Description
Article:
Interventions for Adolescent Mental Health: An Overview of Systematic Reviews
Nurses as Leaders in Healthcare Reform; A description of the most pressing mental health concerns in children and adolescence you selected. Provide an overview of the articles you found (using appropriate APA citations) relating to these concerns and highlight any KEY FINDINGS. Explain the PMHNP leader role that could help psychiatric mental health nursing be at the forefront in transforming mental health care delivery.
IN A 6-PAGES PAPER:
Description of mental health concern selected-1 point
Overview of outside articles with Key Findings-1 point
What is “Healing mental healthcare?”-1 point
How can PMHNP facilitate positive changes in mental health? -3 points
Discuss how the PMHNP as nurse leader could help psychiatric mental health nursing be at the forefront in the transformation of mental health care delivery- 3 points
References-1 point
You will have a total of 4 pages, including
Page 1-Cover page,
Page 2-5, Body of the paper,
Page 6 – Reference Page.
Unformatted Attachment Preview
Journal of Adolescent Health 59 (2016) S49eS60
www.jahonline.org
Review article
Interventions for Adolescent Mental Health: An Overview
of Systematic Reviews
Jai K. Das, M.D., M.B.A. a, Rehana A. Salam, M.Sc. a, Zohra S. Lassi, Ph.D. b, Marium Naveed Khan a,
Wajeeha Mahmood c, Vikram Patel, Ph.D. d, e, f, and Zulfiqar A. Bhutta, Ph.D. g, h, *
a
Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
Robinson Research Institute, University of Adelaide, Adelaide, Australia
c
Ziauddin University, Karachi, Pakistan
d
London School of Hygiene & Tropical Medicine, London, United Kingdom
e
Public Health Foundation of India, New Delhi, India
f
Sangath, Goa, India
g
Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
h
Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
b
Article history: Received January 25, 2016; Accepted July 1, 2016
Keywords: Adolescent health; Mental health; Suicide; Depression; Anxiety; Eating disorders
A B S T R A C T
Many mental health disorders emerge in late childhood and early adolescence and contribute to the
burden of these disorders among young people and later in life. We systematically reviewed literature
published up to December 2015 to identify systematic reviews on mental health interventions in
adolescent population. A total of 38 systematic reviews were included. We classified the included reviews
into the following categories for reporting the findings: school-based interventions (n ¼ 12); communitybased interventions (n ¼ 6); digital platforms (n ¼ 8); and individual-/family-based interventions (n ¼ 12).
Evidence from school-based interventions suggests that targeted group-based interventions and cognitive
behavioral therapy are effective in reducing depressive symptoms (standard mean difference [SMD]: .16;
95% confidence interval [CI]: .26 to .05) and anxiety (SMD: .33; 95% CI: .59 to .06). School-based
suicide prevention programs suggest that classroom-based didactic and experiential programs increase
short-term knowledge of suicide (SMD: 1.51; 95% CI: .57e2.45) and knowledge of suicide prevention
(SMD: .72; 95% CI: .36e1.07) with no evidence of an effect on suicide-related attitudes or behaviors.
Community-based creative activities have some positive effect on behavioral changes, self-confidence,
self-esteem, levels of knowledge, and physical activity. Evidence from digital platforms supports
Internet-based prevention and treatment programs for anxiety and depression; however, more extensive
and rigorous research is warranted to further establish the conditions. Among individual- and familybased interventions, interventions focusing on eating attitudes and behaviors show no impact on body
mass index (SMD: .10; 95% CI: .45 to .25); Eating Attitude Test (SMD: .01; 95% CI: .13 to .15); and
bulimia (SMD: .03; 95% CI: .16 to .10). Exercise is found to be effective in improving self-esteem (SMD:
.49; 95% CI: .16e.81) and reducing depression score (SMD: .66; 95% CI: 1.25 to .08) with no impact on
anxiety scores. Cognitive behavioral therapy compared to waitlist is effective in reducing remission (odds
ratio: 7.85; 95% CI: 5.31e11.6). Psychological therapy when compared to antidepressants have comparable
effect on remission, dropouts, and depression symptoms. The studies evaluating mental health
Conflicts of interest: The authors do not have any financial or nonfinancial competing interests for this review.
