Psychological and educational interventions for preventing depression in children and adolescents

 

Abstract

Background

Depression is common in young people, has a marked negative impact and is associated with self-harm and suicide. Preventing its onset would be an important advance in public health.  

Objectives

To determine whether psychological or educational interventions, or both, are effective in preventing the onset of depressive disorder in children and adolescents.

Search methods

The Cochrane Depression, Anxiety and Neurosis Review Group's trials registers (CCDANCTR) were searched at the editorial base in July 2010. Update searches of MEDLINE, EMBASE, PsycINFO and ERIC were conducted by the authors in September 2009. Conference abstracts, reference lists of included studies and reviews were searched and experts in the field contacted.

Selection criteria

Randomised controlled trials of psychological or educational prevention programmes, or both, compared with placebo, any comparison intervention, or no intervention for young people aged 5 to 19 years-old, who did not currently meet diagnostic criteria for depression or who were below the clinical range on standardised, validated, and reliable rating scales of depression, or both, were included.

Data collection and analysis

Two authors independently assessed studies for inclusion and rated their quality. Sample sizes were adjusted to take account of cluster designs and multiple comparisons. We contacted study authors for additional information where needed. 

Main results

Fifty-three studies including 14,406 participants were included in the analysis. There were only six studies with clear allocation concealment, participants and assessors were mostly not blind to the intervention or blinding was unclear so that the overall risk of bias was moderately high. Sixteen studies including 3240 participants reported outcomes on depressive diagnosis. The risk of having a depressive disorder post-intervention was reduced immediately compared with no intervention (15 studies; 3115 participants risk difference (RD) -0.09; 95% confidence interval (CI) -0.14 to -0.05; P<0.0003), at three to nine months (14 studies; 1842 participants; RD -0.11; 95% CI -0.16 to -0.06) and at 12 months (10 studies; 1750 participants; RD -0.06; 95% CI -0.11 to -0.01). There was no evidence for continued efficacy at 24 months (eight studies; 2084 participant; RD -0.01; 95% CI -0.04 to 0.03) but limited evidence of efficacy at 36 months (two studies; 464 participants; RD -0.10; 95% CI -0.19 to -0.02). There was significant heterogeneity in all these findings. There was no evidence of efficacy in the few studies that compared intervention with placebo or attention controls.

Authors' conclusions

There is some evidence from this review that targeted and universal depression prevention programmes may prevent the onset of depressive disorders compared with no intervention. However, allocation concealment is unclear in most studies, and there is heterogeneity in the findings. The persistence of findings suggests that this is real and not a placebo effect. 

 

Plain language summary

Psychological and educational interventions for preventing depression in children and adolescents

Depressive disorder is common and has a major impact on the functioning of young people. The aim of this review was to assess the effectiveness of programmes designed to prevent its onset.

We found that, compared with no intervention, psychological depression prevention programmes were effective in preventing depression with a number of studies showing a decrease in episodes of depressive illness over a year. There were some problems with the way the studies were done but despite this the results are encouraging. We found data to support both targeted and universal programmes, which is important as universal programmes are likely to be easier to implement. We recommend that further research be undertaken to identify the most effective programmes and to test these in the real world.  

 

摘要

背景

以心理及/或教育介入措施，預防兒童及青少年憂鬱

在估計疾病負擔上，憂鬱症是第四重大的疾病(Murray, 1996)，是一個普遍的問題，在年輕族群上的流行率估計高達8％。青少年憂鬱症關乎學業成績差，社會功能障礙，藥物濫用，企圖自殺，並完成自殺(NHMRC, 1997)。以至於開始發展方案以預防憂鬱症的發生。本篇回顧評估這些介入方案的有效性。

目標

查明對兒童與青少年族群進行心理及/或教育介入措施(包括普遍性與針對性)，能否有效地減少罹患憂鬱症的風險，在介入措施後能立即減少憂鬱症狀，或是在介入後1 – 3年內預防憂鬱症發作。

搜尋策略

搜尋登錄在Cochrane Depression, Anxiety and Neurosis Group 的研究(August 2002)，MEDLINE (1966 to December Week 3 2002), EMBASE (1980 to January Week 2 2003), PsychInfo (1886 to January Week 2 2003) and ERIC (1985 to December 2002)。此外，搜尋會議摘要，研究的參考文獻，及其他回顧文章，對該領域的專家進行聯繫。

