Psychological and/or educational interventions for the prevention of depression in children and adolescents (Cochrane review)

Psychological and/or educational interventions for the

prevention of depression in children and adolescents (Review)

Merry S, McDowell H, Hetrick S, Bir J, Muller N

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library

2007, Issue 3

http://www.thecochranelibrary.com

1Psychological and/or educational interventions for the prevention of depression in children and adolescents (Review)

Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .

4SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .

5METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .

12ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

44Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

44Characteristics of ongoing studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

47ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

47Table 01. Additional Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50Table 02. Anxiety Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

51ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

51Comparison 01. Psychological/educational intervention versus no intervention/wait-list/usual care . . . . . . .

51Comparison 02. Psychological/educational intervention versus placebo/attention/other intervention . . . . . .

52Comparison 03. Psychological/educational intervention versus no intervention/wait list/usual care 3-6 months . .

52Comparison 04. Psychological/educational intervention versus placebo/attention/other intervention 3-6 months . .

52Comparison 05. Psychological/educational intervention versus no intervention/wait list/usual care 12 months . . .

53Comparison 06. Psychological/educational intervention versus placebo/attention/other intervention 12 months . .



54INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

54COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

56Analysis 01.01. Comparison 01 Psychological/educational intervention versus no intervention/wait-list/usual care,

Outcome 01 Depression scores (by population) . . . . . . . . . . . . . . . . . . . . . .


Outcome 02 Depression scores (by intervention) . . . . . . . . . . . . . . . . . . . . . .


Outcome 03 Depression scores (by gender) . . . . . . . . . . . . . . . . . . . . . . . .


Outcome 04 Depression scores (by risk) . . . . . . . . . . . . . . . . . . . . . . . . .


Outcome 05 Depressive disorder (by population) . . . . . . . . . . . . . . . . . . . . .


Outcome 06 Depressive disorder (by intervention) . . . . . . . . . . . . . . . . . . . . .


Outcome 07 Depressive disorder (by gender) . . . . . . . . . . . . . . . . . . . . . . .

iPsychological and/or educational interventions for the prevention of depression in children and adolescents (Review)



Outcome 08 Depressive disorders (by risk) . . . . . . . . . . . . . . . . . . . . . . . .

64Analysis 02.01. Comparison 02 Psychological/educational intervention versus placebo/attention/other intervention,

Outcome 01 Depression scores (by population) . . . . . . . . . . . . . . . . . . . . . .


Outcome 02 Depression scores (by intervention) . . . . . . . . . . . . . . . . . . . . . .


Outcome 03 Depression scores (by gender) . . . . . . . . . . . . . . . . . . . . . . . .


Outcome 04 Depression scores (by risk) . . . . . . . . . . . . . . . . . . . . . . . . .


Outcome 05 Depressive disorder (by population) . . . . . . . . . . . . . . . . . . . . .


Outcome 06 Depressive disorder (by intervention) . . . . . . . . . . . . . . . . . . . . .

68Analysis 03.01. Comparison 03 Psychological/educational intervention versus no intervention/wait list/usual care 3-6

months, Outcome 01 Depression scores (by population) . . . . . . . . . . . . . . . . . . .


months, Outcome 02 Depression scores (by intervention) . . . . . . . . . . . . . . . . . .


months, Outcome 03 Depression scores (by gender) . . . . . . . . . . . . . . . . . . . .


months, Outcome 04 Depression scores (by risk) . . . . . . . . . . . . . . . . . . . . .


months, Outcome 05 Depressive disorder (by population) . . . . . . . . . . . . . . . . . .


months, Outcome 06 Depressive disorder (by intervention) . . . . . . . . . . . . . . . . . .


months, Outcome 07 Depressive disorder (by gender) . . . . . . . . . . . . . . . . . . . .


months, Outcome 08 Depressive disorder (by risk) . . . . . . . . . . . . . . . . . . . . .

76Analysis 04.01. Comparison 04 Psychological/educational intervention versus placebo/attention/other intervention 3-6












80Analysis 05.01. Comparison 05 Psychological/educational intervention versus no intervention/wait list/usual care 12










iiPsychological and/or educational interventions for the prevention of depression in children and adolescents (Review)








88Analysis 06.01. Comparison 06 Psychological/educational intervention versus placebo/attention/other intervention 12








































iiiPsychological and/or educational interventions for the prevention of depression in children and adolescents (Review)


Psychological and/or educational interventions for the

prevention of depression in children and adolescents (Review)

Merry S, McDowell H, Hetrick S, Bir J, Muller N

This record should be cited as:

Merry S, McDowell H, Hetrick S, Bir J, Muller N. Psychological and/or educational interventions for the prevention of de-

pression in children and adolescents. Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD003380. DOI:

10.1002/14651858.CD003380.pub2.

This version first published online: 19 April 2004 in Issue 2, 2004.

Date of most recent substantive amendment: 28 November 2003

A B S T R A C T

Background

Depression is the fourth most important disease in the estimation of the burden of disease (Murray 1996) and is a common problem,

with prevalence rates estimated to be as high as 8% in young people. Depression in young people is associated with poor academic

performance, social dysfunction, substance abuse, suicide attempts, and completed suicide (NHMRC 1997). This has precipitated the

development of programmes aimed at preventing the onset of depression.

This review evaluates evidence for the effectiveness of these prevention programmes.

Objectives

To determine whether psychological and/or educational interventions (both universal and targeted) are effective in reducing risk of

depressive disorder by reducing depressive symptoms immediately after intervention or by preventing the onset of depressive disorder

in children and adolescents over the next one to three years.

Search strategy

The Cochrane Depression, Anxiety and Neurosis Group trials register (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) were

searched. In addition, conference abstracts, the reference lists of included studies, and other reviews were searched and experts in the

field were contacted.

Selection criteria

Each identified study was assessed for possible inclusion by two independent reviewers based on the methods sections. The determinants

for inclusion were that the trial include a psychological and/or educational prevention programme for young people aged 5 to 19 years-

old, who did not meet DSM or ICD criteria for depression and/or did not fall into the clinical range on standardised, validated, and

reliable rating scales of depression.

Data collection and analysis

The methodological quality of the included trials was assessed by two independent reviewers according to a list of pre-determined criteria,

which were based on quality ratings devised by Moncrieff and colleagues (Moncrieff 2001). Outcome data was extracted and entered

into Revman 4.2. Means and standard deviations for continuous outcomes and number of events for dichotomous outcomes were

extracted where available. For trials where the required data were not reported or could not be calculated, further details were requested

from first authors. If no further details were provided, the trial was included in the review and described, but not included in the meta-

analysis. Results were presented for each type of intervention: targeted or universal interventions; and educational or psychological

interventions and if data were provided, by gender. Where possible data were combined in meta-analyses to give a treatment effect

across all trials.

Sensitivity analysis were conducted on studies rated as “adequate” or “high” quality, that is with a score over 22, based on the scale by

Moncrieff et al (Moncrieff 2001). The presence of publication bias was assessed using funnel plots.



Main results

Studies were divided into those that compared intervention with an active comparison or placebo (i.e. a control condition that resembles

the intervention being investigated but which lacks the elements thought to be active in preventing depression) and those that used

a “wait-list” or no intervention comparison group. Only two studies fell into the former category and neither showed effectiveness

although one study was inadequately powered to show a difference and in the other the “placebo” contained active therapeutic elements,

reducing the ability to demonstrate a difference from intervention. Psychological interventions were effective compared with non-

intervention immediately after the programmes were delivered with a significant reduction in scores on depression rating scales for

targeted (standardised mean difference (SMD) of -0.26 and a 95% confidence interval (CI) of -0.40 to -0.13 ) but not universal

interventions (SMD -0.21, 95% CI -0.48, 0.06), with a significant effect maintained on pooling data (SMD -0.26, 95% CI -0.36,

-0.15). While small effect sizes were reported, these were associated with a significant reduction in depressive episodes. The overall risk

difference after intervention translates to “numbers needed to treat” (NNT) of 10.The most effective study is the targeted programme

by Clarke 2001, where the initial effect size of -0.46 is associated with an initial risk difference of -0.22 and NNT 5. There was no

evidence of effectiveness for educational interventions. Reports of effectiveness for boys and girls were contradictory. The quality of

many studies was poor, and only two studies made allocation concealment explicit. Sensitivity analysis of only high quality studies did

not alter the results significantly. The only analysis in which there was significant statistical heterogeneity was the sub-group analysis

by gender where there was variability in the response to different programmes for both girls and boys.

For the most part funnel plots indicate findings are robust for short term effects with no publication bias evident. There are too few

studies to comment on whether there is publication bias for studies reporting long-term (12-36 month) follow-up.

Authors’ conclusions

Although there is insufficient evidence to warrant the introduction of depression prevention programmes currently, results to date

indicate that further study would be worthwhile. There is a need to compare interventions with a placebo or some sort of active

comparison so that study participants do not know whether they are in the intervention group or not, to investigate the impact of

booster sessions to see if effectiveness immediately after intervention can be prolonged, ideally for a year or longer, and to consider

practical implementation of prevention programmes when choosing target populations. Until now most studies have focussed on

psychological interventions. The potential effectiveness of educational interventions has not been fully investigated. Given the gender

differences in prevalence, and the change in these that occurs in adolescence with a disproportionate increase in prevalence rates for

girls, it is likely that girls and boys will respond differently to interventions. Although differences have been reported in studies in this

review the findings are contradictory and a more definitive delineation of gender specific responses to interventions would be helpful.

P L A I N L A N G U A G E S U M M A R Y

Depression is common and has a major impact on the functioning of young people who develop depressive disorder. Concern about

this has led to the development of a number of depression prevention programmes around the world. The aim of this review was to

assess the effectiveness of such intervention programs.

This review found that psychological depression prevention programs were effective in preventing depression in the short term with

some studies showing a decrease in depressive illness over a year. However there were some problems with the way the studies were done.

There were very few studies of educational interventions. Although the results are encouraging, we recommend that further research be

undertaken to confirm these results using better study design before the introduction of depression prevention programs in the future.

B A C K G R O U N D

Depression is a common problem in young people. Epidemiolog-

ical studies show that up to two-fifths of young people suffer from

a depressed mood in any six-month period, with six-month preva-

lence rates of major depressive disorder ranging from 0.4-8.3%

(Anderson 1994; Fleming 1990; Kashani 1987; Lewinsohn 1993;

Lewinsohn 1994) and dysthymic disorder ranging from 0.4-6.6%

(Kashani 1987, Lewinsohn 1993; Lewinsohn 1994, NHMRC

1997). It has been estimated that up to 24% of young people

will have suffered from at least one clinically significant depressive

episode by the time that they are 18 years old (NHMRC 1997).

Depression in young people is associated with poor academic per-

formance, social dysfunction, substance abuse, and attempted and

completed suicide (NHMRC 1997). It is considered the fourth

most important disease in the estimation of disease burden (Mur-

ray 1996). While there are differences in the way that depression

is conceptualised and measured with resulting differences in re-



ported rates of depression Harrington 1998b) the association of

even relatively mild depressive symptoms with problems of func-

tioning (Harrington 1998b) there has been widespread interest in

the development of programmes aimed at preventing the onset of

depression, with a number of studies being published in the last

decade.

The traditional classification of prevention of illness is into pri-

mary, secondary, and tertiary. Primary prevention focuses on de-

creasing the rate of new cases of a disorder and is directed at people

who are essentially healthy. It may include interventions for people

with known risk factors including signs and symptoms deemed

to be precursors of disorder. Secondary prevention is concerned

with the detection and treatment of early signs of illness, as well as

treatment of full blown disorder. Tertiary prevention is concerned

with minimising disability that arises from illness. This has led

to some confusion about whether to classify early intervention as

prevention or as treatment i.e. primary or secondary prevention.

As a result it has been recommended in the Institute of Medicine

Report (Mrazek 1994) that prevention is defined as those inter-

ventions that occur prior to the onset of a clinically diagnosed

disorder. This is the definition used in the present review. It there-

fore includes interventions that target young people with elevated

symptoms of depression who do not meet the criteria for depres-

sive disorder. It does not include interventions targeted to those

with recent onset of a disorder.

Prevention can be universal, where the intervention is imple-

mented for a designated population regardless of risk, or targeted

to a population at high risk for the disorder. Targeted interven-

tions can be further classified into selective interventions which

focus on populations with a risk factor for disorder e.g. family

history, and indicated interventions which focus on populations

with symptoms or signs suggestive of incipient disorder . There

have been promising targeted programmes reported in the liter-

ature indicating potential effectiveness (e.g. Beardslee 1993; Jay-

cox 1994; Clarke 1995). Two universal programmes have been

reported. Neither was effective but they were very short (Clarke

1995). An Australian group has developed an 11-week universal

intervention programme for 13-15 year olds with promising re-

sults (Shochet 2001) and there are further programmes under de-

velopment in Australia. One systematic review has considered the

evidence for the effectiveness of prevention programmes based on

CBT in children and adolescents (Harrington 1998) and there has

been one review of prevention programmes using CBT or family

interventions in children, adolescents or adults (Gillham 2000)

. There have also been reviews of the more general issue of pre-

venting mental illness in children and adolescents (Durlak 1997;

Greenberg 2001) however these are not specific..

Programmes have often been based around psychological inter-

ventions with an underlying focus on principles of cognitive be-

havioural therapy. The interventions are usually delivered weekly

for around 12 to 15 sessions in a group setting and teach partic-

ipants how to deal with negative thoughts, solve problems and

manage stress. The titles usually have a positive focus eg the “Cop-

ing with Stress Course” (Clarke 1995), the Resourceful Adoles-

cent Programme (Shochet 2001) and the “Depression Prevention

Program (Jaycox 1994). Some have concurrent programs for par-

ents (Clarke 1995; Shochet 2001). The education programs have

tended to be short and less well structured (Clarke 1993a; Clarke

1993b; Beardslee 1993).

It is clear from medication trials that there is a strong placebo effect

in interventions for depression (Shapiro 1997). Often this is not

taken into account in studies of psychological or educational in-

terventions. Psychological interventions may appear to be effective

”not because of the theories or therapeutic procedures but because

of underlying, unspecified or not clearly determined non-specific

effects“ (Shapiro 1997 p103). This is of relevance in prevention

programs where interventions designed to appeal to participants

and introduced by enthusiastic research teams could lead to re-

duction in depression, at least in the short-term. Improvement in

mood may then be attributed to the content of the program. Ide-

ally, as in medication trials, the intervention should be compared

with a comparison condition that resembles the intervention but

without the elements thought to be actively therapeutic (Shapiro

1997). At the least there should be some attempt to ensure that

participants in the study do not know whether they are subjects

or controls. If this is not done it is difficult to ensure that effects

reported are not placebo effects.

There is pressure on governments of a number of countries to for-

mulate strategies to curb youth suicide. Depression is an impor-

tant risk factor for both attempted and completed suicide mak-

ing it a logical point of intervention in suicide prevention. There

is therefore increasing interest in the introduction of prevention

and early intervention programmes for depression in schools and

in the community. The concern is that such programmes may be

implemented in the absence of evidence of effectiveness, owing

to the pressure on governments to be seen to be doing something

about youth suicide. It is timely therefore to review the evidence

currently available for the effectiveness of depression prevention

programmes. In doing so it is important to ensure that the non-

specific effects of being in a study are taken into account

O B J E C T I V E S

To determine whether psychological and/or educational interven-

tions (both universal and targeted) are effective in reducing risk of

depressive disorder by reducing depressive symptoms immediately

after intervention or by preventing the onset of depressive disorder

in children and adolescents over the next one to three years.



C R I T E R I A F O R C O N S I D E R I N G

S T U D I E S F O R T H I S R E V I E W

Types of studies

Randomised controlled trials were included.

The reviewers had planned that if there were no, very few, or only

very poor quality trials, the next levels of evidence including con-

trolled and uncontrolled clinical trials, open trials, case controlled,

and cohort studies (Altman 1991; Myles 2000, SIGN 2000) were

to be included. Data would not have been pooled in meta-analysis

but summarised in additional tables and included in the discus-

sion. However there were enough randomised controlled trials to

make this second step unnecessary.

Types of participants

Studies were included if the subjects were children and adolescents

(aged 5 to 19 years) who did not meet the criteria for a clinical

diagnosis of depressive illness, although they may have had sub-

clinical symptoms of depression.

Studies on children and adolescents who met DSM IV or ICD 10

criteria for depression and/or fell into the clinical range on stan-

dardised, validated and reliable rating scales of depression at the

start of the study were excluded. Studies that focused on secondary

or co-morbid disorders, lacked clear definition of participants, or

exhibited a lack of adequate assessment of participants were also

excluded.

Types of intervention

Studies on depression prevention were included if they compared

the effectiveness of educational and/or psychological interventions

with the effectiveness of placebo, any comparison intervention, or

no intervention in children and adolescents. A placebo was con-

sidered to be a control condition that resembled the intervention

being investigated but which lacked the elements thought to be

active in preventing depression. Open trials of educational or psy-

chological interventions were also considered. Interventions were

classified as educational if the focus was on providing informa-

tion only, for example information on how to recognise depressive

illness and how it might be treated. They were classified as psy-

chological if there was some attempt to teach participants skills

to reduce depression. Examples of psychological interventions in-

clude stress management, cognitive restructuring, conflict resolu-

tion and problem solving. As recommended in the Institute of

Medicine Report (Mrazek 1994) prevention was classified as those

interventions that occurred prior to the initial onset of a clini-

cally diagnosable disorder and included intervention for individ-

uals who had elevated symptoms of disorder but who did not yet

meet the criteria for a clinical disorder.

Secondary and tertiary interventions, including relapse preven-

tion, and medical interventions for depression were excluded from

the analysis.

Types of outcome measures

Primary outcomes

Prevention of depression indicated by reduction of depressive

symptoms on pre-post assessment (early intervention) or reduc-

tion in onset of depressive symptoms or disorder measured by:-

1. depression scores on a variety of standardised, validated, and

reliable depression rating scales suitable for children and adoles-

cents including dichotomous and continuous outcomes. Where

there was more than one outcome measure used, the highest qual-

ity outcome measure was entered into the analyses, following the

method described by Hazell 2000. Depression rating instruments

were ranked by quality. A single best available outcome measure

was chosen for each study with reference to the ranking. These

outcomes were then pooled for analysis.

2. a recognised diagnostic system such as DSM 1V or ICD 10.

Secondary outcomes

1. General adjustment

2. Academic/work function

3. Social adjustment

4. Cognitive style

5. Suicidal ideation/attempts

Duration of outcome

Depression scores and diagnoses were pooled for analysis at time

points namely immediately after intervention and, where available,

at 3-6 months, 12 months, 24 months and 36 months.

S E A R C H M E T H O D S F O R

I D E N T I F I C A T I O N O F S T U D I E S

See: Cochrane Depression, Anxiety and Neurosis Group methods

used in reviews.

Electronic searches:

1. The Cochrane Depression, Anxiety and Neurosis Group

trials register was searched (August 2002) using the following

terms: depression or depressive-disorder or dysthymic-disorder

[as CCDANCTR keywords] combined with prevention-and-

control [as a CCDANCTR intervention code] and school* or

educat* or colleg* [as textwords].

2. A search of the following electronic databases was undertaken:-

MEDLINE (1966-December Week 3 2002)

EMBASE (1980 -2003 January Week 2)

PsycINFO (1872-January Week 2 2003)

ERIC (1966-December 2002)

The following search terms were used:

MEDLINE (1966-December Week 3 2002) and PsycINFO

(1872-January Week 2 2003):

1 exp affective symptoms/ or exp depression/ or Behavioral

symptoms/

2 exp depressive disorder/



3 (depressi$ adj3 disorder$).tw.

4 (depressi$ adj3 symptom$).tw.

5 or/1-4

6 prevent$.tw.

7 early intervent$.tw.

8 (educat$ adj3 pack$).tw.

9 (educat$ adj3 interv$).tw.

10 (educat$ adj3 program$).tw.

11 ”group counsel$“.mp.

12 counsel$.mp.

13 Psychotherapy, group.mp. or Psychotherapy, Group/

14 or/6-13

15 drug therapy/

16 (5 and 14) not 15

17 limit 16 to all child <0 to 18 years>

Eric (1966-December 2002):

1 ”Depression (psychology)“/

2 (depressi$ adj3 disorder$).tw.

3 (depressi$ adj3 symptom$).tw.

4 or/1-3

5 prevent$.mp.

6 ”early intervention$“.tw.

7 (educat$ adj3 pack$).tw.

8 (educat$ adj3 interv$).tw.

9 (educat$ adj3 program$).tw.

10 exp group counseling/

11 Drug therapy/

12 or/5-10

13 (4 and 12) not 11

14 limit 13 to (elementary secondary education or elementary

education or primary education)

Reference lists:

The reference lists of articles and other reviews retrieved in the

search were searched.