Disclaimer: Publication of this article was supported by the Bill and Melinda Gates Foundation. The opinions or views expressed in this supplement are those of the
authors and do not necessarily represent the official position of the funder.
* Address correspondence to: Zulfiqar A. Bhutta, Ph.D., Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, Toronto, Ontario M6S 1S6,
Canada.
E-mail address: zulfiqar.bhutta@sickkids.ca (Z.A. Bhutta).
1054-139X/Ó 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
http://dx.doi.org/10.1016/j.jadohealth.2016.06.020
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J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60
interventions among adolescents were reported to be very heterogeneous, statistically, in their populations, interventions, and outcomes; hence, meta-analysis could not be conducted in most of
the included reviews. Future trials should also focus on standardized interventions and outcomes for
synthesizing the exiting body of knowledge. There is a need to report differential effects for gender,
age groups, socioeconomic status, and geographic settings since the impact of mental health interventions
might vary according to various contextual factors.
Ó 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access
article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
studies targeted youth (aged 15e24 years) along with adolescents, exceptions were made to include reviews targeting adolescents and youth. We did not apply any limitations on the start
search date or geographical settings. We considered all available
published systematic reviews on the interventions to prevent
and treat adolescent mental health disorders. A broad search
strategy was used that included a combination of appropriate
keywords, medical subject heading, and free text terms; the
search was conducted in the Cochrane Library, and PubMed. The
abstracts (and the full sources where abstracts are not available)
were screened by two abstractors to identify systematic reviews
adhering to our objectives. Any disagreements on selection of
reviews between these two primary abstractors were resolved by
the third reviewer. After retrieval of the full texts of all the reviews that met the inclusion/exclusion criteria, data from each
review were extracted independently into a standardized form.
Information was extracted on (1) the characteristics of included
studies; (2) description of methods, participants, interventions,
outcomes; (3) measurement of treatment effects; (4) methodological issues; and (5) risk of bias tool. We extracted pooled effect
size for outcomes reported by the review authors with 95%
confidence intervals (CIs). We assessed and reported the quality
of included reviews using the 11-point assessment of the
methodological quality of systematic reviews criteria (AMSTAR)
[17]. We excluded nonsystematic reviews, systematic reviews
focusing on preventive and therapeutic mental health interventions targeting population other than adolescents and
youth, and reviews not reporting outcomes related to mental
health (Table 1).
Figure 1 describes the search flow. Our search identified 107
potentially relevant review titles. Further evaluation of the
abstracts and full texts resulted in the inclusion of 38 eligible
reviews. We classified the included reviews into the following
categories for reporting the findings:
Adolescence is a period for the onset of behaviors and conditions that not only affect health at that time but also lead to
adulthood disorders. Unhealthy behaviors such as smoking,
drinking, and illicit drug use often begin during adolescence and
are closely related to increased morbidity and mortality and
represent major public health challenges [1]. Many mental
health disorders emerge in mid- to late adolescence and
contribute to the existing burden of disease among young people
and in later life [2]. More than 50% of adult mental disorders have
their onset before the age of 18 years [3,4]. Poor mental health
has been associated with teenage pregnancy, HIV/AIDS, other
sexually transmitted diseases, domestic violence, child abuse,
motor vehicle crashes, physical fights, crime, homicide, and
suicide [2]. Globally, neuropsychiatric disorders are the leading
cause of years lost because of disability among 10- to 24-yearolds, accounting for 45% of years lost because of disabilities [5].
