in+the+School+Setting.

CITATION	Johnstone, K. M., Kemps, E., & Chen, J. (2018, December). A Meta-Analysis of Universal School-Based Prevention Programs for Anxiety and Depression in Children. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30105480.
ABSTRACT	Abstract Anxiety and depression are among the most common mental health issues experienced in childhood. Implementing school-based prevention programs during childhood, rather than adolescence, is thought to provide better mental health outcomes. The present meta-analysis aimed to investigate the efficacy of universal school-based prevention programs that target both anxiety and depression in children (aged 13 years or below), and examine three moderators (i.e., program type, primary target of program, and number of sessions) on prevention effects. PsycINFO, PubMED, and Google Scholar were systematically searched for relevant articles published up to and including January 2018. Fourteen randomised controlled trials, consisting of 5970 children, met eligibility criteria. Prevention programs led to significantly fewer depressive symptoms at post-program (g = 0.172) and at long-term follow-up periods (g = 0.180), but not at short-term follow-up. Programs were not found to prevent anxiety symptoms across any time point. Considerable heterogeneity was observed for all effects. Program type and length were found to moderate the relationship between prevention program and outcomes. Prevention programs were effective in preventing depressive symptoms at post-program and long-term follow-up, while no significant preventative effect on anxiety symptoms was observed. The FRIENDS Program and programs which contained a greater number of sessions showed beneficial effects on anxiety and depressive symptoms. Universal programs aimed at preventing both anxiety and depression in children are limited. Future research should investigate the long-term evaluation of school-based prevention programs for anxiety and depression in children.
STUDY	Meta-Analysis
LINK/PDF	https://link.springer.com/article/10.1007%2Fs10567-018-0266-5

CITATION	Werner-Seidler, Aliza, et al. “School-Based Depression and Anxiety Prevention Programs for Young People: A Systematic Review and Meta-Analysis.” Clinical Psychology Review, U.S. National Library of Medicine, Feb. 2017, https://www.ncbi.nlm.nih.gov/pubmed/27821267.
ABSTRACT	Abstract Depression and anxiety often emerge for the first time during youth. The school environment provides an ideal context to deliver prevention programs, with potential to offset the trajectory towards disorder. The aim of this review was to provide a comprehensive evaluation of randomised-controlled trials of psychological programs, designed to prevent depression and/or anxiety in children and adolescents delivered in school settings. Medline, PsycINFO and the Cochrane Library were systematically searched for articles published until February 2015. Eighty-one unique studies comprising 31,794 school students met inclusion criteria. Small effect sizes for both depression (g=0.23) and anxiety (g=0.20) prevention programs immediately post-intervention were detected. Small effects were evident after 12-month follow-up for both depression (g=0.11) and anxiety (g=0.13). Overall, the quality of the included studies was poor, and heterogeneity was moderate. Subgroup analyses suggested that universal depression prevention programs had smaller effect sizes at post-test relative to targeted programs. For anxiety, effect sizes were comparable for universal and targeted programs. There was some evidence that externally-delivered interventions were superior to those delivered by school staff for depression, but not anxiety. Meta-regression confirmed that targeted programs predicted larger effect sizes for the prevention of depression. These results suggest that the refinement of school-based prevention programs have the potential to reduce mental health burden and advance public health outcomes.
STUDY	Systematic Review
LINK/PDF	https://www.ncbi.nlm.nih.gov/pubmed/?term=School-Based+Depression+and+Anxiety+Prevention+Programs+for+Young+People%3A+A+Systematic+Review+and+Meta-Analysis.%E2%80%9D