Handsearches:

Conference abstracts,

The following conferences proceedings were searched

American Academy of Child and Adolescent Psychiatry 1994






.

Personal Communication:

in order to ensure that as many as possible RCTs and CCTs were

identified, the authors of the included studies were consulted to

find out if they knew of any published or unpublished RCTs/

CCTs in the area, and which had not yet been identified.

M E T H O D S O F T H E R E V I E W

Selection of trials:

The selection of trials for inclusion in the review was performed

independently by two reviewers (SM and HM or JB) after

employing the search strategy described previously. Where a title

or abstract appeared to describe a trial eligible for inclusion, the

full article was obtained and inspected to assess relevance to this

review based on the inclusion criteria. Any discrepancies between

the two reviewers were resolved by a third reviewer (SH).

Quality assessment:

In order to ensure that variation was not caused by systematic errors

in the design of a study, the methodological quality of the selected

trials was assessed by two out of three independent reviewers (SM

JB or HM). Any discrepancies were resolved by a third reviewer

(SH).

Methodological quality was assessed using the quality rating scale

devised by Moncrieff and colleagues (Moncrieff 2001). All studies

were scored independently by two of the authors and those scoring

30 or more were deemed ”high“ quality, those scoring 23 or more

were deemed ”adequate.“ A sensitivity analysis was undertaken

including only those studies that scored in the ”high“ or ”adequate“

quality range.

All assessments of the quality of trials were performed

independently by the two reviewers (SM and HM).

Data Management:

Data was independently extracted by two out of three reviewers

(SM HM or JB) and discrepancies were resolved by a third

reviewer (SH). Included trials were analysed for the above quality

characteristics and for the following details. This information is

presented in the ”Table of Included Studies“ and provides a context

for discussing the reliability, internal and external validity and

generalisability of results:

Characteristics of the study participants

1. Age and any other recorded characteristics of participants

2. Other inclusion criteria eg. those with a high risk factor

3. Exclusion criteria

4. Methods used to define and diagnose study participants

Interventions used

1. Location of intervention programme eg. school or community

2. Type of intervention eg. CBT, educational

3. Inclusion/exclusion of parents

4. Type of placebo/control/comparison eg. wait-list, no

intervention, placebo

5. Type of change targeted

Measures:

1. Assessment instruments

2. Assessment intervals

Outcomes



Primary:

1. Depressive symptoms

2. Diagnosis of depressive disorder

Secondary:

3. Measure of general/academic/social adjustment

4. Cognitive style

5. Suicidal ideation and attempts

6. Information on any other outcomes related to the specific

intervention used

When aspects of methodology were unclear, or when the data were

in a form unsuitable for meta-analysis and trials appeared to meet

the eligibility criteria additional information was sought from the

principal author.

Data analysis:

Statistical analysis was performed in accordance with the guidelines

for statistical analysis in the Cochrane Reviewers Handbook.

Where possible the outcomes were pooled statistically.

Where possible, for dichotomous outcomes, the number of events

was extracted. Continuous data were also dichotomised using pre-

determined cut-off points identified as distinguishing between

those likely to have had an event and those not likely to have had

an event. These were derived from manuals where this information

was available. These data were pooled using a Risk Difference

(RD) with a 95% confidence interval. The risk difference was used

because it is straightforward to interpret and can be converted to

”number needed to treat“ easily.

For continuous outcomes, the means and standard deviations were

pooled and analysed using the standardised mean difference with a

95% confidence interval. Both the random and fixed effects model

were used in the calculation. When multiple outcome measures

were described in a single study, for the purposes of pooling results,

the single ’best available’ outcome measure was chosen for each

study, according to the method outlined by Hazell 2000. The

effect sizes were calculated using this best available outcome.

Because it was anticipated that there would be clinical

heterogeneity in the trialsidentifiedd for inclusion, sub-group

analysis to deal was this was planned at the outset.

Trials were analysed separately based on the following pre-specified

subgroups: 1. targeted or universal interventions; 2. educational or

psychological and two additional subgroups: 1. male or female; 2.

high risk or low risk at entry to study based on depression scores.

Heterogeneity in the results of the trials included in each subgroup

was assessed further by inspecting the scatter in the data points

and the overlap in their confidence intervals and, more formally

by checking the results of the chi-squared tests. Where there

was heterogeneity, the random effects model was used to pool

data. Possible reasons for the heterogeneity were discussed. The

effect of targeted, selected, and universal interventions, type of

intervention, age, and gender, of participants on results was

examined.

Sensitivity analysis was carried out to check the robustness of the

results based on the quality of the trials, the statistical model used

to calculate effects sizes, and the clarity of the definition of the

intervention used.

Data that could not be pooled statistically were described in the

results and discussion.

Timeline

A new search for RCTs will be performed two yearly and the review

updated accordingly.

D E S C R I P T I O N O F S T U D I E S

Of those studies retrieved in the search, 21 were eligible for in-

clusion, of which 13 had data suitable for extraction and pooling

in the meta-analysis. Eighteen of the studies were of psychological

interventions (Cardemil 2002a; Cardemil 2002b; Clarke 1993b;

Clarke 1995; Clarke 2001; Hains 1994; Jaycox 1994; Lamb

1998; Lowry-Webster 2001; Pattison 2001; Quayle 2001,Roberts

in press; Seligman 1999; Shatte 1997; Shochet 2001; Spence

2003; Thompson 2000; Yu 2002) one of an educational interven-

tion (Clarke 1993a) and two of psychoeducational interventions

(Gwynn 1987, Petersen 1997).

Psychological interventions

Ten studies were of prevention programmes implemented for uni-

versal populations i.e. designated population receives the pro-

gramme regardless of risk (Cardemil 2002a; Cardemil 2002b,

Clarke 1993b; Hains 1994; Lowry-Webster 2001; Pattison 2001;

Quayle 2001; Shatte 1997; Shochet 2001; Spence 2003). Eight

studies were of prevention programmes implemented to targeted

populations based on risk. Risk was defined as elevated depres-

sion scores in three studies (Clarke 1995; Lamb 1998; Roberts in

press), as having depressed parents in one study (Clarke 2001),

as having elevated depressive symptoms and reporting poor fam-

ily relationships in two studies (Jaycox 1994; Yu 2002), as scor-

ing in the bottom quartile of the Attributional Style Question-

naire i.e. pessimistic, in one study (Seligman 1999) and as school

failure or drop out in one study (Thompson 2000) Whilst their

programmes were implemented universally, some authors (Carde-

mil 2002a, Cardemil 2002b, Hains 1994, Shochet 2001, Spence

2003) analysed data based on high and low risk according to de-

pression scores at the start of the study.

The age of those young people included in each of the studies

was varied, with a total range from 4.7 years through to 19 years.

The ethnicity of young people included was American in nine

studies ( Clarke 1993b; Clarke 1995; Clarke 2001; Hains 1994;

Jaycox 1994; Lamb 1998; Seligman 1999; Shatte 1997; Thomp-

son 2000), Australian in six studies (Lowry-Webster 2001; Patti-

son 2001; Quayle 2001; Roberts in press; Shochet 2001; Spence

2003), Chinese in one study (Yu 2002), Latino in one study



(Cardemil 2002a) and African American in one study (Cardemil

2002b).

Various types of prevention programmes were employed. Eight

of the studies utilised programmes developed at the university of

Pennsylvania such as the original PENN Prevention Programme,

The PENN Resiliency Programme, and the PENN Optimism &

Life Skills Programme (Cardemil 2002a; Cardemil 2002b; Jaycox

1994; Pattison 2001; Quayle 2001; Roberts in press; Yu 2002;

Shatte 1997). Other prevention programmes included the ”Cop-

ing with Stress Course“ (Clarke 1995), ”The Stress Innoculation

Model“ (Hains 1994), ”The Resourceful Adolescent Program“

(RAP) (Shochet 2001), ”Problem Solving for Life“ (Spence 2003),

”Psychological Personal Growth Class“ (Thompson 2000) and the

”FRIENDS“ Program (Lowry-Webster 2001). Others were not

so formally described but stated that they were based on cogni-

tive therapy ( Lamb 1998; Seligman 1999; Clarke 1993b; Clarke

2001).

Various types of comparison conditions were used. Three studies

compared the prevention programme with a wait-list condition

(Hains 1994; Lowry-Webster 2001; Quayle 2001), eight with a

”no intervention“ condition (Cardemil 2002a; Cardemil 2002b;

Jaycox 1994; Lamb 1998; Seligman 1999; Spence 2003; Thomp-

son 2000; Yu 2002), three with a usual class condition (Clarke

1993b; Roberts in press; Shochet 2001), two with a ”usual care“

condition (Clarke 1995; Clarke 2001), and two with an attention

or placebo condition (Pattison 2001; Shatte 1997).

The number of sessions ranged from five (Clarke 1993b) to 180

sessions (Thompson 2000) and were of varying length. Most pro-

grammes were manualised except for one (Thompson 2000), in

two it was unclear (Lamb 1998; Spence 2003). The programmes

were delivered by clinicians or graduate level students of psychol-

ogy or psychiatric nurses in nine studies (Cardemil 2002a; Carde-

mil 2002b; Clarke 2001; Hains 1994; Jaycox 1994; Lamb 1998;

Seligman 1999; Shatte 1997; Shochet 2001), by teachers in three

studies (Clarke 1993b; Lowry-Webster 2001; Spence 2003), by

teachers and counsellors in one study (Thompson 2000), by school

counsellors and psychologists in one study (Clarke 1995), and by

trained facilitators in four studies (Pattison 2001; Quayle 2001;

Roberts in press; Yu 2002).

Educational intervention

The study was of a universal intervention delivered by health class

teachers to 9th - 10th grade students, average age 15 years (Clarke

1993a) Participants were from the United States of America. The

intervention included three 50-minute manualised lectures de-

livered by Health Education Teachers (Clarke 1993a) which was

compared with a usual class condition.

Psychoeducational interventions

One psychoeducational study was of a manualised 16 session in-

tervention delivered by psychologists or clinically trained graduate

students to sixth to seventh grade students with elevated depres-

sion scores (Petersen 1997) and the other was an 8 session pro-

gramme targeted to children aged 9-11, whose parents had been

separated for at least one year (Gwynn 1987). It is unclear who de-

livered the programme in the latter study. The comparison groups

received no intervention. Participants were from the United States

of America in one study (Gwynn 1987) and the country was not

reported in the other (Petersen 1997)

For a full description of each study, see Table of Included Studies.

M E T H O D O L O G I C A L Q U A L I T Y

Psychological interventions (18 studies)

The size of studies varied from 21 (Hains 1994) to 1500 (Spence

2003).

Allocation concealment was not reported in most studies, but was

clearly done in one study (Clarke 2001), and clearly not done in

three studies (Jaycox 1994; Roberts in press; Seligman 1999).

Blinding of assessors was undertaken in only two studies (Roberts

in press; Seligman 1999), was clearly not undertaken in one study

(Clarke 2001), and was not reported in the remainder of the stud-

ies.

Subjects were clearly not blinded in three studies (Clarke 1995;

Clarke 2001; Seligman 1999), and blinding of subjects was not

reported in the remainder of studies.

Most studies had clear diagnostic criteria, or at the very least clearly

described inclusion criteria. Those that did not included Cardemil

2002a; Cardemil 2002b; Clarke 1993b; Pattison 2001.

Adherence to the prevention programme was maintained with

integrity of adherence checked in 15 studies (Cardemil 2002a;

Cardemil 2002b; Clarke 1993b; Clarke 1995; Clarke 2001; Hains

1994; Jaycox 1994; Lowry-Webster 2001; Quayle 2001; Roberts

in press; Seligman 1999; Shatte 1997; Shochet 2001; Spence 2003;

Yu 2002), and was not reported in three studies (Lamb 1998;

Pattison 2001; Thompson 2000).

Times for follow-up varied from those limited to immediate post-

intervention (Gwynn 1987; Lamb 1998; Lowry-Webster 2001;

Roberts in press; Thompson 2000), those that reported short-term

outcomes up to 8 months (Cardemil 2002a; Cardemil 2002b;

Clarke 1993b; Hains 1994; Pattison 2001; Quayle 2001; Yu 2002)

and those that reported a longer term outcome of 10-36 months

(Clarke 1995; Clarke 2001Jaycox 1994; Seligman 1999; Shatte

1997; Shochet 2001; Spence 2003).

All the studies reported depression scores before and after the in-

tervention, however one study included only girls (Quayle 2001)

and in one study scores were for high risk versus low risk only

(Hains 1994).

In five studies it was stated that diagnoses of depressive disorder

were measured (Clarke 1995; Clarke 2001; Quayle 2001; Selig-

man 1999; Spence 2003). An intention-to-treat analysis was un-

dertaken in three studies (Clarke 1995; Clarke 2001; Shatte 1997),



was not undertaken in one study ( Lamb 1998) and was unclear

or not reported in the remainder of studies.

A more detailed analysis of the quality of the studies was under-

taken using the rating scale devised by Moncrieff et al (Moncrieff

2001). Four studies had a Moncrieff quality rating scores of 30

or more (Clarke 2001; Shatte 1997; Seligman 1999; Yu 2002),

eight had scores of 23 to 29 (Cardemil 2002a; Cardemil 2002b;

Clarke 1993b; Clarke 1995; Jaycox 1994; Lowry-Webster 2001;

Roberts in press; Spence 2003) and six had scores below 22 ( Hains

1994; Lamb 1998; Pattison 2001; Quayle 2001; Shochet 2001;

Thompson 2000).

Educational interventions (1 study)

Allocation concealment, blinding of subjects and assesors and ad-

herence to the programme were not reported (Clarke 1993a). In-

clusion criteria were unclear. Depression scores were reported by

gender only. Overall the study scored 24 on the scale by Moncrieff

(Moncrieff 2001) and was therefore considered ”adequate“.

Psychoeducational interventions (2 studies)

Allocation concealment, blinding of subjects and assesors and ad-

herence to the programme were not reported (Gwynn 1987; Pe-

tersen 1997). Follow-up was limited to immediately post-inter-

vention in one study (Gwynn 1987) and was long-term in the

other (Petersen 1997). Inclusion criteria were unclear (Petersen

1997). Data on diagnosis from Petersen could not be pooled be-

cause they were not reported. Both these studies scored below 22

for quality on Moncrieff ’s rating scale (Moncrieff 2001).

For a full description of the quality of included studies, see the

Table of Included Studies.

R E S U L T S

Twenty one studies of depression prevention programmes were

identified. Of these, 13 had data in a form that that could be ex-

tracted and pooled; nine of universal and five of targeted interven-

tions. Twelve of these studies compared intervention and no-in-

tervention groups and only two had attention or placebo compar-

ison groups. Only one of the studies reported the effects of an ed-

ucational intervention (Clarke 1993a) and for this study the data

were only available by gender and could only be included in this

sub-group analysis. The educational intervention was not shown

to be effective. Data were not available in a form that could be

pooled for the studies of psychoeducational intervention Gwynn

1987; Petersen 1997). The results below therefore apply to psy-

chological interventions only, except for the sub-group analysis by

gender where the results from the educational programme have

been included for completeness.

Combined analyses

Studies were separated into those that had a placebo or active

comparison group and those that did not. Analyses were then

carried out in further pre-determinded sub-groups.

A. Compared with active attention or placebo

There was no evidence of effectiveness in the two studies with an

attention or placebo comparison group at any time points.

B. Compared with no intervention, wait-list, or usual care.

1. Targeted vs universal programmes

Depression scores

In the nine studies that could be included in this analysis five

were of targeted interventions (Clarke 1995; Clarke 2001; Roberts

in press; Seligman 1999; Yu 2002), three of universal (Cardemil

2002a; Cardemil 2002b; Spence 2003) and one was universal in

design in that it was delivered to the whole of one class at school

regardless of risk, but was delivered to only girls (Quayle 2001).

The only evidence of effectiveness was seen at immediate follow-

up, when targeted programmes reduced depression with a stan-

dardised mean difference (SMD) of -0.26 and a 95% confidence

interval (CI) of -0.40 to -0.13. Universal programmes were not

shown to be effective (SMD -0.21, CI -0.48, 0.06) but a signifi-

cant effect remained when data from both targeted and universal

programs were pooled (SMD -0.26, CI -0.36, -0.15). At follow-

up, although individual studies showed effectiveness at different

times, pooled data showed no significant effect for either univer-

sal or targeted programmes at any other time point except at 36

months when one study of a targeted intervention showed a sig-

nificant difference between groups (SMD -0.29, CI -0.56, -0.01)

(Seligman 1999).

Diagnosis of depressive disorder

Pooling data from three studies of targeted interventions (Clarke

1995; Clarke 2001; Seligman 1999) indicated significant differ-

ences in diagnoses of depressive disorder between groups imme-

diately after intervention with a risk difference (RD) of -0.13 and

95% confidence interval (CI) -0.22 to -0.05. A significant ef-

fect was also reported for two studies of universal interventions

(RD -0.08, CI -0.15, -0.01) (Cardemil 2002a; Cardemil 2002b).

Pooled data from both targeted and universal interventions showed

effectiveness (RD -0.10, CI -0.15, -0.05). At three to six month

follow-up, one study of a targeted intervention (Clarke 1995)

and three of universal interventions (Cardemil 2002a; Cardemil

2002b; Quayle 2001) failed to show a significant effect on di-

agnoses. At twelve months, two studies of targeted interventions

(Clarke 1995; Clarke 2001) reported a decrease in diagnosis of

depressive disorder (RD -0.12 CI -0.24, -0.01), while two stud-

ies of universal interventions did not (Cardemil 2002a; Cardemil

2002b). Pooling targeted and universal interventions at 12 months

showed no overall effect. One study at 24 months (Clarke 2001)

and one study at 36 months (Seligman 1999) showed no signifi-

cant difference.

2. Educational vs psychological programmes

The same nine studies reported above were included in this sub-

group analysis (Cardemil 2002a; Cardemil 2002b, Clarke 1995;



Clarke 2001; Quayle 2001; Roberts in press; Seligman 1999;

Spence 2003; Yu 2002). All were psychological interventions. Data

from educational programmes was separated into data for boys

and girls (Clarke 1993a) or was in a form that could not be pooled

(Gwynn 1987). The results from this analysis were therefore iden-

tical to those reported above with significant effect for psycholog-

ical interventions (SMD -0.26, CI -0.36, -0.15).

3. Effectiveness for male vs female

Depression scores

In eight studies outcome by gender was reported or authors pro-

vided us with the data (Cardemil 2002a; Cardemil 2002b; Clarke

1993a; Clarke 1993b; Clarke 1995; Clarke 2001; Quayle 2001;

Spence 2003). One of these studies investigated the effect of edu-

cational (Clarke 1993a) and seven of psychological interventions

(Clarke 1993b; Cardemil 2002a; Cardemil 2002b; Clarke 1995;

Clarke 2001; Quayle 2001; Spence 2003). The educational inter-

ventions were not shown to be effective for either gender (Clarke

1993a). The psychological interventions reporting outcomes for

gender showed conflicting results. Immediately after intervention,

depression scores were reduced for boys (SMD -0.24, CI -0.46,

-0.03) but not for girls (SMD -0.16, CI -0.36, 0.05) but pooled

data from both showed effectiveness (SMD -0.20, CI -0.35, -0.04).

There was statistical heterogeneity for both groups in this analysis

(chi-square 35.77, degrees of freedom (df ) 14, p = 0.0011). Three

to six month follow-up data were reported in six studies (Carde-

mil 2002a; Cardemil 2002b; Clarke 1993a; Clarke 1993b; Clarke

1995; Quayle 2001), twelve month data in five studies (Cardemil

2002a; Cardemil 2002b; Clarke 1995; Clarke 2001; Spence 2003)

and twenty four month data in three studies Cardemil 2002a;

Cardemil 2002b; Clarke 2001). At all follow-up points no effect

for either gender was reported in any of these studies.

Depressive disorder

In contrast to the results on depression scores, the six studies that

reported depressive disorder by gender (Cardemil 2002a; Cardemil

2002b; Clarke 1995; Clarke 2001; Quayle 2001; Seligman 1999)

showed effectiveness immediately after intervention for girls (RD

-0.14, CI -0.23, -0.04) rather than boys (RD -0.07, CI -0.15,

0.01). These results are less heterogeneous than the results for the

depression scores (chi-square 10.69, df = 10, p = 0.38). At follow-

up there was no evidence of efficacy at any time point.