The overall prevalence of depression in adolescents is around 6%
and that for children (younger than 13 years) is 3% [6]. Major
depressive disorder (MDD) is one of the leading causes of
disability, morbidity, and mortality and is a major risk factor for
suicide [7]. MDD also puts adolescents and young adults at a
greater risk for suicide as they are seven times more likely to
complete suicide than those without MDD [8]. Suicide itself accounts for 9.1% of deaths in 15- to 19-year age group and ranks as
the third major cause of mortality in this age group, preceded
only by accidents and assault [9].
Given the prevailing burden and impact of mental health
disorders in children and adolescents, it is essential that effective
interventions are identified and implemented. This article is part
of a series of reviews conducted to evaluate the effectiveness of
potential interventions for adolescent health and well-being.
Detailed framework, methodology, and other potential interventions have been discussed in separate articles [10e16]. Our
conceptual framework depicts the individual and general risk
factors through the life cycle perspective that can have implications at any stage of the life cycle [10]. We also acknowledge the
fact that mental health interventions take a life course perspective and that interventions earlier in life can have impacts in
adolescence; however, the focus of our review is to evaluate
potential mental health interventions targeted toward adolescents and youth only. With this focus, we aimed to systematically
review the effectiveness of interventions to prevent and manage
mental health disorders among adolescents and youth.
Table 2 describes the characteristics of the included reviews
while Table 3 provides the summary estimates for all the
interventions.
Methods
Results
We systematically reviewed literature published up to
December 2015, to identify systematic reviews on interventions
to prevent and manage mental health disorders in adolescent
population. For the purpose of this review, the adolescent population was defined as aged 11e19 years; however, since many
School-based interventions
School-based interventions (n ¼ 12)
Community-based interventions (n ¼ 6)
Digital platforms (n ¼ 8)
Individual-/family-based interventions (n ¼ 12)
We found a total of 12 reviews reporting school-based
interventions for adolescent mental health, of which one
review performed meta-analysis. AMSTAR rating ranged
J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60
S51
Table 1
Inclusion/exclusion criteria
Inclusion criteria
Exclusion criteria
Systematic review and/or meta-analysis of interventions for
prevention and treatment of mental health targeting adolescents
(11e19 years) or youth (15e24 years):
Eating disorders
Anxiety
Depression
Suicidal behaviors
eHealth interventions focusing on adolescent/youth mental health
Nonsystematic reviews
Systematic reviews focusing on preventive and therapeutic mental
health interventions targeting population other than adolescents and youth
Reviews not reporting outcomes related to mental health
between 5 and 11 with a median score of 7.5. Five of the included
reviews focused on school-based mental health promotion
interventions; three reviews evaluated school-based programs
for prevention and early intervention for existing mental health
conditions while four reviews evaluated school-based programs
for suicide prevention. A review on school mental health promotion programs based on the findings from 15 studies suggests
that an approach focusing on mental health promotion rather
than on mental illness prevention is effective in promoting
adolescent and youth mental health [18]. However, study populations were limited, and studies either lack clarity regarding
who implemented interventions or lack theoretical foundations,
process evaluations, or youth viewpoints [18]. Meta-analysis was
not conducted due to variations in interventions and outcomes.
Another review reported from 27 studies that school-based
preventive health care is popular with young people and
provides important mental health services [19]. However,
meta-analysis was not done due to study quality. Findings from a
review based on 16 studies focusing on targeted group-based
interventions delivered in school settings suggest that nurture
groups (short-term, focused intervention which addresses
barriers to learning arising from social, emotional, or behavioral
difficulties in an inclusive, supportive manner) have an immediate positive impact on the social and emotional well-being of
young people [20]. Due to heterogeneity of design, it was not
possible to conduct a meta-analysis, and the studies were
examined for effectiveness qualitatively. A review evaluating
solution-focused brief therapy in schools has suggested mixed
results with some promise in working with students in school
settings, specifically for reducing the intensity of students’
negative feelings, managing conduct problems, and externalizing
behavioral problems [21]. These findings are based on seven
studies while meta-analysis could not be conducted. Schoolbased mental health interventions specifically focusing on lowand middle-income countries (LMICs) suggest that the majority
of the school-based life skills and resilience programs indicated
positive effects on students’ self-esteem, motivation, and
self-efficacy. However, there were mixed results, including differential effects for gender and age groups [19], and effect
estimates could not be pooled. A systematic review on the
effectiveness of school nurse implemented mental health
screening for adolescents in schools did not find any evidence of
Figure 1. Search flow diagram. MeSH ¼ Medical Subject Heading.