選擇標準

由兩位審查者獨立評估每一個找出來的研究的方法學方面是否符合條件。納入條款取決於該研究是針對5 – 19歲的年輕族群所進行的心理及/或教育預防方案，受試者不符合DSM或ICD的憂鬱症標準，以及/或臨床上標準化、有信效度的憂鬱評估量表上不屬於憂鬱症者。

資料收集與分析

依據Moncrieff及其同事(Moncrieff 2001)所提出的品質等級，預先表列設定標準，由兩位回顧者獨立評估納入研究的方法品質。研究結果取出後輸入Revman 4.2。取出可獲得的結果，連續變項以平均數和標準差代表，二分法變項以事件發生次數為代表。如果需要的研究資料並沒有發表或無法計算，則向第一作者詢問進一步的資料。如果沒有提供更進一步的細節，該研究仍會納入回顧並描述，但不進行後設分析。每一種介入措施型態的結果都會列出來：目標取向或普遍取向的介入方案；教育性或心理介入，以及是否按性別提供資料。所有可能的資料均合併在後設分析當中，以便瞭解所有研究的治療效果。在敏感度分析方面根據Moncrieff 等人 (Moncrieff 2001)設計的評量，分數超過22分的評量標準評定為「恰當」或「高」品質。現存的發表性偏誤則以漏斗圖評估。

主要結論

研究分為有效介入組，或安慰劑組(也就是在一種控制狀態下,採取類似的介入,但此介入缺乏主動預防憂鬱症的要素)，以及等候治療或沒有介入措施的對照組，進行介入方案的比較。只有兩個研究落入前一類，兩者都沒有效，雖然有一個研究不恰當的強化結果導致有向,而另一個因為包含有療效的治療因素,因此減少了與治療組區分出差異性的能力。心理介入比沒有介入有效，在介入方案進行後後憂鬱量表的分數立即有顯著下降(SMD) of −0.26 and a 95% confidence interval (CI) of −0.40 to −0.13)，但非普遍性的介入(SMD −0.21, 95% CI −0.48, 0.06)在匯集分析的資料中也有顯著效果(SMD −0.26, 95% CI −0.36, −0.15)。憂鬱發作顯著減少但effect size小。介入後的整體風險差異轉換為益一需治數(NNT)為10。最有效的研究是Clarke 2001年的目標性介入計畫，最初的效果量是 −0.46，相關的初期風險差異為 −0.22，NNT 5。沒有證據顯示教育性介入措施是有效的。青少年與青少女的有效性並不一致。許多研究的品質不佳，只有兩個研究有明確隱藏分配。只有高品質的研究的敏感度分析，並無顯著改變結果。唯一分析統計異質性達顯著的是性別的次團體，在不同的方案中，針對青少年或青少女，其反應有變異性。大部分的漏斗圖指出在短期療效方面是明確有效的，而且沒有發表性偏誤。但在長期方面的研究量太少，無法評論在長期(12 – 36個月)追蹤的報告上是否有研究的偏差。

作者結論

儘管沒有充分證據證明目前有必要引進憂鬱症的預防方案，迄今的結果顯示，值得花時間進行進一步的研究。當選擇目標族群時，有需要以對照組比較介入措施或某種積極的比較，讓參與者不知道他們是否屬於介入措施團體，並調查最受幫助單元的作用，以便瞭解在介入措施之後的立即效果是否能夠延長，最好一年或更長，並考量實際執行預防方案的成果。到目前為止，多數的研究都集中在心理介入。教育介入措施的潛在效益並沒有充分調查。考量盛行率上有性別差異，在青少女的盛行率變得過度增加，似乎青少年與青少女對介入方案會有不同的反應。儘管在這些回顧當中報告有差異性，結果是矛盾的，依據性別的特殊反應作明確劃分的介入方案將是比較有幫助的。

翻譯人

本摘要由彰化基督教醫院陳美貴翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

憂鬱症是常見的，對罹患憂鬱的青少年其功能會受到重大影響。在世界各地，因關注此議題而發展了許多憂鬱症的介入措施。本篇回顧的主要目的在於評估這些介入措施的有效性。本篇回顧發現心理方面，短期的憂鬱症預防計畫是有效的，有些研究顯示這些方案能夠在一年內減少憂鬱症。然而，研究的方法有些問題。很少有教育介入措施的研究。雖然結果令人振奮，我們建議未來在推行憂鬱症防治計畫前，先進行進一步的研究，以更好的研究設計證實這些結果。