CITATION	Calear, A. L., & Christensen, H. (2010, June). Systematic review of school-based prevention and early intervention programs for depression. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/19647310.
ABSTRACT	Abstract A systematic review was conducted to identify and describe school-based prevention and early intervention programs for depression and to evaluate their effectiveness in reducing depressive symptoms. Forty-two randomised controlled trials, relating to 28 individual school-based programs, were identified through the Cochrane Library, PsycInfo and PubMed databases. A large proportion of the programs identified were based on cognitive behavioural therapy (CBT), and delivered by a mental health professional or graduate student over 8-12 sessions. Indicated programs, which targeted students exhibiting elevated levels of depression, were found to be the most effective, with effect sizes for all programs ranging from 0.21 to 1.40. Teacher program leaders and the employment of attention control conditions were associated with fewer significant effects. Further school-based research is required that involves the use of attention controls, long-term follow-ups and which focuses on the training and evaluation of sustainable program leaders, such as teachers.
STUDY	Systematic Review
LINK/PDF	https://www.sciencedirect.com/science/article/pii/S0140197109001006?via%3Dihub

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Kristy M. Johnstone Eva Kemps Junwen Chen	Meta-Analysis	14 RCT 5,970 Participants consisting of both children ( aged 13 years and below) and adolescents Short Term Follow up: 6-11 months Long Term Follow up: 12 to 54 months FRIENDS: 10 sessions with 2 booster sessions AOP: total of 8-10 sessions	Primary target goals: Depressive symptoms Anxiety symptoms Both depressive and anxiety symptoms Program type: FRIENDS AOP Number of sessions needed Long Term follow up Short Term follow up	It has been suggested that implementing prevention programs in the early years of children’s lives, rather than during adolescence, may provide better mental health outcomes (Gladstone et al. 2011; WergerSeidler et al. 2017). Results demonstrated small but significant effects for symptoms of depression at post-program and at long-term follow-up periods, but not at short term follow-up. Prevention conditions that used the FRIENDS Program showed significantly fewer symptoms of anxiety compared to the control conditions There was a statistically significant difference between prevention programs that employed the AOP program and control conditions, whereby the AOP program was associated with greater anxiety symptoms at post-program than the control conditions, although at long-term follow-up this difference was no longer significant Small but significant effects for depressive symptoms post-prevention were seen Programs that primarily targeted anxiety OR depression showed in differences in outcomes compared to those programs which armed to target both anxiety AND depression Children in the prevention conditions did not show any difference in anxiety symptoms when compared to the control conditions across any of the time points. Programs delivered by external facilitators (trained mental health professionals, researchers and graduate students) produced greater effects for depression compared to programs delivered by school staff. Type of facilitator was not found to have an impact on anxiety symptoms Number of sessions was found to effect the prevention on anxiety or depression outcomes at long-term follow-up, but not at any other time point. Programs which contained greater number of session showed larger effects for anxiety and depression outcomes at long-term follow-up compared to programs containing fewer sessions. Prevention effects for children who do develop a disorder may be masked by a majority who were never at risk. Therefore, even small effects demonstrate the clinical and practical significance of these programs (Ahlen et al. 2015)	Results reported from studies at the short-term follow-up period may not necessarily be from the same studies that reported the long-term follow-up data as studies did not report both short-term and long-term data. This sampling difference could have contributed to the differences in effects between short-term and long-term follow-up periods. A potential explanation for why significant effects were found for depression outcomes but not for anxiety outcomes could be the personnel who delivered the programs. Research typically found prevention programs for children and adolescents to be more effective when delivered by trained mental health professionals than by teachers (Calear and Christensen 2010) Younger anxious children may feel less comfortable participating in anxiety-prevention programs delivered by unfamiliar external facilitators, thus hindering the effectiveness of the program on anxiety outcomes. Approximately half of the programs were delivered by external facilitators, which could similarly explain the observed differences in effects between anxiety and depression outcomes No study has yet assessed number of sessions as a moderator of anxiety outcomes at short or long-term follow-up periods, or as moderator of depressive outcome effects at long-term follow-up.
Julia Dray Jenny Bowman Elizabeth Campbell	Systematic Review	12 RCT 45 clustered RCT 5,984 participants Included 16 countries Short Term follow up: immediate-post to 12 months postintervention Long-Term: 13-72 months postintervention	Anxiety symptoms Depressive symptoms Hyperactivity Conduct problems Internalizing problems Externalizing problems General psychological distress	Interventions were effective relative to a control for reducing 4 out of 7 mental health outcomes: depressive symptoms, internalizing and externalizing problems, and general psychological distress For child trails (Age 5-10 years) the meta-analysis indicated a significant overall intervention effect for anxiety symptoms and general psychological distress . For Adolescent Trails (11-18 years) meta-analysis was significant for overall intervention effect for internalizing problems only. For short term follow-up meta-analysis indicated a significant overall intervention effect fir depressive symptoms and anxiety symptoms For long term follow up meta-analysis indicated a significant overall effect of intervention at long-term follow-up for the outcome of internalizing problems only. One trailed reported a long-term follow-up for the outcome of general psychological distress, indicating a significant intervention effect maintained at 18-month follow-up.	77.2% of the studies were rated as high risk for bias overall. 94.7% of the studies are rated as high risk of bias for performance and detection bias because of the nature of the interventions, lack of blinding of key study personnel or participants, and common use of self-report outcome measures. Lack of long-term follow-up in school-based intervention studies was evident because of time, funding and other factors. Insufficient number of trails in some subgroups Heterogeneity remained high for the outcomes of depressive symptoms and anxiety symptoms