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Table 2
Characteristics of the included reviews
Intervention
Review
Intervention details
Setting;
HICs/LMICs
Number of
included studies
AMSTAR Outcomes reported
rating
School-based
interventions
O’Mara and Lind [18]
Social and emotional health and well-being, positive
youth development, health promotion, mental
health promotion, primary prevention
Mostly HICs
15 reviews
d
Mason-Jones
et al. [19]
School-based health care including comprehensive
services based at schools, dedicated adolescent health
services, school-linked services based at local health
centers, and servicing a number of schools and other
outreach
Nurture group (NG) intervention delivered in primary
and secondary school settings. NG sessions typically
include circle time meet and greet. A directed activity,
aiming to develop cooperation, listening, teamwork,
turn-taking, problem-solving, and self-esteem. Snack
time. Free time to choose an activity from the range
offered. Saying good-byes
Solution-focused brief therapy on behavioral problems
in schools
HICs
27 (RCTs and
observational
studies)
7
HICs
16 (RCTs and
preepost)
8
Social and emotional well-being
HICs
7 (RCT, quasi,
and case
report)
6
HICs
None
6
Changes in scores from Hare Self-Esteem
Scale; Conners’ Teacher Rating Scale;
Conners’ Parent Rating Scale;
Feelings, Attitudes and Behaviors Scale
for Children; Substance Abuse Subtle
Screening Inventory Adolescent-2; and
Child Behavior Checklist-Youth.
Existing screening tools being applied
by school nurses to detect mental ill health
HICs
42 RCTs
7
Depression
HICs
17 RCTs
8
Outcome related to depression, anxiety,
and suicidality (actual or attempted
suicide and suicidal ideation)
Academic outcomes, behavioral outcomes,
conduct problems, depression, substance
use, internalizing symptoms
Students’ and school staffs’ knowledge and
attitudes toward suicide, suicide attempts
Kim and Franklin [21]
Fothergill et al. [22]
Calear and
Christensen [23]
Kavanagh et al. [24]
Screening tools being used by school nurses for the
identification of emotional, psychological, and
behavioral problems among adolescents in schools.
School-based prevention and early intervention
programs for depression. Mostly including cognitive
behavioral therapy (CBT) delivered by a mental health
professional or graduate student over 8e12 sessions.