4. High risk vs low risk in universal programmes

Depression scores

Five studies split their results into high and low risk groups on the

basis of depression scores at entry to the study (Cardemil 2002a;

Cardemil 2002b; Hains 1994; Roberts in press; Spence 2003). Im-

mediately after intervention two studies, (Cardemil 2002a; Spence

2003) showed clear benefit for both high and low risk groups while

the other three did not show effectiveness for either group. Pooled

data showed significant effectiveness for both the low risk group

(SMD -0.30, CI -0.43,-0.17) and the high risk group (SMD -0.37,

CI -0.70,-0.04). At three to six month follow-up, although one

study reported a significant decrease in scores for the high risk

group (Cardemil 2002a) on pooling data from the three studies

that reported data at this time point (Cardemil 2002a; Cardemil

2002b; Roberts in press) there was no significant effect for either

high or low risk group. A persistent effect to twelve months was

reported by Cardemil (Cardemil 2002a) but pooling data from

three studies (Cardemil 2002a; Cardemil 2002b; Spence 2003)

showed no overall effect. Twenty four month data were available

for two studies (Cardemil 2002a; Cardemil 2002b). A persistent

effect was reported in the high risk group in one study (Cardemil

2002a) but again pooling data showed no overall effect.

Depressive disorder

Data on depressive disorder by risk group was reported at all time

points in two studies (Cardemil 2002a; Cardemil 2002b) and in

the high risk group only at twelve months in one study (Spence

2003). A reduction in depressive disorder immediately after inter-

vention was reported in one study (Cardemil 2002b) but other-

wise no effect on diagnosis of depression was found.

Other outcomes

Due to a paucity of data that could be extracted on other out-

comes, results were not able to be sensibly pooled so they were

included in additional tables. Six studies, both universal and tar-

geted, utilising psychological and education interventions (Gwynn

1987; Hains 1994; Lowry-Webster 2001; Pattison 2001; Roberts

in press; Seligman 1999) reported the effect of the intervention

programme on anxiety. Various measures were used and four of

the six studies reported a significant reduction in symptoms (see

Table 02). All four of these studies compared the intervention pro-

gramme with no intervention.

A number of other outcomes were reported (see Table 01). The ma-

jority of these other outcomes were cognitive variables. Six studies

reported an effect on targeted and universal psychological inter-

ventions compared with no intervention reported on attributional

style (Cardemil 2002a; Cardemil 2002b; Quayle 2001; Roberts in

press; Seligman 1999; Yu 2002). Three of these reported a signifi-

cant effect of the intervention programme in reducing a pessimistic

attributional style. One of the three studies reported that the in-

tervention resulted in less negative thinking compared with no in-

tervention (Cardemil 2002a). Two studies of targeted psycholog-

ical interventions reported reduced hopelessness compared with

no intervention (Cardemil 2002a; Seligman 1999). Two studies

reported that the intervention group had significantly improved

styles of coping compared with the no intervention group (Lamb

1998; Petersen 1997). Two studies reported that self esteem was

significantly improved, and remained so at six months follow-up

compared with no intervention (Cardemil 2002a; Quayle 2001)

and one study found no effect (Seligman 1999).

Sensitivity analyses



Sensitivity analysis was carried out on studies rated as ”adequate“

or ”high“ quality, that is with a score over 22, based on the scale by

Moncrieff et al (Moncrieff 2001). Eleven studies had data in a form

that could be included in this analysis (Cardemil 2002a; Carde-

mil 2002b; Clarke 1993a; Clarke 1993b; Clarke 1995; Clarke

2001; Roberts in press; Seligman 1999; Shatte 1997; Spence 2003;

Yu 2002). One of these compared intervention with attention or

placebo (Shatte 1997). Findings reported above were unchanged

in this analysis.

Heterogeneity

Because it was anticipated that there would be heterogeneity in the

trials identified for inclusion, sub-group analysis to deal was this

was planned at the outset, hence analysis by intervention (educa-

tional vs psychological) and population (targeted vs universal). It

was anticipated that despite this there could still be heterogeneity

due to the different programmes, so this was checked. The only

analyses in which there was significant statistical heterogeneity was

the sub-group analysis by gender. For both boys and girls there

was variability in the response to different programmes. There is

no ready explanation for these differences.

Studies excluded from the meta-analysis

There were a number of studies excluded from the meta-analysis.

The seminal article by Jaycox and co-workers (Jaycox 1994) and

the follow-up reports were not included. Because findings from

this study are widely quoted and work from this group has inspired

many of the studies in this review, it is worth considering this study

in some detail. Originally designed as a five year prospective study,

three versions of a depression prevention programme, one with a

cognitive focus, one with a social problem-solving focus, and one

which was a combination of the two, were combined and com-

pared with a no-intervention control group. Recruitment to the

study had the potential for large and uncontrolled bias. This study

did not randomise participants to intervention and control con-

ditions. Subjects were a high risk group of 69 children who were

recruited after screening from a group of 174 children whose par-

ents responded to a letter describing the study. The letter had been

sent to parents of approximately 900 children from one school

district. The control group consisted of 50 at risk students out of

88 recruited from a different school district with a pool of approx-

imately 700 children, and a further 24 ”wait list“ children. The

follow-up to two and three years is reported by Gillham (Gillham

1995; Gillham 1999) and compares the two recruited groups but

does not include the wait-list controls. While the results of this

study show significant reduction in depression with effects per-

sisting to two years, the results must be interpreted in light of the

methodological shortcomings and could not be included within

the meta-analysis.

Results of the universal programme entitled the Resourceful Ado-

lescent Programme (RAP) (Shochet 2001) was not included, as

this was a cohort study rather than a randomised trial.

The trial by Beardslee was not included as both groups in the study

received interventions (Beardslee 1997).

The study of 594 students who participated in a universal anxi-

ety prevention programme (Lowry-Webster 2001) FRIENDS was

randomised by school, and analysis of data was on individual stu-

dents. Otherwise the quality is rated ”adequate“ based on the scale

by Moncrieff (Moncrieff 2001). Results from this study were not

pooled as the number of participants who completed measures is

unclear.

A study of a psycho-educational programme (Petersen 1997) was

not included, as although participants were reported to have been

randomised into intervention and non-intervention groups, the

baseline population is unclear and described as ”approximately

half“ of students in two school districts. The authors report that

they did not attempt to ensure that they involved all participants

at each time of assessment, attrition is unclear and deemed by the

authors ”not a useful concept in this study.“

Means and standard deviations of depression scores were not re-

ported, so results could not be pooled in the randomised controlled

study of the effectiveness of cognitive skills training delivered in

schools by nurses (Lamb 1998).

An educational intervention targeted to children of separated par-

ents was not a randomised study, and means and standard devia-

tions for depression scores were not reported (Gwynn 1987).

In the study of an indicated prevention programme to reduce de-

pression and suicide risk described by Thompson’s group (Thomp-

son 2000), randomisation procedures are unclear. There were three

comparison groups, two experimental and one control. Different

refusal rates at the first stage of the study were high with 30% of

intervention group and 16% of controls refusing to participate.

The scale used to measure depression was adapted from the CES-

D and validated only by unpublished data on teacher ratings of

sudent depression. Means and standard deviations of depression

scores were not given and the analysis in the study was concerned

with the mediating variables of personal control and peer group

support on suicide risk behaviours. No data could be extracted to

test whether or not depression scores had fallen following inter-

vention.

D I S C U S S I O N

Although there are increasing data on the efficacy of depression

prevention programmes, and the meta-analysis shows short-term

reduction in depressive symptoms and diagnosis of depressive

illness, this is in studies with no active comparison condition.

The importance of considering the placebo effect in trials of psy-

chotherapy is well argued by Shapiro and Shapiro (Shapiro 1997),

and is particularly important in studies of depression, where it is

recognised that the placebo effect is high. There were only two

studies which incorporated an active comparison condition or a



placebo. These did not show efficacy. One (Shatte 1997) was rated

highly in terms of quality, however, although the comparison con-

dition was described as a placebo, it incorporated active therapeu-

tic elements, so that the lack of difference between groups is not

surprising. The other study was inadequately powered to detect a

difference, and quality was ”inadequate“ on the Moncrieff scale.

It should be noted that the change in depression scores is small.

However, in those studies where data are available on reduction

of onset of depressive disorder, the overall risk difference after in-

tervention translates to ”numbers needed to treat“ (NNT) of 10

(NNT is the reciprocal of the risk difference). In a prevention pro-

gramme these results are very encouraging. Reduction in diagnosis

of depression is shown for both targeted interventions with NNT

of 8 and universal interventions where the risk difference trans-

lates to NNT of 13. Where data are available for high and low

risk young people from one population, the magnitude of change

is similar for both groups. The most effective study reported to

date is the targeted programme by Clarke (Clarke 2001), where

the initial effect size of -0.46 is associated with an intitial risk dif-

ference of -0.22 and NNT 5. Effects in this study persisted to

twelve months with an effect size of -0.53 risk difference is -0.17

and NNT is 6. This gives an indication of what may be achieved,

although the method of identification of young people for this

targeted programme, involving contact through parents identified

with mood disorders, would not be a practical public health ini-

tiative.

There were few educational programmes in the review. This may

reflect the focus of the review on depression and depressive disor-

ders. The educational programmes that have been reported show

little effectiveness, however they have been short in duration com-

pared with the psychological interventions.

There are conflicting data on effects of the interventions on boys

and girls. There is no readily available explanation for this. There

are limited data on the effect of programmes in different cultural

groups, with encouraging results reported by Cardemil in a Latino

group, and no effectiveness in an African American group (Carde-

mil 2002a; Cardemil 2002b).

Whilst studies included a range of other outcomes, these were not

consistently measured or reported across studies, nor were data

generally reported in a form that could be pooled for analysis

in the review. Overall, it does appear that depression prevention

programmes may have some effect on anxiety (Table 02) and a

variety of cognitive variables implicated in the development and

maintenance of depressive disorders such as negative thinking, low

self esteem, hopelessness, attributional style, and problem solving

(Table 01).

Limitations

Two fundamental issues limit the confidence in the findings from

these studies. First, allocation concealment is unclear in all in-

cluded studies but one. Secondly, the lack of placebo or attention

comparison groups makes it impossible to ensure that the findings

are not due simply to the research procedure. The reduction in

depressive symptoms in studies with no intervention comparison

groups is not replicated in studies which utilise a placebo group.

However, this may be due to study design issues discussed above.

Another concern is the method used to measure depression. De-

pression rating scales are widely used and most studies report

changes in depression scores only, with a minority reporting in-

cidence of depressive disorder following intervention. Depression

rating scales are problematic. The data generated are extremely

variable, with standard deviations as large as the reported means

in many studies. Doubt has also been raised about the validity of

the use of the Children’s Depression Inventory, one of the most

widely used depression rating scales as a screening and assessment

tool (Matthey 2002). Furthermore, it is depressive disorder that

has been most robustly linked to disability and cost (Murray 1996)

and it is the prevention of disorder with its resulting morbidity

and mortality which is critical.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

The results of this review are encouraging, but the implementation

of depression prevention programmes would be premature until

further data are available which compare intervention to an atten-

tion/placebo group, and until a lasting effect for the programmes

is demonstrated.

The issue of whether to study targeted or universal programmes

remains unresolved. The effect of depression prevention pro-

grammes appears to be similar for both, and in both high and low

risk groups in universal interventions. Given the practical diffi-

culties inherent in implementing a targeted programme, pursu-

ing the implementation of universal depression prevention pro-

grammes is warranted. In prevention programmes, it is often the

asymptomatic group which yield more cases than the sub-syndro-

mal group because it is a larger group (Rose 1992).

Implications for research

The cost of depressive illness is high, both on an individual ba-

sis and to society. An effective depression prevention programme

would reduce individual morbidity. It may also be cost effective.

This is a fruitful area for further research. Preliminary data sug-

gest short-term effectiveness, with some well-conducted studies

showing evidence of longer term effect. This should be confirmed

in well-designed placebo controlled studies. Ideally the placebo

should be credible and resemble therapy except for the specific

components postulated to be effective on theoretical grounds. As

it is depressive disorder that is linked to disability, it is important

to collect data on depressive diagnoses at follow-up.

To date it is short-term effects have been found most consistently.

It would be worth investigating the effect of booster sessions to



see if long-term reductions in symptoms are possible. Once there

is robust evidence of efficacy, studies on effectiveness beyond the

research setting will be needed.

N O T E S

May 2005 - Two comparisons and associated outcomes that do

not currently contain any data have been removed (Psycholog-

ical/educational interventions versus placebo/attention/other in-

tervention at 24 months and 36 months).

This review is in the process of being updated.

P O T E N T I A L C O N F L I C T O F

I N T E R E S T

Drs Merry and McDowell and Ms J Bir have been involved in a

study of a depression prevention programme. The results of this

will be included in the update of this review.

A C K N O W L E D G E M E N T S

The advice of Prof P Hazell is gratefully acknowledged. The work-

shop run at the Cochrane Centre in Melbourne was extremely

helpful and we would like to thank Dr Sally Green and centre staff

for orgainsing this.

S O U R C E S O F S U P P O R T

External sources of support

• Health Research Council NEW ZEALAND

Internal sources of support

• University of Auckland NEW ZEALAND

R E F E R E N C E S

References to studies included in this reviewCardemil 2002a {published data only}

Cardemil EV, Reivich KJ, Seligman M. The prevention of depressive

symptoms in low-income minority middle school students. Preven-

tion and Treatment 2002;5:Article 8.

Cardemil 2002b {published data only}

Cardemil EV, Reivich KJ, Seligman M. The prevention of depressive

symptoms in low-income minority middle school students. Preven-

tion and Treatment 2002;5:Article 8.

Clarke 1993a {published data only}

Clarke GM, Hawkins W, Murphy N, Sheeber L. School-based pri-

mary prevention of depressive symptomatology in adolescents: Find-

ings from two studies. Journal of Adolescent Research 1993;8(2):183–

204.

Clarke 1993b {published data only}

Clarke GM, Hawkins W, Murphy N, Sheeber L. School-based pri-

mary prevention of depressive symptomatology in adolescents: Find-

ings from two studies. Journal of Adolescent Research 1993;8(12):183–

204.

Clarke 1995 {published data only}

Clarke GN, Hawkins W, Murphy M, Sheeber LB, Lewinsohn PM,

Seeley JR. Targetted prevention of unipolar depressive disorder in

an at-risk sample of high school adolescents: A randomized trial of



a group cognitive intervention. Journal of the American Academy of

Child and Adolescent Psychiatry 1995;34(3):312–21.

Clarke 2001 {published data only}

Clarke GN, Hornbrook M, Lynch F, Polen M, Gale J, Beardslee

W, et al. A randomized trial of a group cognitive intervention for

preventing depression in adolescent offspring of depressed parents.

Archives of General Psychiatry 2001;58(12):1127–34.

Gwynn 1987 {published data only}∗ Gwynn C, Brantley H. Effects of a divorce group intervention for

elementary school children. Psychology in the Schools 1987;24:161–4.

Hains 1994 {published data only}

Hains A, Ellman S. Stess Inoculation training as a preventative in-

tervention for high school youths. Journal of Cognitive Psychotherapy:

An International Quarterly 1994;8(3):219–32.

Jaycox 1994 {published data only}

Gillham J, Reivich K. Prevention of depressive symptoms in school-

children. Psychological Science 1999;10(5):461–2.

Gillham J, Reivich K, Jaycox L, Seligman M. Prevention of depres-

sive symptoms in school-children: Two year follow-up. Psychological

Science 1995;6(6):343–51.

Jaycox LH, Reivich KJ, Gillham J, Seligman M. Preventing depressive

symptoms in school children. Behavior Research and Therapy 1994;

32:801–16.

Zubernis L, Cassidy K, Gillham J, Reivich K, Jaycox L. Prevention

of depressive symptoms in preadolescent children of divorce. Journal

of Divorce & Remarriage 1999;30(1/2):11–36.

Lamb 1998 {published data only}

Lamb JM, Puskar KR, Sereika SM, Corcoran M. School based inter-

vention to promote coping in rural teens. American Journal of Ma-

ternity and Child Nursing 1998;23(4):187–94.

Lowry-Webster 2001 {published data only}∗ Lowry-Webster H, Barrett P, Dadds M. A universal prevention trial

of anxiety and depressive symptomatology in childhood: Preliminary

data from an Australian study. Behaviour Change 2001;18(1):36–50.

Pattison 2001 {published data only}

Pattison C, Lynd-Stevenson R. The prevention of depressive symp-

toms in children: The immediate and long-term outcomes of a

school-based program. Behaviour Change 2001;18(2):92–102.

Petersen 1997 {published data only}

Petersen A, Leffert A, Graham B, Alwin J, Ding S. Promoting men-

tal health during the transition into adolescence. In: SchulenbergJ,

MaggsJL, HierrelmannAK editor(s). Health Risks and Developmen-

tal Transitions During Adolescence. New York: Cambridge University

Press, 1997:471–97.

Quayle 2001 {published data only}

Quayle D, Dziuraweic S. The effect of an optimism and lifeskills

progam on depressive symptoms in preadolescence. Behaviour

Change 2001;18(4):194–203.

Roberts in press {published and unpublished data}

Roberts C, Kane R, Thompson H, Bishop B, Hart B. The prevention

of depressive symptoms in rural school children: A randomized con-

trolled trial. Journal of Consulting and Clinical Psychology in press.

Seligman 1999 {published data only}

Seligman ME, Schulman P, DeRubies RJ, Hollon SD. The preven-

tion of depression and anxiety. Prevention and Treatment 1999; Vol.

2, issue Article 8.

Shatte 1997 {published data only}∗ Shatte A J. Prevention of depressive symptoms in adolescents: Issues

of dissemination and mechanisms of change. Dissertation Abstracts

International: Section B: The Sciences and Engineering 1997; Vol.

57, issue 11-B.

Shochet 2001 {published data only}

Shochet IM, Dadds MR, Holland D, Whitefield K, Harnett PH,

Osgarby SM. The efficacy of a universal school-based program to

prevent adolescent depression. Journal of Clinical Child Psychology

2001;30(3):303–15.

Spence 2003 {published data only}

Spence S, Sheffield J, Donovan C. Preventing adolescent depression:

An evaluation of the Problem Solving for Life Program. Journal of

Consulting and Clinical Psychology 2003;71(1):3–13.

Thompson 2000 {published data only}

Thompson E, Eggert L, Herting J. Mediating effects of an indicated

prevention program for reducing youth depression and suicide risk

behaviors. Suicide and Life-Threatening Behavior 2000;30(3):252–

71.

Yu 2002 {published data only}

Yu DL, Seligman M. Preventing depressive symptoms in chinese

children. Prevention & Treatment 2002; Vol. 5.

References to studies excluded from this review

Asarnow 2002∗ Asarnow J, Scott C, Mintz J. A combined cognitive-behavioral ed-

ucation intervention for depression in children: A treatment devel-

opment study. Cognitive Therapy and Research 2002;26(2):221–9.

Beardslee 1993

Beardslee W, MacMillan H. Preventive intervention with the children

of depressed parents. Psychoanalytic Study of the Child 1993;48:249–

76.

Beardslee 1997

Beardslee W, Versage E, Wright E, Salt P, Rothberg P, Drezner K, et al.

Examination of preventive interventions for families with depression:

Evidence of change. Development and Psychopathology 1997;9:109–

30.

∗ Beardslee WR, Wright E, Salt P, Drenzer K, Gladstone T, Versage

E, et al. Examination of childrens responses to two preventive inter-

vention strategies over time. The Journal of the American Academy of


Buhs 1997∗ Buhs L. Program evaluation of the American Indian life skills de-

velopment curriculum with American Indian and Caucasian Adoles-

cents. Dissertation Abstracts International: Section B: The Sciences &

Engineering 2000;61(1-B):523.

DeSouza 1995

DeSouza E, Koller S, Hutz C, Forster L. Preventing depression among

Brazilian street children. International Journal of Psychology 1995;29

(2):261–5.



DiFilippo 2000

DiFilippo J, Overholser JC. Suicidal ideation in adolescent psychi-

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Eggert 1995∗ Eggert L, Thompson E, Herting J, Nicholas L. Reducing suicide

potential among high-risk youth: Tests of a school-based prevention

program. Suicide and Life Threatening Behavior 1995;25(2):48–64.

Eggert 2002∗ Eggert L, Thompson E, Randell B, Pike K. Preliminary effects of

brief school-based prevention approaches for reducing youth suicide-

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and Adolescent Psychiatric Nursing 2002;25(2):96.

Falloon 1992

Falloon IR, Shanahan W, Laporta M. Prevention of major depressive

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Fava GA, Rafenelli C, Cazzaro M, Conti S, Grandi, S. Well-being

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Freres 2002∗ Freres D, Gillham, J, Reivich, K, Shatte A. Preventing depressive

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International Journal of Emergency Mental Health 2002;4(1):31–40.

Hannan 2000∗ Hannan A P, Rapee R, Hudson J. The prevention of depression in

children: A pilot study. Behavior Change 2000;17(2):78–83.

Harper 1999∗ Harper D. A study of adolescent depression, suicide, self-esteem,

and family strengths in special education female students compared

with regular education female students. Dissertation Abstracts Inter-

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Keeler 2000∗ Keeler K. Fresh Start: Treatment effectiveness in a collaborative

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6368.