Alison I. Helen Christensen	Systematic Review	42 RCT Children: 5-12 years old Adolescents: 13-19 years old 23 RCT were studies that were universal trails 10 RCT focused on students exhibiting clincal levels of depression 6 RCT were selective trails that focused on participants with parental divorce, ethnicity, behavioral problems and personality specific cognitive distortions Length of programs ranged from 2 sessions to being a year long	Goal: reduce or prevent the symptoms of depression, or to build resilience	46% of the trails involving adolescents reported a significant reduction in symptoms of depression while 54% od the trails delivered to children reduced depression 62% of the trails that evaluated a program consisting of eight to 12 sessions reported a significant reduction in depressive symptoms, while 36% of trails evaluating programs less than eight sessions or greater than 12 sessions also reported significant effects Results of the review were mixed, with only half of the trails identified reporting a significant reduction in depressive symptoms at post-test or follow-up. A number of factors influenced the outcome, including the intervention structure (indicated vs. universal), program leader (teacher vs. other), and control condition (attention control vs. other). Indicated programs were more efficacious than selective and universal program, with a higher proportion of successful trials at post-test and follow-up, and more consistent outcomes at both post-test and follow-up, meaning indicated programs produce immediate and long-lasting change because there is increased room for change amongst participants with elevated symptoms of depression. Smaller percentage of trials involving teacher program leaders were successful in reducing symptoms of depression, than trails involving other program leaders.	Study failed to report it’s own limitation Even though number of RCT’s were documented, the total number of participants were not documented Trial quality was on the whole poor, results should be interpreted with this in mind The low quality scores tended to stem from a failure to report the details of the randomization process and inability to achieve double-blind standards. Self-report system always leaves room for bias
Werner-Seidler Perry Calear Newby Christen	Systematic Review and Meta- Analysis	81 RCT 31,794 school students Children: 5-9 years Early adolescents: 10-14 years Adolescents: 14-19 years Short term: 0-6 months Medium-term 6-12 months Long-term >12 months	overall effect of school-based depression and/or anxiety prevention programs on symptoms of depression and anxiety the time period over which treatment gains are maintained	For studies that focused on depression, the effect size at post-intervention and short-term follow up indicated a small effect There was evidence of a very small effect of the depression-prevention programs at the medium-term follow-up and long-term follow up. However, several studies included follow-ups for longer-term periods and suggest that gains can be maintained at 24 month follow-up period but tends to deplete at longer intervals For trails that focused on anxiety, small effect at post-intervention at the short-term and medium term follow ups were seen, with marginal effects in long-term follow-ups. It is important to note that even though the effects that are seen are small, these trails are preventative, and the recent review shows that preventive programs are associated with a 53% decrease in risk of internalizing disorder onset in the 6-9 months following program delivery. When comparing universal and targeted prevention programs for depression, targeted prevention yielded a significantly greater effect size relative to universal programs at post-test. This could not be applied for anxiety prevention programs Depression programs were more efficacious when delivered b individuals external to the school environment, such as, researchers, mental health professionals, graduate students, when compared to school staff at post-intervention and short-term follow up. The age at which prevention program was delivered influenced the size of the intervention effects obtained, with children being more effective than those delivered to adolescents.	Study based exclusively on self-report symptoms measures and not clinician-rated measures Studies were included in the review even if they did not exclude participants with significant symptoms, of which over 80% of included studies did not Evidence of publication bias in the depression studies Moderate levels of heterogeneity
Neil Christensen	Systematic Review	24 tTrails 14 RCT 9 CT 1 Non-control group	Effect on depressive symptoms Effect on anxiety symptoms	About 80% of the indicated anxiety programs and 50% of depression programs were associated with reduction in anxiety and depressive symptoms. In the universal programs, improvements were associated with 60% of the programs for anxiety and 58% of those for depression. Effectivnes persisted for at least 6 months for some programs, and for the FRIENDS program, positive outcomes were reported at 12 months. Four indicated trails targeted depression and of these, two were associated with significant reductions in depression Seven of the eight trails that reported 6-month follow-up results were successful, and six of the eleven studies that reported long-term follow-up results were effective.	Number of studies were very limited, only 24 compared to the systematic reviews Many of the trails collected follow-up measurements at one time point only, so the longer-term effectiveness of these programs were unclear Long term versus short term follow up criteria were not established Child and adolescent groups were not differentiated