Other common therapeutic approaches employed
included psychoeducation and interpersonal therapy
Cognitive behavioral therapy
Farahmand et al. [25]
Day therapy programs: a multidisciplinary communityHICs
based approach to the treatment of mental health issues
29 programs
7
Katz et al. [26]
School-based suicide prevention programs:
awareness/education curriculum, gatekeeper training,
peer leadership training, screening, skills training,
reconnecting youth, good behavior game
Psychological interventions for suicide and self-harm
prevention
HICs
16 programs
5
HICs
38 controlled
studies and 6
systematic
reviews
6
De Silva et al. [27]
Mapping of existing literature
(continued on next page)
J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60
Cheney et al. [20]
Subclinical internalizing and externalizing
problems, academic achievement, mood
disorders, anxiety, depressive symptoms,
self-concept, self-esteem, coping skills,
interpersonal skills, quality of peer and
adult relationships, self-control, problemsolving, self-efficacy, school misbehavior,
aggressive behavior and violence,
interpersonal sensitivity, conflict resolution,
school attendance, social functioning
Utilization of mental health services,
ever considered suicide, attempted suicide
Table 2
Continued
Intervention
Intervention details
Setting;
HICs/LMICs
Number of
included studies
AMSTAR Outcomes reported
rating
Harrod et al. [28]
Any intervention that (1) targeted students without
known suicidal risk (i.e., primary prevention); (2)
had the prevention of suicide as one of its primary
purposes; and (3) was delivered in the postsecondary
educational setting in any country
Suicide prevention programs that have been evaluated
for indigenous youth
Music, dance, singing, drama and visual arts, taking
place in community settings or as extracurricular
activities
Parent training or child social skills training and
universal cognitive behavioral therapy (CBT)
Primary prevention intervention designed specifically
to reduce the future incidence of adjustment problems
in currently normal populations, including efforts
directed at the promotion of mental health
Community-based mental health and behavioral
programs
HICs
8 RCTs
11
Completed suicide, suicide attempt, suicidal
ideation, changes in knowledge, attitudes
and behaviors
HICs
11 programs
6
Suicide ideation, knowledge, attitude
Mostly HIC except
one in Tanzania
20 (RCTs and
observational)
5
HICs
15 RCTs
6
Behavioral changes, self-confidence,
self-esteem, levels of knowledge,
and physical activity
Conduct disorder, anxiety, and depression
HICs
144 programs
5
Competencies, performance, successful transitions
HICs
33 (RCTs and
observational)
4
HICs
RCTs and pree
post studies
7
Psychological, behavior, achievement, school
connectedness, antisocial behavior,
interpersonal, social skills community
or prosocial activities, physical health
Clinical outcomes, social, educational, satisfaction
with treatment, costs, attitudes, knowledge,
diagnostic and treatment behavior, costs
HICs
22 RCTs
11
Discrimination or prejudice outcome measures
HICs
101 (observational
studies)
4
Media-based cognitive behavioral therapies
HICs
11 RCTs
11
Cost-effectiveness, geographic flexibility, time
flexibility, waiting time for treatment, stigma,
therapist time, effects on help-seeking and
treatment satisfaction
Behavioral disorders, therapist time
Online mental health promotion and prevention
interventions
BRAVE for ChildrendONLINE and BRAVE for Teenagersd
ONLINE: based on cognitive behavioral therapy (CBT),
these programs consist of 10 weekly sessions for
children and adolescents; two booster sessions
presented 1 and 3 months after the intervention, and
five or six parent sessions. The programs present
information on managing anxiety, recognizing the
physiological symptoms of anxiety, graded exposure,
and problem-solving techniques.
Project CATCH-IT is a free, Internet-based training
program based on behavioral activation, CBT, and
interpersonal psychotherapy.
HICs
28 observational
studies
4 programs
6
Anxiety, depression
9
Anxiety and depression
Harlow and
Clough [29]
Community-based Bungay and
interventions
Vella-Burrows [30]
Waddell et al. [31]
Durlak and
Wells [32]
Farahmand
et al. [33]
Bower et al. [34]
Digital platforms
Clement et al. [35]
Musiat and
Tarrier [36]
Montgomery
et al. [27]
Clarke et al. [38]
Calear and Christensen
2010 [39]
Effectiveness of interventions for child and adolescent
mental health problems in primary care, and
interventions designed to improve the skills of
primary care staff
It was a mass media intervention, defined as an
intervention that uses a channel of communication
intended to reach large numbers, and is not
dependent on person-to-person contact, for example,
newspapers, billboards, pamphlets, DVDs, television,
radio, cinema, some Web- and mobile phoneebased
media, street art, and ambient media
Computerized cognitive behavioral therapy (cCBT)
interventions
HICs
J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60
Review
(continued on next page)
S53
Intervention
S54
Table 2
Continued
Review
Intervention details
Kauer et al. [40]
MoodGYM is a free, interactive, Internet-based program
designed to prevent and decrease symptoms of
depression in young people.