Kellam 1994

Kellam SG, Rebok GW, Mayer LS, Ialongo N, Kalodner CR. De-

pressive symptoms over first grade and their responses to a develop-

mental epidemiologically based preventive trial aimed at improving

achievement. Development and Psychopathology 1994;6:463–81.

Kroll 1996

Kroll L, Harrington R, Jayson D, Fraser J, Gowers S. Pilot study of

continuation cognitive-behavioral therapy for major depression in

adolescent psychiatric patients. Journal of the American Academy of


Munoz 1995

Munoz RF, Ying Y, Bernal G, Perez-Stable EJ, Sorenson L, Hargreave

WA net al. Prevention of depression with primary care patients: A

randomized controlled trial. American Journal of Community Psychol-

ogy 1995;23(2):199–222.

O’Dea 2000∗ O’Dea J, Abraham, S. Improving the body image, eating attitudes,

and behaviors of young male and female adolescents: A new educa-

tional approach that focuses on self-esteem. International Journal of

Eating Disorder 2000;28:43–57.

Peden 2001

Peden AR, Rayens MK, Hall LA, Beebe LH. Preventing depression in

high-risk college women: A report of an 18-month follow-up. Journal

of American College Health 2001;49(6):299–306.

Pfeffer 2002∗ Pfeffer C, Jiang H, Kakuma T, Hwang J, Metsch M. Group in-

tervention for children bereaved by suicide of a relative. Journal of

the American Academy of Child and Adolescent Psychiatry 2002;41(5):

505–13.

Pushkar 1997∗ Pushkar K, Lamb J, Tusai-Mumford K. Teaching kids to cope: A

preventive mental health nursing strategy for adolescents. Journal of

Child and Adoelscent Psychiatric Nursing 1997;10(3):18–28.

Randell 2001∗ Randell B, Eggert L, Pike K. Immediate post intervention effects

of two brief youth suicide prevention interventions. Suicide and Life

Threatening Behavior 2001;31(1):41–61.

Shechtman 1993∗ Shechtman Z. School adjustment and small group therapy: An

Israeli study. Journal of Counseling and Development 1993;72:77–81.

Thompson 2001∗ Thompson E, Eggert L, Randell B, Pike K. Evaluation of indicated

suicide risk prevention approaches for potential high school dropouts.

American Journal of Public Health 2001;19(5):742–52.

Vostanis 1998

Vostanis P, Feehan C, Grattan E. Two-year outcome of children

treated for depression. European Child & Adolescent Psychiatry 1998;

7:12–18.

Zubernis 1999∗ Zubernis L, Cassidy K, Gillham J, Reivich K, Jaycox L. Prevention

of depressive symptoms in preadolescent children of divorce. Journal

of Divorce and Remarriage 1999;30(1/2):11–36.

References to studies awaiting assessment

Olmedo 2000

Olmedo M, del Barrio V, Santed M. Gender and previous emotion

as predictors of changes in depression and anxiety in adolescence

[Sexo y emocion previa como predictores del cambio en depression

y ansiedad en la adolescencia]. Ansiedad y Estres 2000;6(1):47–60.

References to ongoing studies

Gillham in press

Gillham J, Reivich K, Shatte A, Lascher M, Litzinger S, Freres D, et

al. School-based prevention of depressive symptoms. In press.

Hamilton in press

Hamilton J, Gillham J, Patton K. Preventing depressive symptoms

in the primary care setting. In press.

Kowalenko

Kowalenko N, Rapee R, Simmons J, Wignall A, Hoge R, Whitefield

K, et al. Short-term effectiveness of a school-based early intervention

program for adolescent depression. Ongoing.



Merry 2002

Merry SM, McDowell H, Wild CJ, Bir J, Cunliffe R. A prospec-

tive randomized placebo controlled trial of a school-based depression

prevention program. Ongoing.

Patton

Patton G, Bond L, Carlin J, Thomas L, Butler H. Glover S, et al.

Promoting social inclusion in secondary schools: a cluster randomised

trial. Ongoing.

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Beardslee WR, Salt P, Porterfield K, Rothberg PC, van de Velde P,

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Beardslee 1993a

Beardslee WR, MacMillan HL. Preventive intervention with the chil-

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∗Indicates the major publication for the study

T A B L E S

Characteristics of included studies

Study Cardemil 2002a

Methods Study design: Randomised Controlled Trial

Randomisation type: Not reported.

Method of allocation: Not reported.

Concealment of allocation: Not reported.

Blinding: (subjects): Not reported.

Blinding (assessors): Not reported.

Power calculation: Not reported.

Source of subjects described: Yes. Representative sample recruitment: Yes.



Characteristics of included studies (Continued )

Use of diagnostic criteria (or clear specification of inclusion criteria): No.

Intervention integrity: Bi-weekly supervision and sessions audiotaped.

Outcome measures described clearly or use of validated instruments: Yes.

Intent to treat analysis: Not reported.

Follow-up assessment points: 3 and 6 months.

No. approached=75

No.agreed to participate=65.

No. randomised=65.

No. started trial=49.

No dropped out during intervention=5.

No. dropped out during follow-up:

3 months=2.

6 months=3.

No. crossed over: Not reported.

Participants Desription: Universal Latino sample.

Mean age:

Intervention-11.5.

Control-11.19.

Age range: Not reported.

Gender:

Subjects-

Males=42%.

Females=58%.

Control-

Males=67%.

Females=33%.

Source: Low income primary school.

Location: North Philedelphia, USA.

Inclusion criteria: Student and parent consent.

Exclusion criteria: Not reported.

Interventions Intervention: Psychological.

Type: Penn Resiliency Program.

Duration: 90 minutes.

No of sessions: 12; One per week.

Group Size: 10 participants.

Manualised: Yes.

Training: 20 hours.

Delivered by: Masters level graduate students.

Comparison: No intervention.

Type: No treatment condition group.

Assessment points:

pre-test

post -test

Follow-up:

3 months

6 months.

Outcomes Depressive symptoms-Children’s Depression Inventory (CDI).

Explanatory Style-The Children’s Attributional Style Questionnaire (CASQ).

Negative thoughts-The Automatic Thoughts Questionnaire.

Hopelessness-The Hopelessness Scale (H-Scale).

Self-esteem- The Perceived Competence Scale/What I am Like (WIAL).




Notes Study 1 presents data from the Latino sample from School 1.

Data requested:

December 2002.

Moncrieff Rating:

Adequate.

Allocation concealment B – Unclear

Study Cardemil 2002b








Source of subjects described: Yes.

Representative sample recruitment: Yes.


Intervention integrity: Bi-weekly supervision. Sessions audiotaped.




No. approached=819


No. randomised=106


No dropped out during intervention: Not reported.


3 months=2.

6 months=3.


Participants Desription: Universal African American sample.

Mean age:

Intervention-10.93.

Control-10.95.


Gender:

Intervention-

Males=51%.

Females=49%.

Control-

Males=56%.

Females=62%.

Source: Low income primary school.

Location: North Philedelphia., USA.

Inclusion criteria: Student and parent consent.



Type: Penn Resiliency Program.

Duration: 90 minutes




No of sessions: 12. One per week.

Group Size: 10 participants.

Manualised: Yes.

Training: 20 hours.

Delivered by: The first Author.


Type: No treatment condition group.

Assessment points:

pre

post.

Follow-up:

3 months

6 months

Outcomes Depressive symptoms-Children’s Depression Inventory (CDI).

Explanatory Style-The Children’s Attributional Style Questionnaire (CASQ).

Negative thoughts-The Automatic Thoughts Questionnaire.

Hopelessness-

The Hopelessness Scale (H-Scale).

Self-esteem-The Perceived Competence Scale/What I am Like (WIAL).

Notes Study 2 presents data from African American Sample.

Data requested:

December 2002.

Moncrieff Rating:

Adequate.


Study Clarke 1993a










Use of diagnostic criteria (or clear specification of inclusion criteria): Yes.

Intervention integrity: Not reported.


Intent to treat analysis: Unclear.

Follow-up assessment points: 3 months.

No. approached= 622.


No. randomised=622No. started trial=622.


No. dropped out during follow-up=54.


Participants Desription: Universal sample.

Mean age: Treatment-




Females=15.40 (SD=0.61).

Control- Females=15.29 (SD=0.59).

Age range: 9th & 10th grade students.

Gender:

Males=Not reported.

Females-Treatment=42.2%.

Females-Control=42.1%.

Source: Two Surburban high schools and one middle school.

Location: USA.

Inclusion criteria: Student consent.


Interventions Intervention: Educational.

Type: Primary prevention health class sessions which consisted of three structured lectures and two 20 minute

videotapes covering the sypmtoms, causes and treatments of depression.

Duration: 3, 50 minute classes.

No of sessions: 3.

Group size: Not reported.

Manualised: Yes.

Training: 2 hours.

Delivered by: Health class teachers.


Type: Usual health class curriculum.

Assessment points:

pre-test

post-test.

Follow-up:

3 months.

3 months.

Outcomes Depression- Centre for Epidemiological Studies-Depression Scale (CES-D).

Notes Data requested:

August 2002.

Response:

August 2002.

Data unavailable.

Moncrieff Rating:

Adequate.


Study Clarke 1993b










Intervention integrity: Teachers were assessed on a 10 item compliance scale.







No. approached=622


No. randomised=622





Participants Desription: Universal sample.

Mean age:

Treatment Females=15.40 (SD=0.61).

Control Females=15.29 (SD=0.59).

Age range: 9th & 10th grade students.

Gender:

Males=Not reported.

Females-Treatment=42.2%.

Females-Control=42.1%.

Source: 2 surburban high schools & 1 middle school.

Location: USA.

Inclusion criteria: Student consent.



Type: Behavioral skill training intervention for depression.

Duration: 3, 50 minute primary prevention health class sessions.

No of sessions: 3.

Group Size: Not reported.

Manualised: Yes.

Training: 2 hours.

Delivered by: Health class teachers.


Type: Usual health class curriculum.

Assessment points:

pre-test

post-test

Follow-up:

3 months

Outcomes Depression- Centre for Epidemiological Studies-Depression Scale (CES-D).


August 2002.

Response:

August 2002.

Data unavailable.

Moncrieff Rating:

Adequate.





Study Clarke 1995



Method of allocation: Unclear.


Blinding: (subjects): No.


Power calculation: No.



Intervention integrity: Sessions were audiotaped to evaluate compliance with intervention protocol. Protocol

adherence was 93.9% (5.2%).


Intent to treat analysis: Yes.



No. agreed to participate=150.

No. randomised= 150.

No. started trial: Intervention=55

Control=70

Total=125

No. dropped out during intervention=25.

No. dropped out during follow-up: 6 months=30

12 months=40.

No. crossed over: none.

Participants Description:

Targeted sample.

Mean age:

Females= 15.3 yrs (0.7)


Source: 3 surburban high schools.

Location: USA.

Inclusion Criteria: Elevated depressive symptoms on CES-D with a score of >=24;

adolescents who did not meet DSM-III-R criteria for depression.

Exclusion criteria: Current DSM-III R affective disorder.


Type: Coping with Stress Course.

Duration: 45 minute group session offered after school.

No. of sessions: Three sessions per week for 5 weeks.

Group Size: Not reported.

Manualised: Yes.

Training: 40 hours.

Deliverd by: School psychologists and counselors who had a minimum of a masters degree and previous

experience in conducting psychoeducational groups with adolescents.


Type: Usual care condition. Adoelscents were free to continue with any pre-existing intervention or to seek

any new assistance during the study period.

Assessment points:

pre-test

post-test

Follow-up:




6 months

12 months

Outcomes Depressive disorder, sypmtomatology and psychosocial constructs- CES-D, Hamilton Depression Rating

Scale (HAM-D), and The Global Assessment of Functioning Scale (GAF).

Notes Well described but only 222 out of 471 took part in second stage screening. Of those who completed second

stage screening 150/172 agreed to take part.

Data requested:

August 2002.

Data received:

September 2002.

Moncrieff Rating:

High.


Study Clarke 2001

Methods Study design: Randomised Controlled Trial.

Randomisation type: Block randomisation procedure. Method of allocation: Computer generated centrally.

Concealment of allocation: Yes.

Blinding (subjects): No.

Blinding (assessors): No.




Intervention integrity: Sessions were audiotaped and 2 or 3 sessions were randomly selected from each group

and rated by a senior supervisor on a 10 item fidelity scale. Mean therapist compliance was 95.9% (3.9%)

across 15 rated sessions.



Follow-up assessment points:

12 and 24 months.

Number approached=3374.

No. agreed to participate=94.

No. randomised=94.

No. started trial= 94.

No. dropped out during intervention=4.


12 months=9.

24 months=16.

No. crossed over: None.


Targeted sample.

Mean age:

Intervention= 14.4 (1.4).

Controls=14.75 (1.5).

Age range: 13-18 years.

Gender:

Males-

Intervention=21.

Controls=17.

Females:




Intervention=24.

Control=32.

Source: Offspring of patients with parents who had been treated for depressive illenss within an HMO.

Location:

HMO clinic offices. USA.

Inclusion criteria: At-risk offspring of adults treated for depression in a health maintenance organisation

(HMO). Participants did not meet DSM-III-R criteria for criteria for depressive symptoms, affective/mood

disorders.

Exclusion Criteria: Low-severity depression group with no significant depression symptoms and no history

of depressive disorder.


Type: Abbreviated version of the Adolescent Coping with Stress Course.

Duration: 1 hour sessions.

No of sessions: 15 sessions.

Group size: 6-10. Manualised: Yes.

Delivered by: A therapist with a masters degree.

Training: Therapist trained in the approach.


Type: Usual HMO care.

Assessment points:

pre-test

post-test

Follow-up:

12 months

24 months

Outcomes Depression- CES-D, K-SADS-E, 14 item version of the Hamilton Depresion Rating Scale (HAM-D), Global

Assessment of Functioning (GAF) and Achenbach Child Behavior Check List (CBCL).


August 2002.

Data received:

September 2002.

Moncrieff Rating:

High.

Allocation concealment A – Adequate

Study Gwynn 1987

Methods Study design: Clinical Controlled Trial.

Randomisation type: N/A.

Method of allocation: Not reported. Paired using sex and time since parental separation.





Source of subjects described: Yes. Representative sample recruitment: No. volunteers recruited.








Follow-up assessment points: No follow-up assesment conducted.

No. approached=60.


No. randomised= N/A.


No dropped out during intervention=Not reported.

No. dropped out during follow-up= N/A.

No. crossed over=Not reported.

Participants Description: Targeted sample.

Mean age: Not reported.


Gender:

Male=30.

Females=30.

Inclusion criteria: Children whos parents had been separated for at least one year.

Exclusion criteria: Did not volunteer or return signed consent forms.

Interventions Intervention: Educational.

Type: Support group.

Duration: 8 weeks.

No. of sessions: 8, once per week..

Group size: 6 students.

Delivered by: Not reported.

Training: Not reported.

Manualised: Not reported.


Type: Usual class.

Assessment points:

pre-test

post-test

Outcomes Depression-Children’s Depression Inventory (CDI).

Anxiety-What I Think and Feel. State-Trait Anxiety Inventory for Children.

Cognitive knowledge about divorce-Children’s Divorce Information Scale (CDIS) and Children’s Divorce

Affective Scale (CDAS)

Notes No data reported in study.


Study Hains 1994








Source of subjects described: Yes. Representative sample recruitment: No. volunteers recruited.


Intervention integrity: Participants completed monitoring sheets after each session. Therapists discussed

sessions at meetings.







No. approached=25-30.


No. randomised= 21.



No. dropped out during follow-up= 0.

No. crossed over=0.

Participants Description: Universal sample. Participants approached in a midwestern city suburban high school


Age range: 9th-12th graders

Gender:

Male=5.

Females=16.

Inclusion criteria: Volunteers who returned signed student and parent consent forms.

Exclusion criteria: Did not volunteer or return signed consent forms.


Type: The Stress Inoculation Model.

Duration: 8 days

No. of sessions: 13 with a combination of group and individual sessions.


Delivered by: PhD level Psychologists and a counseling psychology doctorate student.


Manualised: Yes.


Type: Wait-list

Delivered by:

Masters level counseling student.

Assessment points:

pre-test

post-test

Follow-up:

2 months

Outcomes Depression-

Reynolds Adolescent Depression Scale (RADS).

Anxiety-STAI.

Anger-STAXI.

Adolescent stress-APES.

Physical health-Student reports.

Academic function-school reports.

Notes Control group participants were given intervention after post-test

assessment. Therefore 2 month follow-up scores cannot be compared with the intervention group scores.

Data requested: November 2002.

Moncrieff Rating:

Inadequate.


Study Jaycox 1994

Methods Study design:




Quasi- randomisation Randomisation type: Quasi-randomsied.

Method of allocation: Experimental conditions randomly assigned to schools rather than individuals






Representative sample recruitment: No.


Intervention integrity: Yes. Assessors were pilot tested and supervised by a licensed psychologist using video-

tapes of sessions

Participants were assigned weekly homework assignment and between sessions.



Follow-up assessment points: 6, 12, 18, 24, 30, & 36 months.



No. randomised= N/A.



No. dropped out during follow-up=

24.



Targeted sample.

Mean age: 11.4 (SD=0.67) yrs.

Age range: 10-13 yrs.

Gender:

Males= 77 (53.85%).

Females=66 (46.15%).

Source: Surburban high schools.

Location: Philedelphia, Penn, USA.

Inclusion criteria: Participants identified as being at risk for depression based on current level of depressive

symptoms and perception of parental conflict measured by CDI and Child’s Perception Questionnaire.

Exclusion criteria: Students identified as ”high risk.“


Type: The Depression Prevention Programme.

Duration: 1 1/2 hr per week for 12 weeks, conducted after school.

No. of sessions: 12.

Group size: 10-12 students.

Manualised: Yes.

Training: Not reported. Delivered by: Doctoral students in clinical psychology.

Comparison: No Intervention.

Type: No Participation Control group.

Combination of wait-list and no participation.

Assessment points:

screening

pre-test

post-test (3 months)

Follow-up:

6 months




Outcomes Depressive symptoms- Children’s Depression Inventory (CDI) and Reynolds Adolescent Depression Scale

(RADS).

Explanatory style- Children’s Attributional Style Questionnaire (CASQ).

Behavioral conduct at home-Child Behavior Checklist (CBCL).

Classroom behavior-

Teacher reports.

Notes Included but not pooled.

Moncrieff Rating:

Adequate.

Allocation concealment C – Inadequate

Study Lamb 1998












Intent to treat analysis: No.

Follow-up assessment points: no follow-up conducted.

No. approached=222


No. randomised=46

No. started trial:

Total=46.

Treatment=27

Control=19.

No dropped out during intervention:

Total=5.

Treatment=4.

Control=1.

No. dropped out during follow-up:N/A



Mean age: 15.8yrs.


Gender:

Males=18 (43.9%).

Females=23 (56.1%).

Source: Rural High school

Location: Not reported.

Inclusion criteria: Students who scored in the moderate-high range for depressive symptoms (a score of 66

or above) on the Reynolds Adolescent Depression Scale (RADS) and student and parent consent.






Type: Cognitive skills training.

Duration: 8 weeks.

No.of sessions: Not reported.




Delivered by: PhD psychiatric mental health nurse.


Type: Control group. Description of group not reported.

Assessment points:

pre-test

post-test

Outcomes Depressive symptomatology-Reynolds Adolescent Depression Scale (RADS).

Life Events-The Life Events Checklist (LEC).

Coping styles-Jalowiec Coping Scale (JES).


June 2002.

Moncrieff Rating:

Inadequate.


Study Lowry-Webster 2001


Randomisation type: not reported.

Method of allocation: Schools matched for size, sociodemographics, and socioeconomics were randomly

allocated to conditons.







Intervention integrity: Yes. Facilitators attended regular meetings and sessions were videotaped.


Intent to treat analysis: No.

Follow-up assessment points: no follow-up conducted.

No. approached=594


No. randomised=85.

No. started trial:

Total=85.


Total=Not reported.

No. dropped out during follow-up:N/A


Participants Description: Universal

sample.






Gender: Not reported.

Source: Seven Catholic schools.

Location: Brisbane, Australia.

Inclusion criteria: Parent and student consent.



Type: FRIENDS For children. A Cognitive-behavioral program.

Duration: 10 weeks.

No.of sessions: 10.


Manualised: Yes.

Training: Yes.

Delivered by: Teachers.


Type: Wait-list.

Assessment points:

pre-test

post-test

Outcomes Anxiety-Spence’s Children’s Anxiety Scale (SCAS). Revised Children’s Manifest Anxiety Scale (RCMAS).

Depression-Children’s Depression Inventory.

Notes


Study Pattison 2001











Intervention integrity: Not reported




No. approached=150


No. randomised= 66.