Conclusion(s):

– Briefly summarize the conclusions of each article, then provide an overarching conclusion.

1) Improving the content that is provided in these prevention programs would show a greater impact on anxiety and depression outcomes. According to this study, future prevention programs should consider including a greater number of sessions to allow for better long-term outcomes. It is important to consider what kind of program was used during the intervention, for example, the FRIENDS program consists of ten session with an additional two booster sessions, whereas the AOP program consists of eight to ten programs in total. The FRIENDS program was found to be more effective in preventing anxiety symptoms compared to the AOP program, thus children in the FRIENDS program would benefit more. It is important that future programs investigate the impact of school-based prevention on children and adolescence by conducting long term studies (greater than 12 months). The main conclusion that could be drawn from this meta-analysis is that current anxiety and depression prevention programs may be effective in preventing symptoms of depression at post-prevention and at long-term follow-up periods, however, there is no evidence that suggest that these programs have an effect on anxiety symptoms.

2) This systematic review suggest promising results when using resilience-focused interventions for short-term reductions in depressive and anxiety symptoms. There were many variations that were found in the effectiveness of the therapy, and this difference might be due to variation in the relevance of a particular protective factor across life stages. These protective factors include strong attachment to family, high levels of pro-social behavior in family, school and community, high social skill/ competence, strong moral beliefs, high levels of religiosity, positive personal disposition, positive social support, and a strong family cohesion. Further investigation should be done to see what protective factors best have the greatest effect on mental health, which may help to guide future programs in reducing variability and build a more effective resilience-focused prevention program. Even though the article mentioned a strong limitation of self-report bias, and lacking of blindness, it also mentioned how this limitation was nearly impossible to avoid considering the nature of the intervention. Contrary to the first article, which did not show significant improvement with mental health in a short-term setting, but showed promising effectiveness in long term follow up, this study showed the exact opposite.