Grip op je dip online is a free, Dutch language, CBT-based
program aimed at 16- to 25-year-olds. Based on the
face-to-face Grip op je dip course, the online program
consists of six moderated chat sessions attended by six
to eight participants.
Online services in facilitating mental health help-seeking
Number of
included studies
AMSTAR Outcomes reported
rating
HICs
18 (RCTs and
observational
studies)
12 (RCTs and
observational
studies)
9
Help-seeking, mental health
9
Clinical outcomes (e.g., symptom alleviation),
patient-level impacts (e.g., improved health
behaviors), patient and health care
professional satisfaction and costs
Depression, anxiety
Martin et al. [41]
Networked communication: e-mail and/or Web-based
electronic diary; videoconference; and virtual reality.
HICs
Farrer et al. [42]
A range of broad technology types including the Internet,
audio, virtual reality, video, stand-alone computer
programs, and/or a combination of these
Eating disorder awareness, promotion of healthy eating
attitudes and behaviors, as well as eating disorder
awareness and coping with general adolescent issues,
training in media literacy and advocacy skills
Gross motor, energetic activity, for example, running,
swimming, ball games and outdoor play of moderate
to high intensity, or strength training, in contrast to
“ordinary” physical activity (e.g., routine physical
education (PE) classes, walking to school, or playtime
activities of low intensity) for at least a duration of
4 weeks
Three types of physical activity programs (i.e., outdoor
adventure, sport and skill-based and physical fitness
programs)
Exercise was defined as “planned, structured and
repetitive bodily movement done to improve or
maintain one or more components of physical fitness”
HICs
27 RCTs
9
HIC
12 RCTs
8
Mostly HIC except
one in Nigeria
23 RCTs
8
BMI, Eating Attitude Test, Eating Disorder
Inventory, Sociocultural Attitudes Towards
Appearance Questionnaire, social perception
profile, body image assessment
Self-esteem
HICs
15 (RCTs, quasi,
and preepost)
9
Social and emotional well-being
Mostly HICs except 39 RCTs
one in Thailand,
one in Brazil
11
HICs
16 RCTs
11
Depression, acceptability of treatment,
number of participants completing the
interventions; quality of life; cost; adverse
events
Anxiety or depression symptoms
post-treatment
HICs
41 RCTs
11
HICs
11 RCTs
Individual-/family- Pratt and
Woolfenden [43]
based
interventions
Ekelend et al. [44]
Lubans et al. [45]
Cooney et al. [46]
Larun et al. [47]
James et al. [48]
Cox et al. [49]
Interventions that included vigorous physical activity
of clearly specified quality with a minimum duration
of 4 weeks
(1) The relative efficacy of CBT versus non-CBT active
treatments; (2) the relative efficacy of CBT versus
medication and the combination of CBT and
medication versus placebo; and (3) the long-term
effects of CBT
Any psychological therapy with any antidepressant
medication; a combination of interventions
(psychological therapy plus antidepressant
medication) with either psychological therapies or
antidepressant medication alone; a combination of
interventions (psychological therapy plus
antidepressant medication) compared with either
intervention (psychological therapy or
antidepressants) plus a placebo; and a combination
Remission, reduction in anxiety symptom,
acceptability
Remission from depressive disorder,
acceptability, suicide-related serious
adverse events, dropouts
(continued on next page)
J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60
Setting;
HICs/LMICs
8 RCTs and
observational
studies
HICs
6
52 RCTs
7 RCTs
HICs
HICs
8
11
25 RCTs
Shinohara et al. [51]
Behavioral therapy, behavioral activation, social
skills training assertiveness training, relaxation
therapies, other psychological therapies
Weisz et al. [52]
Evidence-based psychotherapies
Shepperd et al. [53]
Mental health services providing specialist care,
beyond the capacity of generic outpatient
provision, which provide an alternative to
Deenadayalan et al. [54]
inpatient mental health care
HICs
11
Prevention of a second or next episode,
readmissions, time to relapse, functioning,
depressive symptoms, dropouts, secondary
morbidity
Treatment efficacy, treatment acceptability,
remittance, improvement in depressive
symptoms, improvement in other symptoms
Measures of symptoms and functioning
Disease-specific symptoms, general
psychological functioning, acceptability,
and cost
Symptoms, knowledge, attitude
11
9 RCTs
HICs
Cox et al. [50]
of interventions (psychological therapy plus
antidepressant medication) with a placebo or
treatment as usual
Any type of pharmacotherapy or psychological
therapy
AMSTAR ¼ assessment of the methodological quality of systematic reviews criteria; BMI ¼ body mass index; HIC ¼ high-income country; LMIC ¼ low- and middle-income country; RCT ¼ randomized controlled
trial.