Participants Description: Universal Sample.

Mean age: 10.44 (SD=0.69).

Age range: 9-12yrs.

Gender:

Males=48%.




Females=52%.

Source: High School.

Location: Adelaide, Australia.

Inclusion Criteria: Parental consent.



Type:

1. Normal PENN Prevention Programe.

2.Reversed PENN Prevention Program.

Duration: 2 hour sessions once a week.


Group size: 16.

Manualised: Yes.

Training: By authors of the PENN Program 18 months prior to the implementation of study and with

experience with implementation on 5 previous occassions.

Delivered by: Trained facilitators.

Comparison:

Type: 2 types.

1. Attention control group.

2. Non-intervention control group with no active participation but completed questionnaires.

Duration: Type 1: 2 hour sessions per week.

No.of sessions: 11

Integrity: Not reported



Delivered by: First Author and Teacher-Librarian.

Assessment points:

pre-test

midpoint (5 weeks)

post (11 weeks)

Follow-up:

8 months

Outcomes Depressive symptoms-

Children’s Depression Inventory (CDI).

Anxiety-The Trait Scale of the Spielberger State-Trait Anxiety Inventory for Children (STAIC).

Cognitive style-The Cognitive Triad Inventory for Children (CTI-C).

Social Skills-The Matson Evaluation of Social Skills with Youngsters (MESSY).

Notes Two intervention groups.

Two comparison groups.


Response:

December 2002. Author no longer has access to data.

Moncrieff Rating:

Inadequate.


Study Petersen 1997
















Follow-up assessment points: 6 & 12 months.

No. approached=335


No. randomised=335


No dropped out during intervention=16. (some students were inadvertently dropped from the mailing list

following the intervention and wasn’t discovered until Time 5 data collection for Cohort 2).


6 months=36.

12 months=5.



Targeted sample.


Age range: Cohort 1=Grades 6-8.

Cohort 2=Grades 7-9.

Gender: Gender breakdown not reported.

Source: Two middle schools and one junior school.

Location: USA.

Inclusion criteria: High risk of depressive symptoms determined by two assessments in 6th & 7th grades

who were in the lower third of the distribution in the fall of both 6th & 7th grades


Interventions Intervention:

Psychoeducational.

Type: Penn State Adolescent Study.

Duration: 40 mins.

No of sessions: 16.



Training: Clinical training.

Delievered by: Clinically trained graduate students or psychologists.


Type: Control group.

Assessment points:

pre-test 1

pre-test 2

pre-test 3

post-test

Follow-up:

6 months




12 months

Outcomes Depression-Diagnostic Interview Schedule for Children (DISC).

Depressive symptoms-Children’s Depression Inventory (CDI) & the Achenbach Youth Self-Report (YSR).

Depressive affect-Emotional Tone Scale of the Master and Coping Scale of the Self Image Questionnaire for

Young Adolescents (SIQYA).

Coping-SIQYA & the Seiffe-Krenke Coping Questionnaire.

Notes Data requested: November 2002.

Moncrieff Rating:

Inadequate.


Study Quayle 2001










Intervention integrity: Supervision on a fortnightly basis by registered psychologists. Facilitators kept a log

book on the content covered during each session.




No. approached= 70.


No. randomised=47.




6 months=6.



Universal sample.



Gender:

Females only=47

Source: Private girls school

Location: Suburb of Perth, Australia.

Inclusion criteria: Parental and student consent.


Interventions Intervention: Psychological

Type: The Optimism Program adapted from the Penn Prevention Program.

Duration: 8 weeks.

No of sessions: 8, 40 minute sessions.

Group size: 12.

Manualised: Yes.




Training: 30 hrs

Delievered by: Post-graduate clinical psychology students.


Type: Wait-list/usual care educational programme.

Assessment points:

pre-test

post-test

Follow-up:

6 months

Outcomes Depressive symptoms-The Children’s Depression Inventory (CDI).

Attribution style-The Children’s Attributional Style Questionnaire (CASQ). Loneliness- Asher and Wheeler

Loneliness and Social Dissatisfaction Scale (CLQ).

Self-worth-The Global Self-Worth Sub-Scale of Self Perception Profile for Children (SPPC).


December 2002.

Moncrieff Rating:

Inadequate.


Study Roberts in press




Concealment of allocation: No.


Blinding (assessors): Yes.




Intervention integrity: All sessions audiotaped and checklists used.








Subjects=90.

Control=99.





Targeted sample.

Mean age: 11.89 (SD=0.33).


Gender:

Males=95

( 50.3%).




Females=94 (49.7%).

Source: Rural primary schools in Western Australia.

Location: Australia.

Inclusion criteria: Elevated depressive symptoms or high levels of preceived parental conflict/ Children with

highest scores on CDI 1-37 with parental consent. Exclusion Criteria: Not reported.

Interventions Intervention: Psychological

Type: Penn Prevention Program adapted for Australia.

Duration: Not reported.


Group size: Not reported. Manualised: Yes.

Training: 40 hours from the PPP developers. Co-facilitators: 30 hours training from researchers.

Delivered by: School psychologists and nurses with Bachelor level Behavioural Science degrees.


Type: Usual care control condition. Received the normal health education curriculum plus monitoring of

their symptoms. Different to the usual care condition as parents of children experiencing significant distress

at any assessment were given advice on management.

Assessment points:

pre-test

post-test

Outcomes Depressive symptoms-CDI.

Anxiety-The Reynolds Children’s Manifest Anxiety Scale (RCMACS).

Explanatory Style-CASQ.

Social skills-The Matson Evaluation of Social Skills with Youngsters.

Parents perception of behaviour at home-CBCL.


November 2002.

Moncrieff Rating:

Adequate.


Study Seligman 1999


Randomisation type: Stratified randomisation.




Blinding (assessors): Yes.




Intervention integrity: Trainers met participants on six occasions (beginning of worskhop; middle of work-

shop; 1 month after the workshop; 3 months after the workshop ended; once in fall term of their sophomore

year; once in the spring term of their sophomore year) to review the skills learned in the workshops and its

application to their lives.



Follow-up assessment points: up to 3 years.








Subjects=106.

Control=119.



Follow-up 1=2.

Follow-up 2=1.

Follow-up 3=7.

Follow-up 4=12.

Follow-up 5=0.

Follow-up 6=3.



Targeted sample.


Age range: Ist year undergraduate students.

Gender:

Males=111 (48%)

Females=120 (52%).

Source: University of Pennsylvannia.

Location: USA.

Inclusion criteria: 1. Not receiving psychotherapy or medication for psychological problems.

2. Continued to score in the pessimistic quartile of the ASQ.

3. With scores of 19 or less on the Beck Depression Inventory.

4. Not meeting diagnosis criteria for Axis I disorders.

5. Signed voluntary consent forms. Structured Clinical Interview for the DSM-III-R (SCID) conducted to

determine eligibility.

Exclusion Criteria: Not reported.


Type: Cognitive-Behavioral prevention programme.

Duration:

1-2 hrs.

No of sessions: 8 over 8 weeks.


Manualised: Yes.

Training: Previous training in CBT techniques with experience ranging from 2-30 years.

Delivered by: Trained cognitive therapists who currently worked or had previously worked at Aaron Beck’s

Centre for Cognitive Therapy. Co-trainers were either the same cognitive therapists or doctoral students

enrolled in the clinical psychology program at the University of Pennsylvania.


Type: Assessment only group.

Assessment points:

pre-test

post-test

Follow-up:

3 years

Outcomes Depression- Beck Depression Inventory (BDI) and Hamilton Depression Rating Scale (SIGH-D). Major

Depression: LIFE MDD. Anxiety-Beck Anxiety Inventory

(BAI) & The Hamilton Anxiety Rating Scale (SIGH-A). Explanatory style-ASQ. Hopelessness-




Hopelessness Scale (HS).

Dysfunctional attitudes-Dysfunctional Attitudes Scale (DAS).

Self-esteem-The Self Concept Test.


June 2002.

Moncrieff Rating:

High.


Study Shatte 1997








Intervention integrity: Facilitators received regular supervision and sessions were audiotaped.



Follow-up assessment points: 4, 8 and 12 months.

No. approached=1400.



No. started trial:

Total=152.

Intervention=55.

Placebo=50.

Control=47.


Total=13.

Intervention=4.

Placebo=3.

Control=5.


4 Months-

Total=3.

Intervention=1.

Placebo=2.

Control=0.

8 Month-

Total=9.

Intervention=4.

Placebo=4.

Control=1.

12 Months-

Total=20.

Intervention=6.

Placebo=6.

Control=8.





Participants Description: Universal sample.

Mean age: 12.47 (SD=0.70).


Gender:

Males=81.

Females=71.

Source: Middle school.

Location: Upper Darby School district, Philedelphia, USA.

Inclusion Criteria: Student and parental consent.

Exclusion Criteria: Not reported.


Type:

Penn Optimism Program.

Duration: 2 hours. Sessions: 12 over 12 weeks.

Group size: 9 participants.

Training: 35 hours for graduate students and 40 hours for teachers.

Delivered by: Teachers and graduate students.

Comparison: Placebo condition..

Type: Penn Enhancement Program.

Duration: 12 weeks.


Manualised: Yes.

Training: Same as for the intervention program.

Delievered by: Same as for the intervention program.

Assessment points:

pre-test

post-test

Follow-up:

4 months

8 months

12 months

Outcomes Depression-Children’s Depression Inventory.

Notes


Study Shochet 2001

Methods Study design: Cohort Controlled Study.





Source of subjects described: Yes. Representative sample recruitment: No.


Intervention integrity: Integrity checks completed by facilitators.














Participants Description: Universal sample.

Mean age: 13.49 (SD=0.54).


Gender:

Males=121 (46.54%).

Females=139 (53.46%).

Source: Schools.


Inclusion Criteria: Students who do not meet a clinical diagnosis for depression and with written parental

consent.

Exclusion Criteria: Clinical diagnosis for depression and developmental disability.


Type:

Resourceful Adolescent Program-Adolescents (RAP-A).

Duration: 50 minutes. Sessions: 11 group sessions conducted once a week for 11 weeks during class time.

Group size: 8-12 participants.

Training: 25 hours

Delivered by: Psychologists (experienced clinicians to graduate psychology students).


Type: RAP-Watch-

Previous year cohort at the same school involved normal school curriculum and three assessment points.

Assessment points:

pre-test

post-test

Follow-up:

10 months

Outcomes Depression-Children’s Depression Inventory (CDI), Reynolds Adolescent Depression Scale (RADS), & Beck

Hopelesseness Scale.

Notes Included but not pooled

Data requested:

May 2002.

Moncrieff Rating:

Adequate.

Allocation concealment D – Not used

Study Spence 2003













Intervention integrity: Teachers evaluated after each session and final session. Participants evaluated at the

end of the final session.

Outcome measures described clearly /use of validated instruments: Yes.



No. approached=1500.




No dropped out during intervention=15%

No. dropped out during follow-up=217


Participants Description: Universal sample selected from 16 high schools.



Gender:

Subjects-

Males=47.5%.

Females= 52.5%.

Controls:

Males=49.4%.

Females=50.6%.

Source: High school.


Inclusion criteria:

high risk students defined as scoring 13 or more on the BDI and did not meet criteria for depressive disorder.

Exclusion criteria: Students who met criteria for a depressive disorder.


Type: Problem solving for Life Program.

Duration: 8 weeks. 45-50 mins long.

No of sessions: 8.


Manualised: Unclear but reported that teachers received all teaching materials and resources.

Training: 6 hours.



Type: Monitoring condition.


Assessment points:

pre-test

post-test

Follow-up:

12 months

Outcomes Depression-

Beck Depression Inventory (BDI), Structured Diagnostic Interview with High-Risk Students (ADIS-C).

New or continuing episodes of depression during the follow-up period-Longitudinal Follow-up Evaluation

(LIFE) General psychopathology-Youth Self Report (YSR).

Social functioning-The Child and Adolescent Social Adaptive Functioning Scale (CASAFS).

Problem solving-Social Problem-Solving Inventory-Revised Short Form (SPSI-R). Attributional style-The

Children’s Attributional Style Questionnaire (CASQ-R).




Negative life events-Life Events Record modified.

Family conflict-Family Conflict sub-scale of the Colorado Self- Report of Family Functioning Inventory

(CSRFFI).

Notes Subjects and controls further divided into high-risk versus low-risk groups for analysis.

Data requested:

June 2002.

Data received:

July 2002.

Moncrieff Rating:

Adequate.


Study Thompson 2000








Source of subjects described:

Yes. Representative sample recruitment: Yes.


Intervention integrity: Participants had ongoing monitoring, self assessment, provision of interpersonal

support for goal achievement.



Follow-up assessment points: No follow-up conducted.

No. approached=106


No. randomised=106


Subjects:

Group 1=36.

Group 2=35.

Control=35.



Total=23.

Subjects=13.

Control=10.



Mean age:

Group 1-16.19 (0.92);

Group 2- 15.82 (1.11);

Control: 15.57 (1.01)

Age range: Grades 9-12.

Gender:

Males-




Group 1=15 (41.7%).

Group 2=13 (37.1%).

Group 3=16 (45.7%).

Source: 5 high schools.

Location: USA.

Inclusion criteria: School failure or dropping out. Participants had prior school dropout status; below expected

credits for current grade level; in top 25th percentile for days absent per semester; GPA<2.3 or drop from

.07; referral by school personnel as being in jeopardy of school failure or dropping out.



Type: Personal Growth Class (PGC1 and PGC II).

Duration: PGC I- One semester (5 months). PGCII-Two semesters (10 months).

No. of sessions: PGCI: 90 sessions. PGCII: 180 sessions. 55 minutes daily.

Group size: 12 participants.

Manualised: No.


Delivered by: Teachers, counselors and school nurse.


Type: Assessment only.

Assessment points:

pre-test

post-test

Outcomes Depression- Modified version of Centre for Epidemiological Study-Depression (CES-D).

Teacher support, peer support. Personal growth-High School Questionnaire.

Suicide risk behaviours-New measure-Measure of Adolescent Potential for Suicide (MAPS).

Peer support.

Notes Two intervention programmes.


Moncrieff Rating:

Inadequate.


Study Yu 2002











Intervention integrity: Supervision and weekly meetings.




No. approached= 1,425.





No. randomised=355

No. started trial:

Total=220.

Subjects=104.

Controls=116.


Total=5.

Subjects=3.

Controls=2.


3 months=4.

6 months=4.



Mean age: 11.8 yrs (SD=1.69).

Age range: not reported.

Gender:

Subjects-

Males=60.

Females= 44.

Controls-

Males=62.

Females=54.

Source: Elementery School.

Location: Peking, China.

Inclusion criteria: Overall risk scores >=25 % for their age group.



Type: Penn Optimism Program-

Chinese Version.

Duration: 10; weeks.

No. of sessions: 10. Once a week. Group size: 10-14 participants.

Manualised: Yes.

Training: 40 hours from researchers.



Type: Control group.

Assessment points:

pre-test

post-test

Follow-up:

3 months

6 months

Outcomes Depressive symptoms-

Children’s Depression Inventory (CDI).

Anxiety-CASQ.

Notes Data requested: Request sent to Seligman

December 2002.

Response: December 2002.

Unwilling to send data.



Moncrieff Rating:

High.


Characteristics of excluded studies

Study Reason for exclusion

Asarnow 2002 Study sample includes adolescents with clinical depression.

Beardslee 1993 Not an intervention study. A case study demonstrating family intervention for parents.

Beardslee 1997 Sudy comparing two intervention groups.

Buhs 1997 Not a randomised controlled trial. Study had no comparison group.

DeSouza 1995 Not an intervention study. Compared two populations on depression scores.

DiFilippo 2000 Not an intervention study. Participants were adolescent psychiatric inpatients who met psychiatrist’s diagnosis for

major depression and also had co-morbid disorders.

Eggert 1995 Study reporting intervention for suicide prevention.

Eggert 2002 Study reporting intervention for suicide prevention.

Falloon 1992 Uncontrolled trial with adult population who had DSM-III-R diagnosis.

Fava 1998 Uncontrolled Clinical Trial with adult population who met DSM-IV criteria for depression, or panic disorder with

agoraphobia, or social phobia, or generalised anxiety disorder, or obsessive-compulsive disorder.

Freres 2002 Article describing content of the intervention program and evidence for the program’s efficacy in preventing

depressive symptoms.

Hannan 2000 Study reports on intervention effects only. No comparison group was used.

Harper 1999 No intervention group. A descriptive study only.

Keeler 2000 Study reports on intervention effects only. No comparison group was used.

Kellam 1994 Study reporting intervention for reading achievement.

Kroll 1996 Clinical controlled trial for relapse prevention in adolescents diagnosed with major depressive disorder.

Munoz 1995 A randomised controlled trial with adult populations with mean age of 52.5 yrs.

O’Dea 2000 Study reporting intervention for self-esteem.

Peden 2001 A randomised controlled trial with adult populations with age range of 18-24 years.

Pfeffer 2002 Not a randomised controlled trial.

Pushkar 1997 Study reporting on the description of the trial only

Randell 2001 Study reporting intervention for suicide prevention.

Shechtman 1993 Study reporting intervention for school adjustment.

Thompson 2001 Study reporting intervention for suicide prevention.

Vostanis 1998 Clinical controlled trial for adolescents diagnosed with depressive disorders and co-morbid disorders. Diagnosis

based on DSM-III-R criteria for depression

Zubernis 1999 Not a randomised controlled trial. No comparison group used. Study reported on all intervention groups.

Characteristics of ongoing studies

Study Gillham in press

Trial name or title School based prevention of depressive symptoms



Characteristics of ongoing studies (Continued )

Participants 696 middle school students ages 11-14. Students who scored above 12 on the CDI were excluded if they were

experiencing a depressive disorder.

Interventions Intervention: Penn Optimism Program (POP) based on cognitive-behavioural techniques.

Comparison: Placebo condition called the Penn Enhancement Program (PEP).

Outcomes Depression measured by the Children’s Depression Inventory (CDI).

Starting date

Contact information Jane Gillham.

Psychology Department,

University of Pennsylvania,

3815 Walnut St,

Philadelphia,

PA 19104.

Notes

Study Hamilton in press

Trial name or title Preventing depressive symptoms in the primary care setting.

Participants Source:

Adolescents in a health maintenance organisation (HMO).

Inclusion criteria:

Children with above average and above levels of depressive symptoms but not meeting criteria for a current

depressive disorder.

Age:11-12 year olds.


Penn Optimism Program (POP) a cognitive therapy based intervention.

Comparison:

Usual care where chidlren received routine pediatric care.

Outcomes Depression measured by Children’s Depression Inventory (CDI).

Starting date

Contact information John Hamilton.

The Permanente Medical Group of Northern California,

2025 Morse Ave,

Sacramento,

CA 95825.

Notes

Study Kowalenko

Trial name or title Short-term effectiveness of a school-based early intervention program for adolescent depression.

Participants Source: High school students.

Inclusion criteria: Students who scored above 18 on the CDI at pre-screening.


Adolescents Coping with Emotions (ACE) Program.

Comparison:

Wait list control condition.

Outcomes Depression measured by the Children’s Depression Inventory (CDI)

Negative thoughts measured by the The Children’s Automatic Thoughts Scale (CATS).

Starting date




Contact information Nick Kowalenko.

Department of Child and Adolescent Psychiatry,

Royal North Shore Hospital,

Block 4, Level 2 Pacific Highway

St Leonards,

NSW,

Australia.

Email: [email protected]

Notes

Study Merry 2002

Trial name or title A prospective randomized placebo controlled trial of a school-based depression prevention program

Participants Source: 392 students from two high schools.


Exclusion criteria: Students with scores above 23 on the Beck Depression Inventory (BDI) and 77 on the

Reynolds Adolescent Depression Scale (RADS) and who were referred to the school guidance counsellor.

Interventions Intervention: Resourceful Adolescent Program (RAP) based on cogntive-behavioral therapy techniques.

Comparison: Placebo condition. A programme similar to the intervention programme but without the active

CBT components.

Outcomes Depressive symptoms meansured by the Beck Depression Inventory II (BDI-II) and Reynolds Adolescent

Depression Scale (RADS).

Starting date Year 2000

Contact information Sally Merry.

Department of Psychiatry, Faculty of Medical and Health Sciences,

University of Auckland,

Private Bag 92019,

Auckland,

New Zealand.

Email: [email protected]

Notes

Study Patton

Trial name or title Promoting social inclusion in secondary schools: A cluster randomised trial.

Participants Source: 2677 students from 26 high schools.



Interventions Intervention: The Gatehouse Project draws upon attachment theory with strategies designed to promote a sense

of security, better communication, and extended participation in school life.

Comparison: Control group.

Outcomes Substance abuse measured by self-reported item of frequency. Socially disruptive behaviour measured by Items

from the Self Reported Early Delinquency Scale. And mental health problems measured by the Clinical Interview

Schedule (CIS-R). Depressive symptoms: Moods and Feelings Questionaire.

