A trial protocol for the effectiveness of digital interventions for preventing depression in adolescents : The Future Proofing Study

Background: Depression frequently first emerges during adolescence, and one in five young people will experience an episode of depression by the age of 18 years. Despite advances in treatment, there has been limited progress in addressing the burden at a population level. Accordingly, there has been growing interest in prevention approaches as an additional pathway to address depression. Depression can be prevented using evidence-based psychological programmes. However, barriers to implementing and accessing these programmes remain, typically reflecting a requirement for delivery by clinical experts and high associated delivery costs. Digital technologies, specifically smartphones, are now considered a key strategy to overcome the barriers inhibiting access to mental health programmes. The Future Proofing Study is a large-scale school-based trial investigating whether cognitive behaviour therapies (CBT) delivered by smartphone application can prevent depression. Methods: A randomised controlled trial targeting up to 10,000 Year 8 Australian secondary school students will be conducted. In Stage I, schools will be randomised at the cluster level either to receive the CBT intervention app (SPARX) or to a non-active control group comparator. The primary outcome will be symptoms of depression, and secondary outcomes include psychological distress, anxiety and insomnia. At the 12-month follow-up, participants in the intervention arm with elevated depressive symptoms will participate in an individual-level randomised controlled trial (Stage II) and be randomised to receive a second CBT app which targets sleep difficulties (Sleep Ninja) or a control condition. Assessments will occur post intervention (both trial stages) and at 6, 12, 24, 36, 48 and 60 months post baseline. Primary analyses will use an intention-to-treat approach and compare changes in symptoms from baseline to follow-up relative to the control group using mixed-effect models. Discussion: This is the first trial testing the effectiveness of smartphone apps delivered to school students to prevent depression at scale. Results from this trial will provide much-needed insight into the feasibility of this approach. They stand to inform policy and commission decisions concerning if and how such programmes should be deployed in school-based settings in Australia and beyond

A redesigned training and staff support programme to enhance job retention in employees with moderate-severe depression.

Purpose Closing the treatment gap in depression is vital to prevent people from losing their jobs. Delivering group-based interventions at work could reach more employees than delivering 1:1 interventions in a clinical setting. This study aims to redesign a Treatment Programme to make it more acceptable and accessible for employees with depression. Design/methodology/approach A mixed-methods exploratory sequential design with a high level of stakeholder consultation was used to redesign an interdisciplinary Work-focussed Relational Group CBT Treatment Programme for moderate-severe depression. Qualitative data from focus groups and quantitative data from a small feasibility study were integrated to develop the new Training (and Staff Support) Programme (TSSP), which was fully specified and manualised in line with the Template for Intervention Description and Replication (TIDieR) for future delivery. Findings Focus groups identified a need for improved acceptability and accessibility of the tertiary preventative Work-focussed Relational Group CBT Treatment Programme. This programme was, therefore, simplified for delivery by peer facilitators at the worksite as an intervention for all employees rather than an indicated/targeted intervention for only those with symptoms/risk of depression. The TSSP comprised a compulsory trauma-informed educational/experiential workshop over four days plus optional open-ended, peer-led base groups set up and run by volunteer peer facilitators. Research limitations/implications The focus groups comprised a convenience sample who knew the researchers as a colleague or therapist, so there is a risk of selection or relationship bias. They were not involved in the data analysis which undermines the element of co-production and increases the risk of analytic or confirmation bias. Practical implications Delivering the new intervention in a group format will require peer facilitators to acquire skills in co-facilitation using a structured-directive leadership style and an awareness of the potential side effects of group-based interventions. Social implications The worksite TSSP provides a democratic learning space and empowers employees to stay at work by self-managing their symptoms and by challenging the interpersonal dynamics and organisational structures that might precipitate and perpetuate depression. Originality/value This intervention is fully specified and manualised with an explicit programme theory, unlike most universal worksite-based CBT programmes

Aspects of positive and negative mental health in young people, aged 16-29 years : measurements, determinants, and interventions