Intervention
Table 2
Continued
Review
Intervention details
Setting;
HICs/LMICs
Number of
included studies
AMSTAR Outcomes reported
rating
J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60
S55
existing screening tools to detect mental ill health among
adolescents in schools [22].
A systematic review of 28 school-based prevention and early
intervention programs for depression has shown some support
for the implementation of depression prevention and early
intervention programs in schools [23]. Most of these programs
were based on cognitive behavioral therapy (CBT) and delivered
by a mental health professional or graduate student over 8e12
sessions. Indicated programs, which targeted students exhibiting
elevated levels of depression, were found to be the most effective
in reducing depressive symptoms with effect sizes ranging from
.21 to 1.40. Meta-analysis was not conducted. It was found that
CBT delivered to young people in secondary schools can reduce
the symptoms of depression (standard mean difference
[SMD]: .16; 95% CI: .26 to .05) and anxiety (SMD: .33; 95%
CI: .59 to .06) [24]. School-based therapeutic mental health
programs specifically targeting adolescents with existing mental
health disorders in LMICs suggested negative effects for programs that targeted externalizing problems and were delivered
selectively to youth with existing problems. Distinctive characteristics of low-income, urban schools, and nonschool environments were emphasized as potential explanations for the
findings [25].
School-based suicide prevention programs focused on
awareness/education curricula, screening, gatekeeper, peer
leadership, and skills training [26,27]. Interventions for primary
prevention of suicide in university and other postsecondary
educational settings suggest that classroom-based didactic and
experiential programs increased short-term knowledge of suicide (SMD: 1.51; 95% CI: .57e2.45) and knowledge of suicide
prevention (SMD: .72; 95% CI: .36e1.07) with no evidence of an
effect on participant’s suicide-related attitudes or behaviors;
however, these findings are limited by the overall low quality
[28]. Promising interventions that need further research include
school-based prevention programs with a skills training
component, individual CBT interventions, interpersonal psychotherapy, and attachment-based family therapy [26,27]. A
systematic review evaluating suicide prevention programs targeting indigenous youth (aboriginals) suggested that more
controlled study designs using planned evaluations and valid
outcome measures are needed in research on indigenous youth
suicide prevention [29].
Community-based interventions
We report findings from six systematic reviews evaluating
various community-based interventions targeting adolescents
and youth; meta-analysis was conducted in two reviews.
