What do we want to know?
Health inequalities are recognised as an important problem both nationally and internationally. The research literature which demonstrates the complex interactions between the key axes of social differences in populations including class, education, occupation, income/assets, gender, ethnicity; in relation to health outcomes is yet to be matched by a strong body of evidence of what works to reduce health inequalities. Systematic reviewers wanting to examine how interventions impact upon gaps and gradients have been hampered by a lack of tested tools and methods.
The aim of this report is to increase what is known about promoting good mental health and mental health inequalities. It focuses on the role of interventions based on the techniques of cognitive behavioural therapy (CBT) for preventing and reducing suicidality, depression and anxiety in young people. A further aim of the study is to use the systematic review as a case study to applying an ‘equity lens’ to a review topic, by building on work completed in an earlier systematic map and methodological review.
Who wants to know?
Young people and other member of the public, researchers, research commissioners and funders, policy-makers and practitioners working with young people in schools or in child and adolescent mental health services (CAMHS).
What did we find?
It was found that CBT delivered to young people in secondary schools can reduce the symptoms of depression and anxiety. No evidence was found to assess the impact of CBT on suicidal thinking or behaviour.
Few studies provided any useful data that might be used to examine the impact of CBT-based interventions on inequalities in mental health. Although conclusions about impact of CBT on inequalities are therefore tentative, there are suggestions that it might be less effective for people who are more socio-economically disadvantaged.
What are the implications?
This review has implications for a range of stakeholders.
- Providers of preventive mental health services to young people should consider providing, CBT-based interventions to young people using adequately trained and supported school staff. They may wish to consider providing universal, rather than indicated interventions of at least 10 weeks duration, and to monitor any potential adverse effects.
- Commissioners of research should consider commissioning well-conducted randomised controlled trials (RCTs) of CBT-based interventions with young people in UK secondary schools.
- Intervention developers should: involve young people in the design of the intervention to increase its acceptability and appropriateness to young people; consider using existing school staff to provide the intervention, with appropriate training and support; include suicidal ideation and behaviours as outcome measures; and, examine differential effects of the intervention according to gender, ethnicity, and lower- and higher-SES populations. Process evaluations or qualitative components to identify possible reasons which might generate such differences should be incorporated into evaluations.
- Research commissioners, journal editors and other relevant research stakeholders should encourage authors to report their data and methods of analysis for investigations of differential impact of interventions on the health status of different socio-demographic groups.
How did we get these results?
The results of thirteen RCTs were synthesised to yield the best evidence about the role of school-based CBT-type interventions for promoting young people's mental health and preventing depression and anxiety.
This report should be cited as: Kavanagh J, Oliver S, Caird J, Tucker H, Greaves A, Harden A, Oakley A, Lorenc T, Thomas J (2009) Inequalities and the mental health of young people: a systematic review of secondary school-based cognitive behavioural interventions. London: EPPI Centre, Social Science Research Unit, Institute of Education, University of London.