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Systematic review

The effect of psychosocial interventions for preventing and treating depression and anxiety among at-risk children and adolescents

  • Year: 2014
  • Authors Munthe-Kaas HM, Johansen S, Blaasvær N, Hammerstrøm KT, Nilsen W.
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-846-8

The available evidence suggests that treatment interventions, such as cognitive behavioural probably benefit children and adolescents with anxiety or post-traumatic stress disorder and the severity of obsessive compulsive symptoms. Psychological/ educational interventions, may benefit children with depression compared with no treatment, and have possibly no effect compared with placebo or attention control. CBT combined with medication may have little or no effect on depressive symptoms, functioning or remission from depression, but may benefit children with obsessive compulsive disorder (OCD).



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Key message

Many children and adolescents struggle with mild symptoms of depression and/or anxiety at some point. When these symptoms begin to interfere with daily functioning and quality of life, children may need professional assistance to improve their well-being. Psychosocial interventions aimed at depression or anxiety are non-medicinal interventions, and can target children from risk groups (preventive interventions), children with elevated symptoms of, or diagnoses of depression or anxiety (treatment interventions).

The Norwegian Knowledge Centre for the Health Service has identified, evaluated and summarized research on the effect of psychosocial interventions. We included nine systematic reviews. The available evidence shows:

Preventive interventions: We are uncertain of the effect of preventive interventions.

Treatment interventions:

  • CBT for children with anxiety disorders seems to result in fewer symptoms of anxiety, depression and post-traumatic stress. The evidence is of low quality.
  • CBT possibly reduces the severity of symptoms of obsessive compulsive disorder. The evidence is of low quality.
  • CBT combined with medication compared to medication alone has possibly little or no effect on functioning, depressive symptoms or suicidal thoughts among children with depression. Children with obsessive compulsive disorder possibly improve after treatment with CBT. The evidence is of low quality.
  • Children who receive psychological/educational treatment possibly show fewer symptoms of depression after three to nine months after treatment when compared to no treatment. The interventions have possible no effect when compared with placebo. The evidence is of low quality.

 

It is difficult to conclude on the effects of any of the included interventions given that the results are mostly based on evidence of very low to low quality.

Summary

Background

May children and youth struggle with depression and anxiety, which can continue into adulthood (2). Some groups of children are at greater risk for developing anxiety or depression based on individual (e.g. personality or exposure to trauma), family (e.g. parent with a mental health disorder) or community characteristics (e.g. poor neighbourhood). Psychosocial interventions are non-medicinal (pharmacological) interventions aimed either at preventing or treating depression and anxiety symptoms among at-risk children and adolescents, or those who have already been diagnosed. Examples of psychosocial interventions include coping skills programmes (such as parenting programmes for teenage parents), exercise, psychological or educational interventions, cognitive behavioural therapy (CBT), or combined therapy (psychological therapy with antidepressant medications).

Objective

The objective of this report is to systematically identify, evaluate, and review the evidence on the effects of psychosocial prevention and treatment interventions for at-risk children and adolescents (0-18 years old).

Method

We searched for systematic reviews in relevant databases from January to April 2013. Two researchers independently assessed titles and full text articles for inclusion based on predefined inclusion criteria: systematic reviews of high quality that examined the effect of selective and indicated psychosocial interventions and psychosocial treatment interventions aimed at preventing or treating depression and/or anxiety among children and adolescents (0-18 years old) exposed to either child, family or community risk factors for developing symptoms of depression and/or anxiety, or who have an existing diagnosis. Preventive interventions are aimed at children who are exposed to risk factors. Treatment interventions target children who have been identified as having elevated symptoms of, or a diagnosis of depression and/or anxiety.

Relevant reviews were then critically appraised by two researchers, and moderate and low quality reviews were excluded. We extracted data from the remaining included reviews using a form. We then assessed the quality of the evidence using GRADE. We reviewed the quality of the evidence for outcomes related to symptoms severity, presence of diagnosis, and quality of life.

Results

We identified 3392 systematic reviews in the literature search. We assessed the quality of relevant systematic reviews using the checklist for systematic reviews from the Norwegian Knowledge Centre. We included nine high quality systematic reviews. These reviews included children and adolescents in risk groups, such as teenage parents, and those with depression, anxiety, obsessive compulsive disorder, and post-traumatic stress disorder. Most of the interventions were compared to wait-list, treatment as usual, or a placebo. The certainty of the evidence was of very low to moderate quality, however, most was assessed as having very low to low quality. This was often because there were an insufficient number of participants or the results were too imprecise (the confidence intervals around the effect size were very wide) to draw strong conclusions from, or because the primary studies were at high risk of bias. Based on the available evidence, we found that:

Preventive interventions: We are uncertain of the effect parenting programs for adolescent parents.

Treatment interventions:

  • CBT compared to wait list/placebo probably leads to improvement among children with anxiety diagnoses, and improves anxiety, PTSD and depression symptoms (moderate quality evidence).
  • CBT compared to wait list may improve the severity of obsessive compulsive symptoms. When compared to placebo it may lead to fewer OCD symptoms, and remission from OCD after treatment (low quality evidence).
  • CBT combined with medication compared to medication alone may have little or no effect on levels of functioning and depressive symptoms, remission rates, and suicide thoughts among children with depression. It may slightly reduce the severity of OCD symptoms and improve remission post-treatment (low quality evidence).
  • Psychological/educational interventions compared to no intervention may improve depressive scores and remission (number with diagnosis) up to three to nine months post-treatment. Compared to placebo they may have little or no effect on depression scores post-treatment (low quality evidence).

 

Discussion

The evidence for selective, indicated and treatment interventions for depression and anxiety disorders was assessed as being mainly of very low to low quality, with the exception of evidence on CBT for anxiety and post-traumatic stress disorders which was of moderate quality. This is mostly because the included reviews included small studies with high methodological concerns or insufficient reporting of methods and/or results. Moreover, results from the meta-analyses in the included reviews were often imprecise. This very low and low quality evidence means that we are very uncertain regarding the results for most of the reported outcomes.

 

Conclusion

The available evidence suggests that treatment interventions, such as cognitive behavioural probably benefit children and adolescents with anxiety or post-traumatic stress disorder and the severity of obsessive compulsive symptoms. Psychological/ educational interventions, may benefit children with depression compared with no treatment, and have possibly no effect compared with placebo or attention control.

CBT combined with medication may have little or no effect on depressive symptoms, functioning or remission from depression, but may benefit children with obsessive compulsive disorder (OCD).

It is difficult to conclude with certainty on the effects of most of the included interventions given that the results are based on evidence of low or very low quality.

 

Need for further research

While it is likely that more primary research has been published since the included systematic reviews were conducted, there is still a need for high quality primary research examining at-risk groups of children and youth. Given that the majority of relevant reviews were excluded from this review due to low methodological quality, we also need more high quality systematic reviews with recent searches in order to capture primary research conducted after 2011. We also need more systematic reviews examining interventions such as talk therapy, physical activity, and psycho-education. Moreover there is a need for reviews on the effect of psychosocial interventions on risk groups such as children in contact with child services, children of divorced parents, or children who have a parent with mental health problems.