AMSTAR ratings ranged between 4 and 7 with a median score of
5. Evidence from 20 studies evaluating community-based creative activities (including music, dance, singing, drama, and visual
arts) suggests some positive effect on behavioral changes, selfconfidence, self-esteem, levels of knowledge, and physical activity [30]. The interventions used in the studies were diverse,
and the research was heterogeneous, and hence overall synthesis
of the results was not attempted. Another review based on 15
studies on community-based parent training and social skills
training for preventing depression suggested significant reductions in symptom and/or diagnostic measures at follow-up
[31]. However, meta-analysis was not conducted. Evidence
from a review evaluating primary prevention mental health
programs for adolescents suggests that individually focused
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J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60
Table 3
Summary estimates for adolescent mental health interventions
Interventions
(number of reviews)
Comparison
Outcomes and estimates
School-based
interventions (n ¼ 12)
School-based CBT
CBT in secondary schools
Symptoms of depression: effect size range: .21 to 1.40
Depression (SMD: L.16; 95% CI: L.26 to L.05)
Anxiety (SMD: L.33; 95% CI: L.59 to L.06)
Knowledge of suicide (SMD: 1.51; 95% CI: .57 to 2.45)
Knowledge of suicide prevention (SMD: .72; 95% CI: .36 to 1.07)
Social acceptance at 3-month follow-up (SMD: .03; 95% CI: .10 to .04)
Affective education (SMD: .33; 95% CI: .18 to .48)
Aggregate of positive mental health outcome (SMD: .03; 95% CI: .19 to .25)
Aggregate of positive mental health outcome (SMD: .27; 95% CI: .16 to .37)
Aggregate of positive mental health outcome (SMD: .38; 95% CI: .15 to .60)
Discrimination: effect size range: SMD .85 to .17
Prejudice: effect size range: SMD 2.94 to 2.40
Internalization or acceptance of societal ideals relating to appearance
at a 3- to 6-month follow-up (SMD: L.28; 95% CI: L.51 to L.05)
BMI at 12- to 14-month follow-up (SMD: .10; 95% CI: .45 to .25)
Eating Attitude Test at 6- to 12-month follow-up
(SMD: .01; 95% CI: .13 to .15)
Eating Disorder Inventory “bulimia” at 12- to 14-month
follow-up (SMD: .03; 95% CI: .16 to .10)
Close friendship at 3-month follow-up (SMD: .01; 95% CI: .09 to .06)
Self-esteem (SMD: .49; 95% CI: .16 to .81)
Self-esteem (SMD: .51; 95% CI: .15 to .88)
Depression (SMD: L.62; 95% CI: L.81 to L.42)
Dropouts (RR: 1.00; 95% CI: .97 to 1.04)
Depression (SMD: .03; 95%CI .32 to .26)
Depression (SMD: .11; 95% CI: .34 to .12)
Anxiety scores (SMD: .48; 95% CI: .97 to .01)
Depression score (SMD: L.66; 95% CI: L1.25 to L.08)
Anxiety scores (SMD: .14; 95% CI: .41 to .13)
Depression scores (SMD: .15; 95% CI: .44 to .14)
Anxiety scores (SMD: .13; 95% CI: .43 to .17)
Depression scores (SMD: .10; 95% CI: .21 to .41)
Anxiety remission (OR: 7.85; 95% CI: 5.31 to 11.6)
Participants lost to follow-up: (OR: .93; 95% CI: .58 to 1.51)
Remission (OR: .62; 95% CI: .28 to 1.35)
Dropouts (OR: .61; 95% CI: .11 to 3.28)
Suicidal ideation (SMD: L3.12; 95% CI: L5.91 to L.33)
Depression symptoms (SMD: .16; 95% CI: .69 to 1.01)
Remission (OR: 1.50; 95% CI: .99 to 2.27)
Dropouts (OR: .84; 95% CI: .51 to 1.39)
Suicidal ideation (OR: .75; 95% CI: .26 to 2.16)
Depression symptoms (SMD: .27; 95% CI: 4.95 to 4.41)
Functioning (SMD: .09; 95% CI: .11 to .28)
Remission (OR: 1.61; 95% CI: .38 to 6.90)
Dropouts (OR: 1.23; 95% CI: .12 to 12.71)
Suicidal ideation (SMD: .60; 95% CI: 2.25 to 3.45)
Depression symptoms (SMD: .28; 95% CI: 1.41 to .84)
Dropouts (OR: .98; 95% CI: .42 to 2.28)
Remission (OR: 2.15; 95% CI: 1.15 to 4.02)
Depression symptoms (SMD: L.5
