This report aims to increase what is known about prevention and inequalities. It is the second report in a study of health inequalities and health promotion intervention research about young people, funded by the English Department of Health, which aims to build on the findings of the first report (Oliver et al. 2008).
The first report contains a descriptive map of the available research evidence on health promotion research, inequalities and young people’s health; and a methodological study examining how well health promotion research with children and young people takes into account health inequalities, diverse populations and the involvement of children, young people and their carers in the development and implementation of health promoting interventions.
The mental health of young people is of significant concern for policymakers and practitioners in the UK (Department of Health 2004). Statistics show that, at any one time in the UK, one in ten children under 16 years of age has a clinically diagnosed mental health disorder, and among 11-16 year-olds, 13% of boys and 10% of girls are affected (Office for National Statistics 2004a).
Variations in a broad range of social, economic and environmental determinants of mental health, have contributed to inequalities in the distribution of mental health problems that some young people experience. These determinants include factors such as gender, socio-economic status (SES) and ethnicity. However, measuring the impact of an intervention on health inequalities, including inequalities in the distribution of mental health problems, raises methodological challenges both for primary research and research synthesis.
In order to describe systematically the socio-demographic and socio-economic factors implicated in health inequalities, we drew on the classifactory framework PROGRESS (Place of residence, Race/ethnicity, Occupation, Gender, Religion, Education, Socio-economic status (SES) and Social Capital). We expanded this to form PROGRESS-Plus with the addition of the variables of age disability, sexual orientation, and other specific vulnerable or excluded groups.
This current review focuses specifically on the role of interventions based on the techniques of cognitive behavioural therapy (CBT) in secondary schools for preventing and reducing suicidality, depression and anxiety in young people. A central aim of these interventions is to improve the social skills and problem- solving-abilities young people require to cope with life and its many challenges, and thereby decreasing the likelihood of depressive symptoms developing when the individual is faced with biological or environmental stressors. As these interventions can be delivered and implemented at different levels we chose to evaluate the relative effectiveness of the following three approaches:
- Universal – approaches applied to a broad population, regardless of clinical risk factors
- Indicated – approaches delivered to those with identified clinical risk factors or early symptoms identified through screening
- Targeted – approaches delivered to a population which is at a higher risk of poor mental health due to specific social determinants (e.g. participants living within an economically deprived neighbourhood), regardless of clinical risk factors
Given that the school is both a supportive environment for young people, and a location for community level interventions to be delivered and evaluated, this was considered to be a particularly appropriate choice of review scope, both substantively and methodologically.
Aims and research questions
The aim of the current study was to conduct a systematic review of interventions addressing an aspect of health in which young people are already known to experience health inequalities.
A further aim of the study was to use the systematic review as a case-study to explore approaches to applying an ‘equity lens’ to a review topic, by building on work completed in the systematic map and methodological review (Oliver et al., 2008).
A two-stage review process was used, beginning with a broad substantive review question, which was then given a narrower focus in consultation with the steering group and a policy adviser from the Child and Adolescent Mental Health Services (CAMHS) team at the Department of Health (England).
- Are secondary school-based mental health promotion interventions based on cognitive behavioural techniques effective in preventing or alleviating depression, anxiety and suicidality among young people?
- To what extent do they reduce or increase inequalities in depression, anxiety and suicidality experienced by some groups of young people?
Sensitive search strategies were developed for a comprehensive range of cross-disciplinary databases. The results of searches were screened for relevance against a pre-specified list of inclusion criteria.
The methodological quality of relevant randomised controlled trials was assessed for quality, and data from those studies which were judged to be methodologically sound was extracted by two researchers working independently.
Standardised and tested methods for meta-analysis, subgroup analysis and meta-regression were employed to synthesise data.
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. No studies presented data relevant to evaluating the differential impact of interventions according to differences in the participants’ gender, age, religion, education or social capital.
Several studies reported findings about gender, but did not report their data. While a number of studies include subgroup analyses according to clinical risk factors, no subgroup analyses on the basis of socio-demographic group were reported in any of the included studies.
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.
Recommendations for practice
Relevant providers wishing to implement preventive mental health programmes in secondary schools should consider the use of CBT-based interventions for reducing depression and anxiety levels.
Providers of preventive mental health services to young people should:
- consider using adequately trained and supported school staff to provide CBT-based interventions to young people
- consider providing programmes of 10 or more weeks’ duration
- be aware of, and consider monitoring, potential adverse effects
Providers of preventive mental health services to young people should consider providing universal, rather than indicated, interventions. Providers implementing indicated interventions may wish to monitor any potential adverse effects due to stigma associated with mental health problems.
Recommendations for research
There is a need for well-conducted randomised controlled trials (RCTs) of CBT-based interventions with young people in UK secondary schools. Consideration should be given to developing and piloting a CBT-based intervention for the prevention of depression and anxiety, to be delivered 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
- examine differential effects of the intervention on lower- and higher-SES populations, and include process evaluations or qualitative components to identify possible reasons which might generate such differences
- examine differential effects of the intervention on other PROGRESS-Plus populations, and include process evaluations or qualitative components to identify possible reasons which may generate such differences
We recommend the PROGRESS-Plus framework as a useful core framework for describing and analysing data in systematic reviews.
The PROGRESS-Plus terms may require further modification and definition to reflect the context and focus of particular research projects.
Future trials of health promotion interventions should consider including subgroup analyses of population groups at risk of inequalities on specified health measures.
Choice of subgroup populations should be a priori, and have an appropriate rationale. Underpowered subgroup analyses which meet these criteria should be conducted only for the purposes of monitoring for potential adverse effects, or hypothesis generation.
Recommendations for reporting
There needs to be better and fuller reporting of socio-demographic data of participants in reports of primary research.
Research commissioners, journal editors and other relevant research stakeholders should encourage authors to report their data and methods of analysis for their investigations of differential effect of interventions on the health status of different socio-demographic groups.