Starting date

Contact information George Patton. Centre for Adolescent Health, Murdoch Children’s Research Institute.

2 Gatehouse Street, Parkville 3052, Australia.




Notes

A D D I T I O N A L T A B L E S

Table 01. Additional Outcomes

Study Results Summary Supporting Statistic

Asarnow 2002 Significant intervention effect for frequency

of negative automatic thoughts with the

Intervention Group showing less negative

thinking. Significant intervention effect for

internalised coping with the intervention

group showing less of this style of avoidant

coping after the intervention.

Negative thinking F(1,20)=4.50, p<.02.

Coping Style F (1,20)=3.44 p<.04

Beardslee 1996 Significant intervention effect for parental self

rated behaviour and attitude change at time 4

follow-up

Behaviour Change t=3.7 p<.001. Attitude

change t=2.07 p<.05

Beardslee 1997a Significant intervention effect for rater

generated child behaviour and attitude change.

No intervention effect on Child Behaviour

Checklist, Parent and Youth Self report, on

Family Relation Inventory or Harter measure

of self worth.

Total Change F(1,49)=13.32 p<.01

Beardslee 1997b Significant intervention effect for clinican

rated children’s behaviour and attitude change.

Behaviour Change F(1,65)=13.16 p<.001.

Attitude Change F(1,65)=22.63 p<.001. Total

Change F(1,65)=23.19 p<.001.

Cardemil 2002 - Latino No significant intervention effect for

attribution style measured on the Childrens

Attributional Style Questionnaire. Significant

intervention effect for negative automatic

thoughts measured by the Automatic

Thoughts questionnaire with Intervention

group having significantly less negative

thoughts post intervention and 6 month

follow-up, for Hopelessness with intervention

group reporting lower hopelessness at 6

month follow-up, and for self-esteem with the

intervention group showing better self esteem

at 6 month follow-up.

Negative Automatic Thoughts post

intervention F(1,38)=5.78 p<.01; 6 month

follow-up F(1,31)=3.36 p<.05. Hopelessness

6 month follow-up F(1,34)=2.90 p<.05. Self

Esteem 6 month follow-up F(1,35)=6.97

p<.01.

Cardemil 2002 - African American No significant intervention effect for

attribution style, automatic negative thoughts,

hopelessness and self esteem.

Clarke 1993 No additional outcomes reported.

Clarke 1995 Significant intervention (group x time)

interaction effect on Global Assessment of

Functioning from intake to post intervention

with the intervention group showing improved

functioning. Effect not maintained at 12

GAF F(1,118)=3.89 p<.05



Table 01. Additional Outcomes (Continued )


months.

Clarke 2001 No significant intervention effect for

internalising and externalising behaviour on

the CBCL

Gwynn 1997 Intervention group showed significantly more

change than did their matched controls on

knowledge about divorce.

Hains 1994 Significant intervention effect for State Anger,

Trait Anger and Anger Expression as measured

by the State Trait Anger Expression Inventory

with the intervention group showing less anger

symptomology.

State Anger F(1,14)=3.68 p<.076. Trait

Anger F(1,14)=5.08 p<.04. Anger Expression

F(1,14)=5.37 p<.036.

Jaycox 1994 Significant intervention effect for parent

reported externalising and conduct problems

as measured by the CBCL with the treatment

group showing fewer conduct problems than

the control group. However, within each group

there were no significant changes from pre to

post test measures. There was no significant

intervention effect for the internalising scale

on the CBCL. There were no significant

group differences in explanatory style on the

Children’s Attributional Style Questionnaire

except for in the treatment group where

children were less likely to attribute negative

events to stable enduring causes by the end

of treatment and follow-up. The changes in

attributional style appeared to mediate the

impact of treatment in decreasing depressive

symptomology.

Externalising behaviour F(1,60)=3.02, P<.05;

Post test attributional style Post Test F(1,94)=

5.48, P<.05; Follow-up F(1,99)=6.49, P<.05)

Kellam 1994 Stability of depressive symptoms is greatly

reduced over the course of the first grade

amongst girls whose achievement gain is at or

above the national average. The intervention

did increase the numbers of such girls but it

had no additional effect. Boys also improved

in achievement and the improvement in

achievement was linked to a reduction in

the stability of depressive symptoms and a

reduction in depressive symptoms in boys who

had initially been more depressed.

Lamb 1998 Non significant trend suggesting intervention

increased usage of supportive coping style

(rather than evasive or emotive styles of

problem solving)

Lowry-Webster 2001 No other outcomes reported





Pattison 2001 No significant intervention effect for Negative

Cognitive Style or Social Skills

Peterson 1997 Intervention produced better coping as

measured by the Mastery and Coping Scale

of the Self Image Questionnaire for Youth

Adolescents at post intervention but not at

one year follow-up.

Quayle 2001 There were no significant intervention

effects on pessimistic attributional style

measured by the Childrens Attributional

Style Questionnaire, or on loneliness and

social dissatisfaction. There was a significant

intervention effect for self worth as measured

by a subscale of the Self Perception Profile

with the Intervention Group showing higher

self worth at 6 months follow-up

Self Worth F (1,27)=4.89 P<.05

Rice 1994 No other outcomes reported

Roberts in press There was a significant intervention effect for

positive explanatory style as measured on the

Children’s Attribution Style Questionnaire

with the intervention group showing more

optimisitic explanations for positive events at

post intervention but not at 6 month follow-

up. There was no significant intervention

effect for negative explanatory style as

measured on the Children’s Attribution Style

Questionnaire, nor for appropriate social

skills, nor for inappropriate assertiveness.

Positive Explanatory Style post intervention

F(1,15)=4.93 p<.05.

Seligman 1999 Significant intervention effect for attributional

style measured by the Children’s Attributional

Style Questionnaire and dysfunctional

attitudes measured on the Dysfunctional

Attitudes Scale for post intervention and

three follow-up points with intervention

showing better level of explanatory style

and less dysfunctional attitudes. Significant

intervention effects for hopelessness with

intervention group showing less hopelessness

at post intervention and follow-up three but

not follow-up five. There was no significant

intervention effect for self esteem. Explanatory

style, dysfunctional attitudes and hopelessness

were all significant mediators of depressive

symptoms at post intervention and follow-up.

Attribution post intervention F(1,223)=

4.6 p<.02; Follow-up 5 F(1,185)=6.7

p<.005. Dysfunctional Attitudes post

intervention F(1,223)14.9 p<.0001; Follow-

up 5 F(1,185)2.7 p<.05. Hopelessness post

intervention F(1,223) 7.9 p<.003; follow-up 3

F(1,218)4.8 p<.02

Shatte 1996 No other outcomes reported

Shocket 2001 No additional outcomes reported





Spence 2003 In the high risk group there was a significant

intervention effect for problem solving skills

with the treatment group showing a greater

improvement in problem solving skills with

a greater reduction in negative and avoidant

problem solving. In the low risk group there

was a significant intervention effect for

problem solving with the treatment group

showing a greater improvement in problem

solving skills.

High risk Negative Problem solving F(1,229)=

4.54, P<.05; Avoidant problem solving

F(1,229)=9.28, P<.01. Low Risk Problem

solving F(1,919)=12.61, P<.01.

Thompson 2000 Enhanced personal control contributed

independently for reductions in both

depression and suicide risk.

Yu 2002 There was a significant intervention effect on

overall explanatory style and composite score

for negative events measured by the Children’s

Attributional Style Questionniare with the

intervention group having significantly higher

overall explanatory style composite scores at

post intervention and 6 month follow-up,

lower composite scores for negative events at

post intervention and 6 month follow-up.

Also demonstrated a mediation effect whereby

change in the explanatory style mediated the

intervention effect on depressive symptoms.

Overall explanatory Style post intervention

F(1,204)=15.57 p<.001. Score for negative

events post intervention F(1,204)=16.67

p<.001. Overall Explanatory style 6 month

follow-up F(1,205)=6.22 p<.05. Scores for

negative events F(1,205)=4.21 p<.05.

Table 02. Anxiety Outcomes

Study Results Supporting Statistic

Gwynn 1997 Intervention group showed significantly more change

than did their matched controls on anxiety (as

measured by ”What I Think and Feel“, and State

Anxiety on the State Trait Anxiety Inventory for

Children).

Hains 1994 Significant intervention effect for trait anxiety

measured by the State Trait Anxiety Inventory with

intervention group showing less anxiety.

Trait Anxiety F(1,14)=3.35 p<.089

Lowry-Webster 2001 No significant intervention effect as measured by the

Revised Childrens Manifest Anxiety Scale at post

test. On the Spence Children’s Anxiety Scale there

was a significant intervention effect for self reported

anxiety post intervention with benefits even more

pronounced for children who reported clinical levels

of anxiety before the intervention.

Pattison 2001 No significant intervention effect on anxiety

measured by the Trait Anxiety Scale of the State Trait



Table 02. Anxiety Outcomes (Continued )

Study Results Supporting Statistic

Anxiety Inventory for Children.

Roberts in Press Significant intervention effect on anxiety as measured

by the Revised Childrens Manifest Anxiety Scale

with the intervention group showing fewer anxiety

symptoms at post intervention and 6 months follow-

up

Anxiety post intervention F(1,15)=8.72 p<.01; 6

month follow-up F(1,15)=3.86 p<.05.

Seligman 1999 Significant intervention effect on Anxiety measured

by the Beck Anxiety Inventory for mean of follow-

up scores, and highest level of symptomology post

intervention with the intervention group showing less

anxiety.

Anxiety mean follow-up F(1,223)=4.4 p<.02. Anxiety

highest post intervention F(1,223) 3.3 p<.03.

A N A L Y S E S

Comparison 01. Psychological/educational intervention versus no intervention/wait-list/usual care

Outcome titleNo. of

studies

No. of

participants Statistical method Effect size

01 Depression scores (by

population)

9 2270 Standardised Mean Difference (Random) 95%

CI

-0.26 [-0.36, -0.15]


intervention)


CI

-0.26 [-0.36, -0.15]

03 Depression scores (by gender) 15 2464 Standardised Mean Difference (Random) 95%

CI

-0.20 [-0.35, -0.04]

04 Depression scores (by risk) 10 1580 Standardised Mean Difference (Random) 95%

CI

-0.31 [-0.45, -0.17]

05 Depressive disorder (by

population)

5 588 Risk Difference (Random) 95% CI -0.10 [-0.15, -0.05]


intervention)

5 588 Risk Difference (Random) 95% CI -0.10 [-0.15, -0.05]

07 Depressive disorder (by gender) 11 640 Risk Difference (Random) 95% CI -0.09 [-0.14, -0.04]

08 Depressive disorders (by risk) 4 146 Risk Difference (Random) 95% CI -0.06 [-0.17, 0.05]

Comparison 02. Psychological/educational intervention versus placebo/attention/other intervention

Outcome titleNo. of

studies

No. of



population)


CI

0.13 [-0.21, 0.47]


intervention)


CI

0.13 [-0.21, 0.47]


CI

0.09 [-0.31, 0.49]


CI

0.24 [-0.15, 0.64]


population)

1 98 Risk Difference (Random) 95% CI 0.10 [-0.07, 0.27]




intervention)


07 Depressive disorder (by gender) 0 0 Risk Difference (Random) 95% CI Not estimable

08 Depressive disorder (by risk) 0 0 Risk Difference (Random) 95% CI Not estimable

Comparison 03. Psychological/educational intervention versus no intervention/wait list/usual care 3-6 months

Outcome titleNo. of

studies

No. of



population)


CI

-0.17 [-0.36, 0.01]


intervention)


CI

-0.17 [-0.36, 0.01]


CI

-0.05 [-0.19, 0.09]


CI

-0.25 [-0.63, 0.13]


population)

4 276 Risk Difference (Random) 95% CI -0.09 [-0.21, 0.03]


intervention)


07 Depressive disorder (by gender) 7 276 Risk Difference (Random) 95% CI -0.07 [-0.14, 0.00]

08 Depressive disorder (by risk) 4 121 Risk Difference (Random) 95% CI -0.01 [-0.08, 0.06]

Comparison 04. Psychological/educational intervention versus placebo/attention/other intervention 3-6 months

Outcome titleNo. of

studies

No. of



population)


CI

-0.11 [-0.52, 0.29]


intervention)


CI

-0.11 [-0.52, 0.29]


CI

-0.14 [-0.79, 0.50]


CI

-0.19 [-0.60, 0.23]


population)



intervention)




Comparison 05. Psychological/educational intervention versus no intervention/wait list/usual care 12 months

Outcome titleNo. of

studies

No. of



population)


CI

-0.16 [-0.36, 0.04]


intervention)


CI

-0.16 [-0.36, 0.04]


CI

-0.15 [-0.35, 0.06]




CI

-0.05 [-0.19, 0.09]


population)



intervention)



08 Depressive disorder (by risk) 5 343 Risk Difference (Random) 95% CI 0.01 [-0.05, 0.06]

Comparison 06. Psychological/educational intervention versus placebo/attention/other intervention 12 months

Outcome titleNo. of

studies

No. of



population)


CI

0.11 [-0.28, 0.51]


intervention)


CI

0.11 [-0.28, 0.51]


CI

0.27 [-0.19, 0.73]


CI

0.23 [-0.23, 0.68]


population)



intervention)



08 Depressive Disorder (by risk) 0 0 Risk Difference (Random) 95% CI Not estimable


Outcome titleNo. of

studies

No. of



population)


CI

-0.05 [-0.32, 0.23]


intervention)


CI

-0.05 [-0.33, 0.23]


CI

-0.09 [-0.40, 0.21]


CI

-0.27 [-0.81, 0.28]


population)



intervention)



08 Depressive disorder (by risk) 4 110 Risk Difference (Random) 95% CI -0.04 [-0.14, 0.06]




Outcome titleNo. of

studies

No. of



population)


CI

-0.29 [-0.56, -0.01]


intervention)


CI

-0.29 [-0.56, -0.01]


CI

Not estimable


CI

Not estimable


population)



intervention)




I N D E X T E R M S

Medical Subject Headings (MeSH)

Adolescent; Depression [diagnosis; ∗prevention & control]; Depressive Disorder [diagnosis; ∗prevention & control]; Psychotherapy

[methods]; Randomized Controlled Trials

MeSH check words

Adult; Child; Child, Preschool; Female; Humans; Male

C O V E R S H E E T

Title Psychological and/or educational interventions for the prevention of depression in children

and adolescents

Authors Merry S, McDowell H, Hetrick S, Bir J, Muller N

Contribution of author(s) Sally Merry, Heather McDowell, Julliet Bir, Sarah Hetrick devised the protocol.

SM and JB conducted searches. SM and HM both selected trials for inclusion. SM, HM,

JB, SH all extracted trial information and quality information from trials, and extracted

outcome data. JB and SH entered data. SM drafted text of review, with all authors providing

comment and feedback.

Issue protocol first published 2001/3

Review first published 2004/1

Date of most recent amendment 16 February 2007

Date of most recent

SUBSTANTIVE amendment

28 November 2003

What’s New Information not supplied by author

Date new studies sought but

none found

Information not supplied by author



Date new studies found but not

yet included/excluded


Date new studies found and

included/excluded


Date authors’ conclusions

section amended


Contact address Dr Sally Merry

Senior Lecturer

Department of Psychiatry

The University of Auckland

Private Bag 92019

Auckland

NEW ZEALAND

E-mail: [email protected]

Tel: 0064 9 3737599

Fax: 0064 9 367 7128

DOI 10.1002/14651858.CD003380.pub2

Cochrane Library number CD003380

Editorial group Cochrane Depression, Anxiety and Neurosis Group

Editorial group code HM-DEPRESSN

G R A P H S A N D O T H E R T A B L E S



Analysis 01.01. Comparison 01 Psychological/educational intervention versus no intervention/wait-list/usual

care, Outcome 01 Depression scores (by population)

Review: Psychological and/or educational interventions for the prevention of depression in children and adolescents

Comparison: 01 Psychological/educational intervention versus no intervention/wait-list/usual care

Outcome: 01 Depression scores (by population)

Study Intervention No intervention Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)

N Mean(SD) N Mean(SD) 95% CI (%) 95% CI

01 Targeted

Clarke 1995 55 17.88 (9.30) 70 21.67 (12.30) 7.8 -0.34 [ -0.70, 0.02 ]

Clarke 2001 41 17.80 (8.70) 49 22.50 (11.30) 5.8 -0.46 [ -0.88, -0.04 ]

Roberts in press 84 8.51 (9.26) 95 8.97 (9.90) 10.8 -0.05 [ -0.34, 0.25 ]

Seligman 1999 106 3.20 (3.00) 119 4.30 (3.40) 12.9 -0.34 [ -0.60, -0.08 ]

Yu 2002 101 13.64 (9.01) 114 16.02 (10.16) 12.5 -0.25 [ -0.51, 0.02 ]

Subtotal (95% CI) 387 447 49.8 -0.26 [ -0.40, -0.13 ]

Test for heterogeneity chi-square=3.41 df=4 p=0.49 I² =0.0%

Test for overall effect z=3.79 p=0.0002

02 Universal

Cardemil 2002a 24 6.58 (6.25) 22 11.17 (7.47) 3.0 -0.66 [ -1.25, -0.06 ]

Cardemil 2002b 47 6.24 (5.31) 55 7.31 (5.99) 6.6 -0.19 [ -0.58, 0.20 ]

Quayle 2001 21 6.97 (9.02) 21 4.04 (5.11) 2.9 0.39 [ -0.22, 1.00 ]

Spence 2003 624 6.25 (7.87) 622 8.69 (10.12) 37.8 -0.27 [ -0.38, -0.16 ]

Subtotal (95% CI) 716 720 50.2 -0.21 [ -0.48, 0.06 ]



Total (95% CI) 1103 1167 100.0 -0.26 [ -0.36, -0.15 ]


Test for overall effect z=4.73 p<0.00001

-1.0 -0.5 0 0.5 1.0

Intervention No intervention




care, Outcome 02 Depression scores (by intervention)



Outcome: 02 Depression scores (by intervention)



01 Educational

Subtotal (95% CI) 0 0 0.0 Not estimable

Test for heterogeneity: not applicable

Test for overall effect: not applicable

02 Psychological

Cardemil 2002a 24 6.58 (6.25) 22 11.17 (7.47) 3.0 -0.66 [ -1.25, -0.06 ]

Cardemil 2002b 47 6.24 (5.31) 55 7.31 (5.99) 6.6 -0.19 [ -0.58, 0.20 ]

Clarke 1995 55 17.88 (9.30) 70 21.67 (12.30) 7.8 -0.34 [ -0.70, 0.02 ]

Clarke 2001 41 17.80 (8.70) 49 22.50 (11.30) 5.8 -0.46 [ -0.88, -0.04 ]

Quayle 2001 21 6.97 (9.02) 21 4.04 (5.11) 2.9 0.39 [ -0.22, 1.00 ]

Roberts in press 84 8.51 (9.26) 95 8.97 (9.90) 10.8 -0.05 [ -0.34, 0.25 ]

Seligman 1999 106 3.20 (3.00) 119 4.30 (3.40) 12.9 -0.34 [ -0.60, -0.08 ]

Spence 2003 624 6.25 (7.87) 622 8.69 (10.12) 37.8 -0.27 [ -0.38, -0.16 ]

Yu 2002 101 13.64 (9.01) 114 16.02 (10.16) 12.5 -0.25 [ -0.51, 0.02 ]

Subtotal (95% CI) 1103 1167 100.0 -0.26 [ -0.36, -0.15 ]



Total (95% CI) 1103 1167 100.0 -0.26 [ -0.36, -0.15 ]



-1.0 -0.5 0 0.5 1.0





care, Outcome 03 Depression scores (by gender)



Outcome: 03 Depression scores (by gender)

Study Intervention No Intervention Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)


01 Males

Cardemil 2002a 10 4.70 (5.66) 13 9.99 (5.83) 2.5 -0.89 [ -1.76, -0.01 ]

Cardemil 2002b 24 7.23 (5.51) 21 8.55 (6.81) 4.6 -0.21 [ -0.80, 0.38 ]

Clarke 1993a 163 11.75 (10.00) 137 13.74 (11.10) 10.7 -0.19 [ -0.42, 0.04 ]

Clarke 1993b 94 13.04 (9.50) 66 13.67 (10.10) 8.8 -0.06 [ -0.38, 0.25 ]

Clarke 1995 12 17.75 (7.33) 24 15.87 (9.90) 3.6 0.20 [ -0.49, 0.90 ]

Clarke 2001 20 18.90 (5.80) 17 18.90 (8.70) 4.0 0.00 [ -0.65, 0.65 ]

Spence 2003 288 3.95 (5.43) 310 8.32 (11.05) 12.1 -0.50 [ -0.66, -0.33 ]

