Identifying and treating depression in children and adolescents is particularly important because of the ongoing development of children and the potential for adult outcomes. It is estimated that only 20% of adolescents with depression are diagnosed and receive appropriate treatment, and that approximately 1/2 of lifelong psychiatric disorders begin at age 14. 20% of adolescents with depression develop persistent, chronic depression that is difficult to treat. Therefore, we need not only early detection but also early intervention to prevent individuals who exhibit depressive symptoms. Preventive measures targeting children and adolescents may help prevent the development of lifelong illness.
Risk and protective factors for the development of psychopathology
The development of psychopathology is associated with many risk factors. And protective factors can help reduce these risks. Children are more likely to develop psychopathology when they are exposed to multiple risk factors and also lack protective factors. Interventional prevention works primarily by counteracting the effects of risk factors and helping to increase or enhance the effects of protective factors.
Preventive interventions
There are three main forms.
Universal Intervention (Universal Intervention): Universal interventions treat the population as a whole. This intervention does not take into account the risk status of the individual and is easily accepted because it is less biased by the participants. School-based intervention programs focus on reinforcing protective factors, such as improving cognitive, problem-solving, and social skills. Other programs include health promotion programs, and programs to reduce child abuse/neglect and bullying.
Selective Interventions: Selective interventions focus on individuals at higher than average risk for mental illness, such as teaching behavior-based parenting strategies to parents of children with conduct problems, teaching children to cope positively with major life events (divorce or death of a loved one), etc.
Indicated Interventions: Targeted interventions are for individuals who show signs or symptoms of psychological disorders but do not meet diagnostic criteria. Cognitive-behavioral prevention programs for adolescents with depressive symptoms and evidence-based anxiety prevention programs have been shown to be effective.
Universal intervention: health education in elementary schools
Universal interventions for the prevention of mental disorders are often incorporated into health education curricula. There is evidence that health education during elementary school may be effective if it is geared toward multiple risk factors. However, the effects of universal interventions are not statistically significant when compared to active interventions.
There are a variety of current intervention programs. The Michigan Model for Health (MMOH) is a comprehensive prevention curriculum. Students receive 25 lessons between grades 4 and 5 on social and emotional health, alcohol, tobacco, safety, nutrition, and physical activity. One study found that students who participated in the Michigan Model for Health program had greater social and emotional skills, social skills, and resistance to drugs. Schools are an ideal place for universal interventions, and these effects have only been seen in small studies and have yet to be validated in large trials in daily settings.
Selective interventions: family factors
Selective versus targeted interventions are more effective than universal interventions, and Horowitz and colleagues evaluated the effectiveness of 30 interventions for prevention. Selective interventions had small to moderate effect sizes on reducing depressive symptoms. The researchers provided children in single-parent families with 8 weeks of education including: how to properly understand parental divorce, problem-solving skills training, and encouraging emotional expression. Ultimately, these interventions were found to show large post-intervention effect sizes, but no further effects at the 6-month follow-up.
Approximately 1 in 5 Americans will experience depression during their lifetimes. As a result, many children live with parents in a depressed state, and 61% of these children will develop psychiatric disorders during adolescence.Beardslee et al. conducted a family-based intervention strategy for nondepressed children (8-15 years of age) with depressed parents. This intervention strategy was divided into curricular education and clinical intervention. Parenting behaviors and attitudes improved in both groups, but the improvements were higher in the clinical intervention group. Moreover, these improvements lasted for 2.5 years after the intervention. Thus a family-based intervention approach can reduce depressive symptoms.
Targeted interventions: cognitive-behavioral prevention programs
Stice et al. conducted a Meta-analysis of 32 intervention programs (including universal intervention, selective intervention and targeted intervention). Forty-one percent of these intervention programs significantly reduced depressive symptoms (with smaller effect sizes) and 13% significantly reduced the risk of future episodes of major depression. One important finding was that targeted interventions were more likely to prevent future major depressive episodes. For example, one study sought to explain whether a cognitive-behavioral group intervention program could prevent depressive episodes in adolescents. The adolescents in this study generally had a history of subsyndromal depression, major depression, or both.
And, they all had at least one guardian with a history of major depressive episodes. The intervention protocol consisted of 90-minute group sessions for eight weeks, followed by monthly group sessions for six months or usual care only. The study found an 11 percent lower rate of depressive episodes in the cognitive behavioral intervention group. Another study evaluated the efficacy of a simplified cognitive treatment program targeting children whose parents had subsyndromal depression or depression. 15-month (mean) follow-up found that the cumulative incidence of major depression was 9.3 percent in the cognitive treatment group and 18.8 percent in the usual care group.
Summary
There was some similarity in the intervention approaches with statistical significance. The study was primarily conducted with high-risk individuals, had a short study duration, included a home program, was conducted by professionals, and had a larger sample of females and slightly older adolescents. The incidence of depression was higher in females and the risk of depression increased with age in adolescents. In addition most studies evaluated the degree of reduction in depressive symptoms rather than the reduction in the incidence of depression. Most intervention programs have a small effect size of reducing depressive symptoms.
In addition, intervention programs should consider cost-effectiveness, replicability, and applicability. Selective versus targeted interventions are more effective in children and adolescents with multiple risk factors. Depression is a debilitating illness and many individual lifelong disorders can be prevented by focusing on children and adolescents with risk factors.