Background: Mental health problems in young people, i.e. those self-reported as well as registered diagnoses, have been of concern for decades. For Western societies, most studies indicate a rise in symptoms, but also in diagnoses of depression, anxiety and stress in younger age groups since the 1990s. The increase follows a pattern of societal changes, namely a prolongation of young people’s years in education, later entry into the labour market with frequently insecure conditions, longerstanding time without own housing and postponed building of partnership and family. A large number of studies focusing on young people’s mental ill health have been carried out, but less attention has been paid to positive mental health (PMH) in the age group of 16-29 years. PMH allows a view where building on strengths, capacity and health promotion is accentuated rather than leaning on deficit models and prevention of mental ill health. A balanced consideration of both aspects of mental health should give a more complete picture of the mental health characteristics in young people. Aim: The overall aim was to identify which potential determinants are associated with or may predict positive and negative mental health (NMH) in the age group of 16-29 years by self-reporting measurements, and to investigate the effectiveness of mental health interventions. Methods: The thesis is built on analyses of two population surveys (Study I and Study II), along with merged data from intervened secondary schools (Study III), and lastly on a systematic review and meta-analysis of mental health interventions for students in tertiary education (Study IV). Specifically, the data-sources and study populations for the specific research questions were as follows. First, we investigated if the 12-item General Health Questionnaire (GHQ-12) had the capacity to measure PMH in addition to NMH. We employed data from the cross-sectional Swedish National Public Health Survey 2004-2009, including 41,668 individuals aged 16-29 years. Additionally, we investigated if the survey’s health and background factors, i.e. potential determinants of mental health, could be related to either PMH or NMH factors (Study I). Second, we examined which potential determinants predict stable mental health, specifically reporting < 3 GHQ-points at all four measurement waves in the population aged 18-29 years compared to older age groups. We utilised longitudinal data from the Stockholm Public Health Cohort 2002, 2007, 2010, and 2014 including 3,373 individuals in the younger group, and 16,614 individuals aged 30-84 years (Study II). Third, we explored whether subjective well-being (SWB), i.e. emotional well-being and life satisfaction, is associated with personality traits at baseline and at 15-18 months of follow-up and whether personality traits may prospectively predict subjective well-being and vice versa. We employed our earlier data-collection from four secondary schools, two intervention- and two control schools, including 446 pupils (Study III). Finally, we investigated sustainable promotive and preventive mental health intervention effects for students in higher education. A systematic review and meta-analyses based on 26 included studies and a study population of 8,136 individuals were conducted (Study IV). Results: Study I. The General Health Questionnaire 12 (GHQ-12) in the National Health Survey revealed a capacity to measure PMH as well as NMH. However, when we examined the association between the GHQ-12 scores and 22 potential determinants of health, we found that most determinants showed significant and opposing effects on both PMH and NMH. Nonetheless, female sex, economic strain, risky gambling, and, above all, suicide ideation and perceived humiliation increased NMH more than they decreased PMH, and could qualify as risk factors. Participating in societal events and moderate gambling elevated PMH more than they reduced NMH and could subsequently be ascribed as promotive factors. Being a student was associated with lower PMH and higher NMH compared to being employed. Lastly, PMH decreased as age increased in the group of 16-29 years, whereas no age-related changes were found for NMH. Study II. In the Stockholm Public Health Cohort, 46% for males and 36% for females reported stable mental health among young people aged 18-29 years, compared to 66% and 55% respectively, in the age group 30 years and above. Out of 17 possible determinants of health, six predicted stable mental health in the younger group: occupational status, especially employment, emotional support, being male, being born in Sweden, absence of financial strain, and consumption of fruit and berries. In the older age group, the pattern was similar, with 11 significant determinants of health. However, more determinants were related to social capital and health behaviour compared to the younger group, and a significant group difference was evident for physical activity and absence of financial strain with higher importance in the older group. Study III. Among secondary school pupils aged 16 years, SWB at baseline and follow-up was associated with low levels of Neuroticism, and high levels of Conscientiousness, Extraversion and Agreeableness. In particular, the correlation between SWB and Neuroticism was strong. Compared to boys, trait stability was significantly higher in girls. However, one exception was Neuroticism, the only trait with stability in boys. SWB showed one prospective effect, namely on Agreeableness and only in girls. For personality traits, no prospective effects on SWB were found. Study IV. According to our systematic review and meta-analysis combined effects for interventions designed to prevent mental ill health in students in higher education showed that the symptom reduction sustained up to 7-12 months postintervention, although the effect size was small, ES of -0.28 (95% CI -0.49, -0.08). Specifically, for depression the sustainability was up to 13-18 months, for anxiety up to 7-12 months, and for stress up to 3-6 months. The sustainability for interventions designed to increase positive mental health was up to 3-6 months for all effects combined, and the effect size was small, ES of 0.32 (95% CI 0.05, 0.59). Specifically, active coping sustained 3-6 months with a medium effect size, ES of 0.75 (95% CI 0.19, 1.30). Conclusions: In our national sample, the GHQ-12 did not systematically discriminate potential determinants associated to positive and negative mental health, respectively, and therefore should be reserved for its purpose of origin, namely to measure symptoms of mental ill health in the population. Our results which show that young females seem to perceive less stable mental health and higher levels of Neuroticism compared to their male peers confirm the results from earlier studies. This is also true regarding young people’s less stable mental health and higher levels of mental ill health symptoms compared to older age groups. As occupational status, especially employment, and emotional support may serve as determinants predicting mental health stability among young people, promoting them should be a matter of urgency. Interventions in higher education showed sustainable effects, and it may be of importance to endorse those interventions. As other interventions enhancing positive mental health, and those with a whole-system approach in schools, higher education, and working-life are less well explored, further research should shed a light on these important topic

What role can local and national supportive services play in supporting independent and healthy living in individuals 65 and over?