Subtotal (95% CI) 611 588 46.1 -0.24 [ -0.46, -0.03 ]



02 Females

Cardemil 2002a 14 7.93 (6.51) 9 12.89 (9.48) 2.6 -0.61 [ -1.47, 0.25 ]

Cardemil 2002b 23 5.21 (5.00) 34 6.53 (5.38) 5.2 -0.25 [ -0.78, 0.28 ]

Clarke 1993a 116 16.12 (13.10) 97 14.94 (11.70) 9.7 0.09 [ -0.18, 0.36 ]

Clarke 1993b 57 17.16 (11.40) 83 17.05 (11.70) 8.3 0.01 [ -0.33, 0.35 ]

Clarke 1995 43 17.85 (9.76) 46 24.70 (12.50) 6.7 -0.60 [ -1.03, -0.18 ]

Clarke 2001 21 16.70 (10.80) 32 24.40 (12.10) 4.8 -0.65 [ -1.22, -0.09 ]

Quayle 2001 21 6.97 (9.02) 21 4.04 (5.11) 4.3 0.39 [ -0.22, 1.00 ]

Spence 2003 336 8.22 (9.03) 312 9.05 (9.11) 12.2 -0.09 [ -0.25, 0.06 ]

Subtotal (95% CI) 631 634 53.9 -0.16 [ -0.36, 0.05 ]



Total (95% CI) 1242 1222 100.0 -0.20 [ -0.35, -0.04 ]



-1.0 -0.5 0 0.5 1.0





care, Outcome 04 Depression scores (by risk)



Outcome: 04 Depression scores (by risk)



01 High Risk

Cardemil 2002a 12 9.67 (6.36) 9 17.48 (6.00) 2.1 -1.21 [ -2.16, -0.25 ]

Cardemil 2002b 25 8.81 (5.62) 30 10.09 (6.63) 6.1 -0.20 [ -0.74, 0.33 ]

Hains 1994 6 62.67 (9.48) 4 78.00 (12.19) 0.9 -1.31 [ -2.77, 0.16 ]

Roberts in press 23 18.32 (10.23) 24 18.12 (11.46) 5.4 0.02 [ -0.55, 0.59 ]

Spence 2003 144 10.68 (9.10) 156 14.34 (10.98) 23.2 -0.36 [ -0.59, -0.13 ]

Subtotal (95% CI) 210 223 37.7 -0.37 [ -0.70, -0.04 ]



02 Low Risk

Cardemil 2002a 10 2.30 (3.89) 13 6.81 (4.82) 2.4 -0.98 [ -1.86, -0.10 ]

Cardemil 2002b 22 3.32 (2.98) 25 3.97 (2.50) 5.3 -0.23 [ -0.81, 0.34 ]

Hains 1994 5 58.00 (9.42) 6 54.20 (9.39) 1.3 0.37 [ -0.83, 1.57 ]

Roberts in press 61 4.80 (4.86) 71 5.88 (7.07) 13.0 -0.17 [ -0.52, 0.17 ]

Spence 2003 463 4.17 (5.11) 471 6.44 (8.67) 40.3 -0.32 [ -0.45, -0.19 ]

Subtotal (95% CI) 561 586 62.3 -0.30 [ -0.43, -0.17 ]



Total (95% CI) 771 809 100.0 -0.31 [ -0.45, -0.17 ]



-1.0 -0.5 0 0.5 1.0

Intervention No interventention




care, Outcome 05 Depressive disorder (by population)



Outcome: 05 Depressive disorder (by population)

Study Intervention No intervention Risk Difference (Random) Weight Risk Difference (Random)

n/N n/N 95% CI (%) 95% CI

01 Targeted

Clarke 1995 4/55 12/70 19.7 -0.10 [ -0.21, 0.01 ]

Clarke 2001 1/41 12/49 14.7 -0.22 [ -0.35, -0.09 ]

Seligman 1999 42/106 57/119 14.7 -0.08 [ -0.21, 0.05 ]

Subtotal (95% CI) 202 238 49.1 -0.13 [ -0.22, -0.05 ]

Total events: 47 (Intervention), 81 (No intervention)



02 Universal

Cardemil 2002a 1/24 3/22 9.1 -0.09 [ -0.26, 0.07 ]

Cardemil 2002b 0/47 4/55 41.8 -0.07 [ -0.15, 0.00 ]

Subtotal (95% CI) 71 77 50.9 -0.08 [ -0.15, -0.01 ]




Total (95% CI) 273 315 100.0 -0.10 [ -0.15, -0.05 ]




-0.5 -0.25 0 0.25 0.5





care, Outcome 06 Depressive disorder (by intervention)



Outcome: 06 Depressive disorder (by intervention)


n/N n/N 95% CI (%) 95% CI

01 Educational





02 Psychological

Cardemil 2002a 1/24 3/22 9.1 -0.09 [ -0.26, 0.07 ]

Cardemil 2002b 0/47 4/55 41.8 -0.07 [ -0.15, 0.00 ]

Clarke 1995 4/55 12/70 19.7 -0.10 [ -0.21, 0.01 ]

Clarke 2001 1/41 12/49 14.7 -0.22 [ -0.35, -0.09 ]

Seligman 1999 42/106 57/119 14.7 -0.08 [ -0.21, 0.05 ]

Subtotal (95% CI) 273 315 100.0 -0.10 [ -0.15, -0.05 ]




Total (95% CI) 273 315 100.0 -0.10 [ -0.15, -0.05 ]




-0.5 -0.25 0 0.25 0.5





care, Outcome 07 Depressive disorder (by gender)



Outcome: 07 Depressive disorder (by gender)


n/N n/N 95% CI (%) 95% CI

01 Males

Cardemil 2002a 0/10 1/13 6.1 -0.08 [ -0.28, 0.13 ]

Cardemil 2002b 0/24 3/21 9.3 -0.14 [ -0.31, 0.02 ]

Clarke 1995 1/12 3/43 8.2 0.01 [ -0.16, 0.19 ]

Clarke 2001 0/20 2/17 8.3 -0.12 [ -0.29, 0.05 ]

Seligman 1999 18/54 18/54 7.8 0.00 [ -0.18, 0.18 ]

Subtotal (95% CI) 120 148 39.6 -0.07 [ -0.15, 0.01 ]




02 Females

Cardemil 2002a 1/14 2/9 2.8 -0.15 [ -0.45, 0.15 ]

Cardemil 2002b 0/23 1/34 26.6 -0.03 [ -0.12, 0.06 ]

Clarke 1995 3/43 9/46 12.5 -0.13 [ -0.26, 0.01 ]

Clarke 2001 1/21 10/32 7.3 -0.26 [ -0.45, -0.08 ]

Quayle 2001 1/20 4/13 3.6 -0.26 [ -0.53, 0.01 ]

Seligman 1999 24/52 39/65 7.6 -0.14 [ -0.32, 0.04 ]

Subtotal (95% CI) 173 199 60.4 -0.14 [ -0.23, -0.04 ]




Total (95% CI) 293 347 100.0 -0.09 [ -0.14, -0.04 ]




-0.5 -0.25 0 0.25 0.5





care, Outcome 08 Depressive disorders (by risk)



Outcome: 08 Depressive disorders (by risk)

Study Treatment Control Risk Difference (Random) Weight Risk Difference (Random)

n/N n/N 95% CI (%) 95% CI

01 High Risk

Cardemil 2002a 1/12 3/9 8.7 -0.25 [ -0.60, 0.10 ]

Cardemil 2002b 0/25 4/30 28.3 -0.13 [ -0.27, 0.00 ]

Subtotal (95% CI) 37 39 36.9 -0.15 [ -0.27, -0.02 ]

Total events: 1 (Treatment), 7 (Control)



02 Low Risk

Cardemil 2002a 0/10 0/13 24.7 0.00 [ -0.16, 0.16 ]

Cardemil 2002b 0/22 0/25 38.4 0.00 [ -0.08, 0.08 ]

Subtotal (95% CI) 32 38 63.1 0.00 [ -0.07, 0.07 ]



Test for overall effect z=0.00 p=1

Total (95% CI) 69 77 100.0 -0.06 [ -0.17, 0.05 ]




-0.5 -0.25 0 0.25 0.5

Intervention No Intervention



Analysis 02.01. Comparison 02 Psychological/educational intervention versus placebo/attention/other

intervention, Outcome 01 Depression scores (by population)


Comparison: 02 Psychological/educational intervention versus placebo/attention/other intervention


Study Intervention Placebo Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)


01 Targeted




02 Universal

Pattison 2001 16 8.64 (8.41) 16 7.53 (8.27) 24.6 0.13 [ -0.56, 0.82 ]

Shatte 1997 51 9.53 (10.85) 47 8.19 (9.40) 75.4 0.13 [ -0.27, 0.53 ]

Subtotal (95% CI) 67 63 100.0 0.13 [ -0.21, 0.47 ]



Total (95% CI) 67 63 100.0 0.13 [ -0.21, 0.47 ]



-1.0 -0.5 0 0.5 1.0

Intervention Placebo


intervention, Outcome 02 Depression scores (by intervention)






01 Educational




02 Psychological

Pattison 2001 16 8.64 (8.41) 16 7.53 (8.27) 24.6 0.13 [ -0.56, 0.82 ]

Shatte 1997 51 9.53 (10.85) 47 8.19 (9.40) 75.4 0.13 [ -0.27, 0.53 ]

Subtotal (95% CI) 67 63 100.0 0.13 [ -0.21, 0.47 ]



-1.0 -0.5 0 0.5 1.0

Intervention Placebo (Continued . . . )



(. . . Continued)



Total (95% CI) 67 63 100.0 0.13 [ -0.21, 0.47 ]



-1.0 -0.5 0 0.5 1.0



intervention, Outcome 03 Depression scores (by gender)






01 Males

Shatte 1997 27 6.56 (8.32) 25 7.12 (6.52) 53.3 -0.07 [ -0.62, 0.47 ]

Subtotal (95% CI) 27 25 53.3 -0.07 [ -0.62, 0.47 ]



02 Females

Shatte 1997 24 12.88 (12.47) 22 9.41 (11.92) 46.7 0.28 [ -0.30, 0.86 ]

Subtotal (95% CI) 24 22 46.7 0.28 [ -0.30, 0.86 ]



Total (95% CI) 51 47 100.0 0.09 [ -0.31, 0.49 ]



-1.0 -0.5 0 0.5 1.0





intervention, Outcome 04 Depression scores (by risk)






01 High Risk

Shatte 1997 23 16.09 (12.15) 23 13.83 (10.46) 47.2 0.20 [ -0.38, 0.78 ]

Subtotal (95% CI) 23 23 47.2 0.20 [ -0.38, 0.78 ]



02 Low Risk

Shatte 1997 28 4.14 (5.56) 24 2.79 (3.16) 52.8 0.29 [ -0.26, 0.84 ]

Subtotal (95% CI) 28 24 52.8 0.29 [ -0.26, 0.84 ]



Total (95% CI) 51 47 100.0 0.24 [ -0.15, 0.64 ]



-1.0 -0.5 0 0.5 1.0



intervention, Outcome 05 Depressive disorder (by population)




Study Intervention Placebo Risk Difference (Random) Weight Risk Difference (Random)

n/N n/N 95% CI (%) 95% CI

01 Targeted


Total events: 0 (Intervention), 0 (Placebo)



02 Universal

Shatte 1997 15/51 9/47 100.0 0.10 [ -0.07, 0.27 ]

Subtotal (95% CI) 51 47 100.0 0.10 [ -0.07, 0.27 ]



-0.5 -0.25 0 0.25 0.5




(. . . Continued)


n/N n/N 95% CI (%) 95% CI


Total (95% CI) 51 47 100.0 0.10 [ -0.07, 0.27 ]




-0.5 -0.25 0 0.25 0.5



intervention, Outcome 06 Depressive disorder (by intervention)





n/N n/N 95% CI (%) 95% CI

01 Educational





02 Psychological

Shatte 1997 15/51 9/47 100.0 0.10 [ -0.07, 0.27 ]

Subtotal (95% CI) 51 47 100.0 0.10 [ -0.07, 0.27 ]




Total (95% CI) 51 47 100.0 0.10 [ -0.07, 0.27 ]




-0.5 -0.25 0 0.25 0.5




Analysis 03.01. Comparison 03 Psychological/educational intervention versus no intervention/wait list/usual

care 3-6 months, Outcome 01 Depression scores (by population)


Comparison: 03 Psychological/educational intervention versus no intervention/wait list/usual care 3-6 months




01 Targeted

Clarke 1995 54 19.35 (10.00) 66 18.55 (11.20) 15.6 0.07 [ -0.29, 0.43 ]

Roberts in press 65 6.35 (7.30) 72 6.90 (7.61) 16.9 -0.07 [ -0.41, 0.26 ]

Seligman 1999 106 2.90 (3.90) 117 3.30 (3.30) 21.5 -0.11 [ -0.37, 0.15 ]

Yu 2002 99 13.55 (8.76) 112 16.68 (10.32) 20.8 -0.32 [ -0.60, -0.05 ]

Subtotal (95% CI) 324 367 74.9 -0.13 [ -0.29, 0.02 ]



02 Universal

Cardemil 2002a 21 4.33 (5.51) 21 10.23 (9.70) 7.2 -0.73 [ -1.36, -0.11 ]

Cardemil 2002b 40 5.96 (5.78) 41 5.41 (5.34) 12.3 0.10 [ -0.34, 0.53 ]

Quayle 2001 20 4.86 (5.42) 13 10.47 (10.71) 5.7 -0.69 [ -1.41, 0.03 ]

Subtotal (95% CI) 81 75 25.1 -0.40 [ -0.99, 0.20 ]



Total (95% CI) 405 442 100.0 -0.17 [ -0.36, 0.01 ]



-1.0 -0.5 0 0.5 1.0





care 3-6 months, Outcome 02 Depression scores (by intervention)






01 Educational




02 Psychological

Cardemil 2002a 21 4.33 (5.51) 21 10.23 (9.70) 7.2 -0.73 [ -1.36, -0.11 ]

Cardemil 2002b 40 5.96 (5.78) 41 5.41 (5.34) 12.3 0.10 [ -0.34, 0.53 ]

Clarke 1995 54 19.35 (10.00) 66 18.55 (11.20) 15.6 0.07 [ -0.29, 0.43 ]

Quayle 2001 20 4.86 (5.42) 13 10.47 (10.71) 5.7 -0.69 [ -1.41, 0.03 ]

Roberts in press 65 6.35 (7.30) 72 6.90 (7.61) 16.9 -0.07 [ -0.41, 0.26 ]

Seligman 1999 106 2.90 (3.90) 117 3.30 (3.30) 21.5 -0.11 [ -0.37, 0.15 ]

Yu 2002 99 13.55 (8.76) 112 16.68 (10.32) 20.8 -0.32 [ -0.60, -0.05 ]

Subtotal (95% CI) 405 442 100.0 -0.17 [ -0.36, 0.01 ]



Total (95% CI) 405 442 100.0 -0.17 [ -0.36, 0.01 ]



-1.0 -0.5 0 0.5 1.0





care 3-6 months, Outcome 03 Depression scores (by gender)






01 Males

Cardemil 2002a 7 2.29 (3.50) 15 10.71 (9.62) 2.1 -0.98 [ -1.93, -0.03 ]

Cardemil 2002b 19 6.97 (6.16) 14 6.00 (4.90) 3.8 0.17 [ -0.52, 0.86 ]

Clarke 1993a 163 13.68 (11.10) 137 13.16 (10.30) 23.5 0.05 [ -0.18, 0.28 ]

Clarke 1993b 94 11.97 (9.40) 66 14.68 (10.40) 14.8 -0.27 [ -0.59, 0.04 ]

Clarke 1995 12 16.67 (8.29) 22 16.19 (9.91) 3.7 0.05 [ -0.65, 0.75 ]

Subtotal (95% CI) 295 254 47.8 -0.11 [ -0.38, 0.16 ]



02 Females

Cardemil 2002a 14 5.36 (6.13) 6 9.02 (10.72) 2.0 -0.46 [ -1.43, 0.51 ]

Cardemil 2002b 21 5.05 (5.40) 27 5.11 (5.63) 5.4 -0.01 [ -0.58, 0.56 ]

Clarke 1993a 116 17.38 (12.70) 97 16.63 (12.20) 18.7 0.06 [ -0.21, 0.33 ]

Clarke 1993b 57 15.95 (12.10) 83 15.11 (10.50) 13.4 0.07 [ -0.26, 0.41 ]

Clarke 1995 42 20.18 (10.36) 44 19.97 (11.79) 9.2 0.02 [ -0.40, 0.44 ]

Quayle 2001 20 4.86 (5.42) 13 10.47 (10.71) 3.5 -0.69 [ -1.41, 0.03 ]

Subtotal (95% CI) 270 270 52.2 -0.01 [ -0.18, 0.16 ]



Total (95% CI) 565 524 100.0 -0.05 [ -0.19, 0.09 ]



-1.0 -0.5 0 0.5 1.0





care 3-6 months, Outcome 04 Depression scores (by risk)






01 High Risk

Cardemil 2002a 11 4.82 (6.40) 8 16.89 (11.86) 9.9 -1.27 [ -2.29, -0.26 ]

Cardemil 2002b 20 8.96 (6.55) 22 6.73 (6.07) 18.3 0.35 [ -0.26, 0.96 ]

Roberts in press 18 11.27 (8.48) 19 13.34 (9.24) 17.3 -0.23 [ -0.88, 0.42 ]

Subtotal (95% CI) 49 49 45.5 -0.30 [ -1.11, 0.51 ]



02 Low Risk

Cardemil 2002a 8 2.13 (3.09) 13 6.13 (5.21) 11.3 -0.84 [ -1.77, 0.08 ]

Cardemil 2002b 20 2.97 (2.60) 19 3.89 (3.98) 17.7 -0.27 [ -0.90, 0.36 ]

Roberts in press 47 4.46 (5.87) 53 4.59 (5.38) 25.5 -0.02 [ -0.42, 0.37 ]

Subtotal (95% CI) 75 85 54.5 -0.22 [ -0.62, 0.17 ]



Total (95% CI) 124 134 100.0 -0.25 [ -0.63, 0.13 ]



-1.0 -0.5 0 0.5 1.0





care 3-6 months, Outcome 05 Depressive disorder (by population)





n/N n/N 95% CI (%) 95% CI

01 Targeted

Clarke 1995 5/54 14/66 28.3 -0.12 [ -0.24, 0.01 ]

Subtotal (95% CI) 54 66 28.3 -0.12 [ -0.24, 0.01 ]




02 Universal

Cardemil 2002a 1/21 3/21 22.2 -0.10 [ -0.27, 0.08 ]

Cardemil 2002b 1/40 1/41 35.7 0.00 [ -0.07, 0.07 ]

Quayle 2001 1/20 4/13 13.8 -0.26 [ -0.53, 0.01 ]

Subtotal (95% CI) 81 75 71.7 -0.09 [ -0.26, 0.09 ]




Total (95% CI) 135 141 100.0 -0.09 [ -0.21, 0.03 ]




-0.5 -0.25 0 0.25 0.5





care 3-6 months, Outcome 06 Depressive disorder (by intervention)





n/N n/N 95% CI (%) 95% CI

01 Educational





02 Psychological

Cardemil 2002a 1/21 3/21 22.2 -0.10 [ -0.27, 0.08 ]

Cardemil 2002b 1/40 1/41 35.7 0.00 [ -0.07, 0.07 ]

Clarke 1995 5/54 14/66 28.3 -0.12 [ -0.24, 0.01 ]

Quayle 2001 1/20 4/13 13.8 -0.26 [ -0.53, 0.01 ]

Subtotal (95% CI) 135 141 100.0 -0.09 [ -0.21, 0.03 ]




Total (95% CI) 135 141 100.0 -0.09 [ -0.21, 0.03 ]




-0.5 -0.25 0 0.25 0.5





care 3-6 months, Outcome 07 Depressive disorder (by gender)





n/N n/N 95% CI (%) 95% CI

01 Males

Cardemil 2002a 0/7 2/15 8.3 -0.13 [ -0.38, 0.11 ]

Cardemil 2002b 1/19 0/14 19.7 0.05 [ -0.09, 0.20 ]

Clarke 1995 1/12 4/22 9.7 -0.10 [ -0.32, 0.13 ]

Subtotal (95% CI) 38 51 37.7 -0.03 [ -0.15, 0.10 ]




02 Females

Cardemil 2002a 1/14 1/6 4.9 -0.10 [ -0.42, 0.23 ]

Cardemil 2002b 0/21 1/27 31.8 -0.04 [ -0.14, 0.07 ]

Clarke 1995 4/42 10/44 18.6 -0.13 [ -0.28, 0.02 ]

Quayle 2001 1/20 4/13 7.0 -0.26 [ -0.53, 0.01 ]