3) Though the trails that saw the most improvement with depressive symptoms consisted of participants with elevated depressive symptoms, these findings should not disvalue the use of universal depression programs in schools. This study does show that there are some trails that show improvement of depressive symptoms through the universal approach but the quality of the universal programs should be of importance, focusing on the content and delivery style which makes the universal approach more or less effective. The results also suggest that programs are more effective in the hands of mental health professionals or the programs developers, meaning there needs to be clarification if specific training of classroom teachers can lead to improved outcomes. If this is the case, future research should focus on ways to improve the implementation of these programs by classroom teachers through specialist training. It was seen that the greatest amount of improvement in depressive symptoms were seen in trails that provided eight to 12 sessions, which may also suggest that overly short and long programs may be less successful in reducing depressive symptoms because either there is insufficient exposure to the program material or participants are exposed to too much infromation and it is not absorbed or applied. This study stressed the importance of long-term follow up, stating that they are essential in determining the duration of effects and that booster sessions may be beneficial. Overall conclusion states that participants that benefited most of the school-based programs were those with elevated depressive symptoms, had an average of eight to 12 sessions and were in therapy with a mental health specialist.

4) This study focuses on the symptoms of anxiety and depression, suggesting that even though small effects were seen, it is important to stay focused on the fact that the trails that were included were preventative programs, and participants were not diagnosed with any mental health issues at the time of initial evaluation. The data suggest that the effect of anxiety prevention programs is maintained at 6-12 months but more studies need to be implemented on long-term follow up for anxiety intervention. This study also highlighted their limitations, stating that 80 out of the 81 RCT included some form of bias, suggesting that there is substantial room for improvement in the quality of research conducted, reporting of study methodologies and outcomes. This study also points out that there needs to be more research showing programs delivered by internal providers and whether they are effective. It could also be drawn that depression programs would be best delivered in childhood between the ages of 11 to 14 years, while for anxiety, delivery would be most beneficial at the early age of onset. Overall, the findings of the study suggest that there needs to be more research done on school based prevention programs for depression and anxiety.

5) This study strongly supports mental health prevention and early intervention programs, where both indicated and universal programs produced small to moderate reductions in anxiety and depression in schools at the short to mid term follow up. Even though previous studies have urged the importance of establishing effectiveness in routine practice, this study highlights that the findings from both the targeted groups and universal groups were both positive.

Overall Conclusion:

School based prevention programs for depression and anxiety have shown small amounts of reduction in depressive symptoms and anxiety. With this minute success, long term follow up results were limited and even with documentation, results were overall mixed, with some studies showing effectiveness and others not. Programs that seemed to gave the great positive effect on depressive symptoms included students participating with a mental health specialist, instead of a school-staff, however these results could not be said about children, considering that they might not be comfortable speaking to a stranger. In majority of the studies, it was noted that the group the received most benefit from a school-based intervention program was the indicated group, where children and adolescents were showing symptoms of depression, versus the universal group. Almost all the studies indicated some sort of bias, but it is clear that based on the nature of this research, it would be impossible to avoid self-reporting bias. There is also a need on focusing on the quality that is provided during these programs, focusing on weak points and excelling on strong. Overall, the evidence suggest that even though school-based intervention programs for preventing depression shows small efficiency, it prevents depressive symptoms in about half of the participants that are exposed to it.

Clinical Bottom Line:

Please include an assessment of the following:

Though there is minimal statistical significance to this intervention, I believe that there is major clinical significance that could be obtained. The major focus on further research should focus on children and adolescents in the indicated group, where they are showing symptoms of depression and should be intervened by a mental health professional instead of a staff member. This particular group, should show the greatest outcome from the school-based intervention programs and would benefit most from preventative programs. Even if only half of the participants are affected by this intervention, the benefit for long term outcomes into adult are substantial consideration the initial intervention. The major weakness in the studies in this research was the bias involved for self-reporting symptoms. Though majority of the articles pointed out this flaw, they also stressed the importance of how this factor could not be eliminated. In order to decrease future bias in this type of research, studies should focus on allowing mental health professionals to interact with children and adolescents, and also making a clinical judgment, instead of solely focusing on the participants answers to specific questions. The quality of the programs need much improvement, which decrease heterogenicity. Overall, I believe that if the proper studies are set up, results and significance would play a huge role in the mental health community.

This entry is licensed under a Creative Commons CC0 1.0 Universal Public Domain Dedication license.

Kiran Kazmi

PA-S

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