Executive summary The UK population is ageing rapidly and the extent of comorbidities will continue to increase. This greater demand for support and care will need to be met within an environment of continued economic restraint. One policy response to mitigate such demand has been the reinvigorated focus on prevention and early intervention in health, social and third sector care. Prevention is broadly defined to include a wide range of services that promote independence; prevent or delay the deterioration of health and well-being resulting from ageing, illness or disability; and delay the need for more costly and intensive services. In exploring the existing evidence base around effective and cost-effective preventative services, our typology of prevention includes the accepted discourse of primary, second and tertiary prevention, while placing those ‘upstream’ well-being interventions at the core of any prevention strategy. Well-being preventative services across the continuum • In mitigating social isolation and loneliness, there is relatively good evidence that befriending interventions, social prescribing services, group activities and volunteer schemes can reduce loneliness and depressive symptomology, improve physical health, and result in differences in mortality. • A range of exercise provision is able to improve balance, cognition, well-being, mobility, core strength and cardio-metabolic health, and reduce fall or fracture risk, depressive symptomology and cognitive decline. Physical activity can be supported through community-based interventions (e.g. walking for health groups, peer-supported exercise programmes), resulting in improved health-related quality of life and reductions in the use of secondary health care. • Information, advice and signposting are seen as fundamental by individuals, as well as their families or carers, who need (or in the future may need), care and support to maintain independence. However, few studies concentrate on what works for older people, or whether timely and appropriate advice is able to maintain independence or improve quality of life. There is emerging evidence that care navigators (CNs) can provide effective practical and social support to older people, ensuring timely signposting to interventions and acting as a ‘link’ between community and statutory services. • There is a range of low-level practical interventions that can support older people to remain at home, e.g. minor housing repairs, assisted gardening and shopping. While the link between such services and the use of higher-intensity provision is little discussed in the literature, a timely and trusted response can improve quality of life and reduce service use. Gardening has been shown to improve physical strength, fitness and cognitive ability and to reduce depression and anxiety. Primary, secondary and tertiary prevention Available primary and secondary preventative services (e.g. health screening, vaccinations, care management, day services, reablement) should be delivered holistically, i.e. ‘making every contact count’. • Two national population health screening programmes – breast and bowel screening – demonstrate efficacy. In contrast, the level of uptake of the NHS Health Check has been lower than expected. While older people are more likely to attend, older individuals most likely to benefit (e.g. smokers, minority ethnic groups and those living in more deprived areas) seem less keen to engage. • Day services for older people are a contested area, often perceived as part of the ‘one-size-fits-all’ welfarist agenda. Where the evidence is available, day services improve social care and quality of life for users and carers, reduce social isolation, may delay institutionalisation for people with dementia, and provide a sense of purpose for the individual, but are unlikely to reduce health service use. • Care management, essential in supporting the individual to ‘age in place’, can reduce hospital admissions, lengths of stay and Accident and Emergency (A&E) attendances, although outcomes are dependent on the structure and processes adopted. Improved outcomes can be achieved by delivering well-being services alongside statutory provision. • While reablement improves independence, health-related quality of life and service use, there are continuing process difficulties in appropriately involving or transferring older people to further service provision. • In exploring tertiary prevention (minimising disability and deterioration from established diseases), the evidence base remains fragmented, with little clarity on the processes, structures or outcomes of, for example, rapid response teams (RRTs) or ambulatory emergency care (AEC) units. Fragmented evidence base? There is a wide range of available and effective well-being preventative services that can support older people to live independent and healthy lives. However, there are still gaps in the evidence base. Few evaluations explore whether reported changes in quality of life, service use, morbidity or mortality are maintained long term, with even fewer reporting cost-effectiveness. There is also little evidence that identifies the types of package of early interventions that should be provided, when these need to be offered, and to whom they would make the most difference. The evidence is non-existent on the structures and processes of effective preventative pathways. The future role of services to 2030 If appropriate management of future pressures on the health and social care environment is to be delivered, the system needs to be rebalanced toward well-being interventions, and primary, secondary and tertiary prevention. However, the budget for such care is continually under threat. There is an urgent need to apply a single health and social care budget, incorporating housing and transport and delivered through a single commissioning point. Perhaps the main challenge in reorienting provision toward preventative care is that there first needs to be an accepted clarity from all partners across the health and social care environment as to what is being prevented – unnecessary hospital admissions or morbidity (ill health). The rhetoric of prevention needs to be embedded into service provision with appropriate care strategies, processes and structures able to support the promotion of well-being and health, rather than the management of disease

CLINICAL PHENOMENOLOGY OF DEPRESSIVE BEHAVIOR DISORDER IN ADOLESCENTS: DIAGNOSIS, THERAPY, PREVENTION

The informativeness of behavioral patterns of depressive behavior disorder in adolescents in the age and gender aspect is determined. It is proved that many variants of behavioral disorders in adolescents with depressive disorders indicate the complex nature of relationships formation of behavioral disorders presence, which is the practical value for the development of specific preventive therapeutic programs.The informativeness of behavioral patterns of depressive behavior disorder in adolescents in the age and gender aspect is determined. It is proved that many variants of behavioral disorders in adolescents with depressive disorders indicate the complex nature of relationships formation of behavioral disorders presence, which is the practical value for the development of specific preventive therapeutic programs