For anyone working with children or young people, it will come as no surprise to discover that the prevalence of poor mental health is growing, with most teachers able to think of at least one student struggling with low mood. Recent UK data suggests that 9% of 11-16 year olds and 15% of 17-19 years have a diagnosable disorder such as anxiety or depression (Vizard et al., 2018), however many argue that this is just the tip of the iceberg, with there being many more young people just below the threshold for diagnosis (Bertha & Balazs, 2013).

It is important that we intervene early to address emerging poor mental health as studies repeatedly show that emotional disorders during childhood and adolescence can lead to consequences such as long term poor mental and physical health, low educational achievement, unemployment and increased risk of substance abuse and criminal behaviour (Clayborne, Varin, & Colman, 2018; Essau, Lewinsohn, Olaya, & Seeley, 2014; Keenan- Miller, Hammen, & Brennan, 2007).

The evidence suggests that early intervention can prevent this downward slide (Bockting, Hollon, Jarrett, Kuyken, & Dobson, 2015; Neufeld, Dunn, Jones, Croudace, & Goodyer, 2017) but it also reveals that most young people are failing to access it (Children & Young People’s Mental Health & Wellbeing Taskforce, 2015; Merikangas et al., 2011). There are many possible reasons for this including:

• Lack of knowledge about mental health leading to stigma and failure to seek help (Langer et al., 2015; Plaistow et al., 2013; Reardon et al., 2017).
• The failure of primary health care professionals such as GPs to make the necessary referrals to specialist services (O’Brien, Harvey, Howse, Reardon, & Creswell, 2016).
• The threshold for child and adolescent mental health services (CAMHS) being too high (Department of Health & Department for Education, 2017; Frith, 2016), leading to long waiting lists and failure to meet the threshold for treatment (Crenna- Jennings & Hutchinson, 2018).

Schools have the potential to make a real difference in terms of all three of these barriers. Not only do teachers have the advantage of already having built good relationships with young people, their experience makes them well placed to identify young people struggling with emotion and mood (Patel et al., 2018; Public Health England, 2015).

The green paper ‘Transforming Children and Young People’s Mental Health Provision’ (Department of Health & Department for Education, 2017) is the start of government recognising the important role schools can play in addressing mental health concerns. The paper details how money and training have been made available for nurse-led mental health support teams to provide evidence-based interventions in a school setting (Department of Health & Department for Education, 2017).

A recent review by Gee et al (2020) examines and evaluates data from randomised controlled trials of targeted school-based interventions for treating adolescents who are already showing signs of depression and anxiety. In order to establish the quality of the evidence presented, the review also examines the methods using the ‘preferred reporting items for systematic reviews and meta analyses’ (PRISMA) statement (Moher et al., 2009) to ensure the evidence is valid and applicable.

Methods

Eight electronic databases and reference lists were searched in order to identify randomised controlled trials that met the criteria of:

• A school-based intervention
• Use of a manual
• A treatment, not a preventative measure
• Targeted young people (ages 10-19) who were already displaying signs of anxiety and depression
• Aimed at reducing the symptoms of emotional disorders.

The original research was required to meet set standards (Cuijpers et al., 2010) including those used to measure the impact of mental health interventions (Moncrieff, Churchill, Colin Drummond, and McGuire, 2001), this included the use of trained therapists, monitoring for accurate use of the manual, and anonymised data collection.

Results

Anxiety focused interventions

Group interventions targeting anxiety were more effective than those for depression. It is believed that this is because the use of a group normalised anxiety whilst providing peer support and modelling in a social environment (Wergeland et al., 2014).

Anxiety interventions delivered outside of school were more effective than those delivered internally (Reynolds et al., 2012), potentially because school-based interventions were unable to use the exposure-based strategies available to external groups (Bernstein, 2010; Drmic, Aljunied, & Reaven, 2017; Masia-Warner et al., 2016).

Depression focused interventions

One to one sessions appear to have been more effective than group interventions (Wergeland et al., 2014), but the original researchers highlight that numbers involved were low so this should be viewed with caution. Surprisingly, the study also revealed that parental involvement had little impact on the symptoms of depression, possibly due to practical difficulties, such as resources and time, surrounding this (Drmic et al., 2017; Melnyk, Kelly, & Lusk, 2014). This is significant as other research and guidelines from the National Institute for Health and Care Excellence (NICE) encourage parental involvement (Dardas, van de Water, & Simmons, 2018; NICE, 2005).

Effectiveness of interventions delivered by school staff

From examining data across the 45 studies, researchers established that school-based interventions delivered by specialists were more effective than a do nothing approach.

Unfortunately, when interventions were delivered by school staff, there was no significant impact on either depression or anxiety symptoms; this is believed to be due to failure to adhere fully to the programme or manual. This is a crucial finding as in order for school based interventions to be sustainable, school staff need to able to take part in delivery, consequentially this is something that needs further examination (Herzig-Anderson, Colognori, Fox, Stewart, & Masia-Warner, 2012).

Long-term impact

Disappointingly the research showed that the long-term impact of all school-based interventions was limited with only a slight impact on depression symptoms for up to 6 months after the intervention, and no significant long-term effects on anxiety. This suggests that additional strategies are needed to prolong the efficacy of such interventions once they have come to an end.

Conclusions

This review of 45 studies of school-based interventions revealed that, dependent on a number of factors, they can have a positive impact on both depression and anxiety, but that the long-term benefits have yet to be demonstrated.

As the government and local authorities begin to implement the Green Paper by introducing Mental Health Support Teams into schools, it is ever more vital that we understand the lessons of previous interventions in order to create effective and sustainable treatment programmes to target the growing number of young people with emerging emotional disorders.

Strengths and limitations

• The results are potentially biased due to not being able to obtain missing data for all eligible studies.
• It was not possible to adjust data from cluster randomised trials due to missing data, meaning results may be skewed.
• The analysis of subgroups is not directly comparable due to them not being randomised, therefore results should be treated with caution.

Implications for practice

There is a need for more high quality trials of school-based interventions for anxiety and depression, which also need to incorporate longer term follow-ups.

There is an urgent need for research into psychological interventions delivered in post 16 years old education and specialist schools including those for expelled students.

Research needs to look at the potential costs and adverse effects of school-based psychological interventions.

Conflicts of interest

None reported.

Links

Primary paper

Gee, B., Reynolds, S., Carroll, B., Orchard, F., Clarke, T., Martin, D., Wilson, J. and Pass, L. (2020) Practitioner Review: Effectiveness of indicated school‐based interventions for adolescent depression and anxiety – a meta‐analytic review. J Child Psychol Psychiatr. doi:10.1111/jcpp.13209

There’s a video abstract featuring first author Brioney Gee on @TheJCPP Twitter.

Other references

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Photo credits

• Photo by You X Ventures on Unsplash
• Photo by Bill on Unsplash