Subtotal (95% CI) 97 90 62.3 -0.10 [ -0.19, 0.00 ]




Total (95% CI) 135 141 100.0 -0.07 [ -0.14, 0.00 ]




-0.5 -0.25 0 0.25 0.5





care 3-6 months, Outcome 08 Depressive disorder (by risk)



Outcome: 08 Depressive disorder (by risk)


n/N n/N 95% CI (%) 95% CI

01 High Risk

Cardemil 2002a 1/11 3/8 3.5 -0.28 [ -0.66, 0.09 ]

Cardemil 2002b 1/20 1/22 28.9 0.00 [ -0.12, 0.13 ]

Subtotal (95% CI) 31 30 32.4 -0.10 [ -0.43, 0.22 ]




02 Low Risk

Cardemil 2002a 0/8 0/13 15.4 0.00 [ -0.18, 0.18 ]

Cardemil 2002b 0/20 0/19 52.1 0.00 [ -0.09, 0.09 ]

Subtotal (95% CI) 28 32 67.6 0.00 [ -0.08, 0.08 ]




Total (95% CI) 59 62 100.0 -0.01 [ -0.08, 0.06 ]




-0.5 -0.25 0 0.25 0.5





intervention 3-6 months, Outcome 01 Depression scores (by population)


Comparison: 04 Psychological/educational intervention versus placebo/attention/other intervention 3-6 months




01 Targeted




02 Universal

Shatte 1997 50 7.96 (8.41) 45 9.02 (10.02) 100.0 -0.11 [ -0.52, 0.29 ]

Subtotal (95% CI) 50 45 100.0 -0.11 [ -0.52, 0.29 ]



Total (95% CI) 50 45 100.0 -0.11 [ -0.52, 0.29 ]



-1.0 -0.5 0 0.5 1.0



intervention 3-6 months, Outcome 02 Depression scores (by intervention)






01 Educational




02 Psychological

Shatte 1997 50 7.96 (8.41) 45 9.02 (10.02) 100.0 -0.11 [ -0.52, 0.29 ]

Subtotal (95% CI) 50 45 100.0 -0.11 [ -0.52, 0.29 ]



Total (95% CI) 50 45 100.0 -0.11 [ -0.52, 0.29 ]



-1.0 -0.5 0 0.5 1.0





intervention 3-6 months, Outcome 03 Depression scores (by gender)






01 Males

Shatte 1997 29 5.34 (5.76) 24 8.71 (8.72) 52.0 -0.46 [ -1.01, 0.09 ]

Subtotal (95% CI) 29 24 52.0 -0.46 [ -1.01, 0.09 ]



02 Females

Shatte 1997 21 11.57 (10.16) 21 9.38 (11.55) 48.0 0.20 [ -0.41, 0.80 ]

Subtotal (95% CI) 21 21 48.0 0.20 [ -0.41, 0.80 ]



Total (95% CI) 50 45 100.0 -0.14 [ -0.79, 0.50 ]



-1.0 -0.5 0 0.5 1.0



intervention 3-6 months, Outcome 04 Depression scores (by risk)






01 High Risk

Shatte 1997 23 12.84 (9.08) 19 15.19 (11.54) 45.8 -0.22 [ -0.83, 0.38 ]

Subtotal (95% CI) 23 19 45.8 -0.22 [ -0.83, 0.38 ]



02 Low Risk

Shatte 1997 25 3.08 (3.52) 24 3.62 (3.36) 54.2 -0.15 [ -0.72, 0.41 ]

Subtotal (95% CI) 25 24 54.2 -0.15 [ -0.72, 0.41 ]


-1.0 -0.5 0 0.5 1.0




(. . . Continued)




Total (95% CI) 48 43 100.0 -0.19 [ -0.60, 0.23 ]



-1.0 -0.5 0 0.5 1.0



intervention 3-6 months, Outcome 05 Depressive disorder (by population)





n/N n/N 95% CI (%) 95% CI

01 Targeted





02 Universal

Shatte 1997 12/50 11/45 100.0 0.00 [ -0.18, 0.17 ]

Subtotal (95% CI) 50 45 100.0 0.00 [ -0.18, 0.17 ]




Total (95% CI) 50 45 100.0 0.00 [ -0.18, 0.17 ]




-0.5 -0.25 0 0.25 0.5





intervention 3-6 months, Outcome 06 Depressive disorder (by intervention)





n/N n/N 95% CI (%) 95% CI

01 Educational





02 Psychological

Shatte 1997 12/50 11/45 100.0 0.00 [ -0.18, 0.17 ]

Subtotal (95% CI) 50 45 100.0 0.00 [ -0.18, 0.17 ]




Total (95% CI) 50 45 100.0 0.00 [ -0.18, 0.17 ]




-0.5 -0.25 0 0.25 0.5





care 12 months, Outcome 01 Depression scores (by population)


Comparison: 05 Psychological/educational intervention versus no intervention/wait list/usual care 12 months




01 Targeted

Clarke 1995 52 18.40 (9.30) 58 18.34 (11.00) 15.4 0.01 [ -0.37, 0.38 ]

Clarke 2001 41 15.10 (10.00) 45 21.50 (13.60) 13.1 -0.53 [ -0.96, -0.10 ]

Seligman 1999 103 2.20 (3.30) 116 3.10 (3.80) 21.1 -0.25 [ -0.52, 0.02 ]

Subtotal (95% CI) 196 219 49.6 -0.24 [ -0.51, 0.02 ]



02 Universal

Cardemil 2002a 21 4.29 (5.20) 20 8.74 (7.86) 7.7 -0.66 [ -1.29, -0.03 ]

Cardemil 2002b 40 5.80 (6.44) 39 5.41 (5.76) 12.7 0.06 [ -0.38, 0.50 ]

Spence 2003 484 7.75 (9.69) 515 7.72 (8.39) 29.9 0.00 [ -0.12, 0.13 ]

Subtotal (95% CI) 545 574 50.4 -0.09 [ -0.40, 0.21 ]



Total (95% CI) 741 793 100.0 -0.16 [ -0.36, 0.04 ]



-1.0 -0.5 0 0.5 1.0





care 12 months, Outcome 02 Depression scores (by intervention)






01 Educational




02 Psychological

Cardemil 2002a 21 4.29 (5.20) 20 8.74 (7.86) 7.7 -0.66 [ -1.29, -0.03 ]

Cardemil 2002b 40 5.80 (6.44) 39 5.41 (5.76) 12.7 0.06 [ -0.38, 0.50 ]

Clarke 1995 52 18.40 (9.30) 58 18.34 (11.00) 15.4 0.01 [ -0.37, 0.38 ]

Clarke 2001 41 15.10 (10.00) 45 21.50 (13.60) 13.1 -0.53 [ -0.96, -0.10 ]

Seligman 1999 103 2.20 (3.30) 116 3.10 (3.80) 21.1 -0.25 [ -0.52, 0.02 ]

Spence 2003 484 7.75 (9.69) 515 7.72 (8.39) 29.9 0.00 [ -0.12, 0.13 ]

Subtotal (95% CI) 741 793 100.0 -0.16 [ -0.36, 0.04 ]



Total (95% CI) 741 793 100.0 -0.16 [ -0.36, 0.04 ]



-1.0 -0.5 0 0.5 1.0





care 12 months, Outcome 03 Depression scores (by gender)






01 Males

Cardemil 2002a 7 2.00 (3.21) 14 6.66 (6.17) 4.0 -0.83 [ -1.78, 0.12 ]

Cardemil 2002b 20 5.45 (6.24) 12 5.97 (6.33) 6.3 -0.08 [ -0.80, 0.64 ]

Clarke 1995 12 17.17 (7.22) 18 14.06 (8.06) 6.0 0.39 [ -0.35, 1.13 ]

Clarke 2001 19 13.20 (7.60) 16 22.40 (11.60) 6.4 -0.93 [ -1.64, -0.23 ]

Spence 2003 225 5.55 (9.27) 247 6.40 (8.68) 22.0 -0.09 [ -0.28, 0.09 ]

Subtotal (95% CI) 283 307 44.7 -0.25 [ -0.65, 0.15 ]



02 Females

Cardemil 2002a 14 5.43 (5.71) 6 13.60 (9.75) 3.4 -1.11 [ -2.14, -0.08 ]

Cardemil 2002b 20 6.15 (6.77) 27 5.16 (5.60) 8.5 0.16 [ -0.42, 0.74 ]

Clarke 1995 40 18.78 (9.81) 40 20.19 (10.72) 12.0 -0.14 [ -0.57, 0.30 ]

Clarke 2001 22 16.60 (11.50) 29 21.10 (14.70) 9.0 -0.33 [ -0.89, 0.23 ]

Spence 2003 259 9.67 (9.67) 268 8.93 (7.93) 22.4 0.08 [ -0.09, 0.25 ]

Subtotal (95% CI) 355 370 55.3 -0.10 [ -0.37, 0.18 ]



Total (95% CI) 638 677 100.0 -0.15 [ -0.35, 0.06 ]



-1.0 -0.5 0 0.5 1.0





care 12 months, Outcome 04 Depression scores (by risk)






01 High Risk

Cardemil 2002a 11 4.91 (6.71) 8 13.65 (8.60) 2.0 -1.11 [ -2.10, -0.11 ]

Cardemil 2002b 20 8.30 (7.91) 20 7.12 (6.63) 4.9 0.16 [ -0.46, 0.78 ]

Spence 2003 111 12.03 (11.09) 113 12.63 (8.44) 24.5 -0.06 [ -0.32, 0.20 ]

Subtotal (95% CI) 142 141 31.4 -0.18 [ -0.69, 0.33 ]



02 Low Risk

Cardemil 2002a 8 3.75 (3.20) 11 5.59 (5.75) 2.3 -0.36 [ -1.28, 0.56 ]

Cardemil 2002b 20 3.30 (3.05) 19 3.60 (4.12) 4.8 -0.08 [ -0.71, 0.55 ]

Spence 2003 360 5.84 (7.86) 389 6.01 (7.65) 61.5 -0.02 [ -0.17, 0.12 ]

Subtotal (95% CI) 388 419 68.6 -0.03 [ -0.17, 0.11 ]



Total (95% CI) 530 560 100.0 -0.05 [ -0.19, 0.09 ]



-1.0 -0.5 0 0.5 1.0





care 12 months, Outcome 05 Depressive disorder (by population)





n/N n/N 95% CI (%) 95% CI

01 Targeted

Clarke 1995 8/52 14/58 24.0 -0.09 [ -0.23, 0.06 ]

Clarke 2001 5/41 13/44 20.2 -0.17 [ -0.34, -0.01 ]

Subtotal (95% CI) 93 102 44.1 -0.12 [ -0.24, -0.01 ]




02 Universal

Cardemil 2002a 1/21 2/20 21.6 -0.05 [ -0.21, 0.11 ]

Cardemil 2002b 3/40 2/39 34.3 0.02 [ -0.08, 0.13 ]

Subtotal (95% CI) 61 59 55.9 0.00 [ -0.09, 0.09 ]




Total (95% CI) 154 161 100.0 -0.06 [ -0.15, 0.03 ]




-0.5 -0.25 0 0.25 0.5





care 12 months, Outcome 06 Depressive disorder (by intervention)





n/N n/N 95% CI (%) 95% CI

01 Educational





02 Psychological

Cardemil 2002a 1/21 2/20 21.6 -0.05 [ -0.21, 0.11 ]

Cardemil 2002b 3/40 2/39 34.3 0.02 [ -0.08, 0.13 ]

Clarke 1995 8/52 14/58 24.0 -0.09 [ -0.23, 0.06 ]

Clarke 2001 5/41 13/44 20.2 -0.17 [ -0.34, -0.01 ]

Subtotal (95% CI) 154 161 100.0 -0.06 [ -0.15, 0.03 ]




Total (95% CI) 154 161 100.0 -0.06 [ -0.15, 0.03 ]




-0.5 -0.25 0 0.25 0.5





care 12 months, Outcome 07 Depressive disorder (by gender)





n/N n/N 95% CI (%) 95% CI

01 Males

Cardemil 2002a 0/7 0/14 14.1 0.00 [ -0.19, 0.19 ]

Cardemil 2002b 1/20 1/12 15.3 -0.03 [ -0.22, 0.15 ]

Clarke 1995 1/12 4/18 8.4 -0.14 [ -0.39, 0.11 ]

Clarke 2001 1/19 3/16 11.0 -0.13 [ -0.35, 0.08 ]

Subtotal (95% CI) 58 60 48.8 -0.06 [ -0.17, 0.04 ]




02 Females

Cardemil 2002a 1/14 2/6 3.2 -0.26 [ -0.66, 0.14 ]

Cardemil 2002b 2/20 1/27 23.0 0.06 [ -0.09, 0.21 ]

Clarke 1995 7/40 10/40 16.1 -0.08 [ -0.25, 0.10 ]

Clarke 2001 4/22 10/28 8.9 -0.18 [ -0.42, 0.06 ]

Subtotal (95% CI) 96 101 51.2 -0.07 [ -0.21, 0.07 ]




Total (95% CI) 154 161 100.0 -0.05 [ -0.12, 0.02 ]




-0.5 -0.25 0 0.25 0.5





care 12 months, Outcome 08 Depressive disorder (by risk)




Study Intervention No Intervention Risk Difference (Random) Weight Risk Difference (Random)

n/N n/N 95% CI (%) 95% CI

01 High Risk

Cardemil 2002a 1/11 2/8 2.4 -0.16 [ -0.50, 0.19 ]

Cardemil 2002b 3/20 2/20 6.9 0.05 [ -0.15, 0.25 ]

Spence 2003 11/111 10/118 51.7 0.01 [ -0.06, 0.09 ]

Subtotal (95% CI) 142 146 61.1 0.01 [ -0.06, 0.08 ]

Total events: 15 (Intervention), 14 (No Intervention)



02 Low Risk

Cardemil 2002a 0/8 0/8 6.5 0.00 [ -0.21, 0.21 ]

Cardemil 2002b 0/20 0/19 32.5 0.00 [ -0.09, 0.09 ]

Subtotal (95% CI) 28 27 38.9 0.00 [ -0.09, 0.09 ]




Total (95% CI) 170 173 100.0 0.01 [ -0.05, 0.06 ]




-0.5 -0.25 0 0.25 0.5





intervention 12 months, Outcome 01 Depression scores (by population)


Comparison: 06 Psychological/educational intervention versus placebo/attention/other intervention 12 months




01 Targeted




02 Universal

Pattison 2001 10 6.20 (4.10) 13 7.79 (7.88) 23.2 -0.23 [ -1.06, 0.59 ]

Shatte 1997 40 9.00 (8.55) 35 7.26 (6.95) 76.8 0.22 [ -0.24, 0.67 ]

Subtotal (95% CI) 50 48 100.0 0.11 [ -0.28, 0.51 ]



Total (95% CI) 50 48 100.0 0.11 [ -0.28, 0.51 ]



-1.0 -0.5 0 0.5 1.0



intervention 12 months, Outcome 02 Depression scores (by intervention)






01 Educational




02 Psychological

Pattison 2001 10 6.20 (4.10) 13 7.79 (7.88) 23.2 -0.23 [ -1.06, 0.59 ]

Shatte 1997 40 9.00 (8.55) 35 7.26 (6.95) 76.8 0.22 [ -0.24, 0.67 ]

Subtotal (95% CI) 50 48 100.0 0.11 [ -0.28, 0.51 ]



-1.0 -0.5 0 0.5 1.0




(. . . Continued)



Total (95% CI) 50 48 100.0 0.11 [ -0.28, 0.51 ]



-1.0 -0.5 0 0.5 1.0



intervention 12 months, Outcome 03 Depression scores (by gender)






01 Males

Shatte 1997 22 7.68 (8.75) 17 4.47 (3.81) 50.9 0.45 [ -0.20, 1.09 ]

Subtotal (95% CI) 22 17 50.9 0.45 [ -0.20, 1.09 ]



02 Females

Shatte 1997 18 10.61 (8.25) 18 9.89 (8.24) 49.1 0.09 [ -0.57, 0.74 ]

Subtotal (95% CI) 18 18 49.1 0.09 [ -0.57, 0.74 ]



Total (95% CI) 40 35 100.0 0.27 [ -0.19, 0.73 ]



-1.0 -0.5 0 0.5 1.0





intervention 12 months, Outcome 04 Depression scores (by risk)






01 High Risk

Shatte 1997 20 12.70 (9.17) 17 10.47 (7.72) 49.1 0.26 [ -0.39, 0.91 ]

Subtotal (95% CI) 20 17 49.1 0.26 [ -0.39, 0.91 ]



02 Low Risk

Shatte 1997 20 5.30 (6.09) 18 4.22 (4.52) 50.9 0.20 [ -0.44, 0.83 ]

Subtotal (95% CI) 20 18 50.9 0.20 [ -0.44, 0.83 ]



Total (95% CI) 40 35 100.0 0.23 [ -0.23, 0.68 ]



-1.0 -0.5 0 0.5 1.0



intervention 12 months, Outcome 05 Depressive disorder (by population)





n/N n/N 95% CI (%) 95% CI

01 Targeted





02 Universal

Shatte 1997 10/40 7/35 100.0 0.05 [ -0.14, 0.24 ]

Subtotal (95% CI) 40 35 100.0 0.05 [ -0.14, 0.24 ]



-0.5 -0.25 0 0.25 0.5




(. . . Continued)


n/N n/N 95% CI (%) 95% CI


Total (95% CI) 40 35 100.0 0.05 [ -0.14, 0.24 ]




-0.5 -0.25 0 0.25 0.5



intervention 12 months, Outcome 06 Depressive disorder (by intervention)





n/N n/N 95% CI (%) 95% CI

01 Educational





02 Psychological

Shatte 1997 10/40 7/35 100.0 0.05 [ -0.14, 0.24 ]

Subtotal (95% CI) 40 35 100.0 0.05 [ -0.14, 0.24 ]




Total (95% CI) 40 35 100.0 0.05 [ -0.14, 0.24 ]




-0.5 -0.25 0 0.25 0.5











01 Targeted

Clarke 2001 40 19.50 (9.80) 47 19.90 (10.40) 25.9 -0.04 [ -0.46, 0.38 ]

Seligman 1999 84 2.70 (3.40) 99 2.40 (3.80) 37.6 0.08 [ -0.21, 0.37 ]

Subtotal (95% CI) 124 146 63.6 0.04 [ -0.20, 0.28 ]



02 Universal

Cardemil 2002a 19 4.79 (5.58) 14 9.88 (7.53) 12.2 -0.77 [ -1.49, -0.05 ]

Cardemil 2002b 41 5.44 (5.28) 37 4.81 (6.01) 24.3 0.11 [ -0.33, 0.56 ]

Subtotal (95% CI) 60 51 36.4 -0.28 [ -1.14, 0.57 ]



Total (95% CI) 184 197 100.0 -0.05 [ -0.32, 0.23 ]



-1.0 -0.5 0 0.5 1.0











01 Educational




02 Psychological

Cardemil 2002a 19 4.79 (5.58) 14 9.88 (7.53) 12.3 -0.77 [ -1.49, -0.05 ]

Cardemil 2002b 41 5.44 (5.28) 37 4.81 (6.01) 24.5 0.11 [ -0.33, 0.56 ]

Clarke 2001 41 19.50 (9.80) 41 19.90 (10.40) 25.3 -0.04 [ -0.47, 0.39 ]

Seligman 1999 84 2.70 (3.40) 99 2.40 (3.80) 37.9 0.08 [ -0.21, 0.37 ]

Subtotal (95% CI) 185 191 100.0 -0.05 [ -0.33, 0.23 ]



Total (95% CI) 185 191 100.0 -0.05 [ -0.33, 0.23 ]



-1.0 -0.5 0 0.5 1.0











01 Males

Cardemil 2002a 7 4.54 (6.38) 9 9.81 (6.25) 8.4 -0.79 [ -1.83, 0.25 ]

Cardemil 2002b 19 4.43 (4.19) 12 5.36 (6.15) 16.4 -0.18 [ -0.90, 0.54 ]

Clarke 2001 20 17.30 (7.60) 14 19.90 (11.10) 18.0 -0.28 [ -0.96, 0.41 ]

Subtotal (95% CI) 46 35 42.8 -0.34 [ -0.78, 0.11 ]



02 Females

Cardemil 2002a 12 4.94 (5.36) 5 10.00 (10.30) 7.8 -0.68 [ -1.76, 0.39 ]

Cardemil 2002b 22 6.32 (6.03) 25 4.55 (6.05) 24.5 0.29 [ -0.29, 0.86 ]

Clarke 2001 21 21.40 (11.10) 27 19.90 (10.20) 24.9 0.14 [ -0.43, 0.71 ]

Subtotal (95% CI) 55 57 57.2 0.08 [ -0.35, 0.51 ]



Total (95% CI) 101 92 100.0 -0.09 [ -0.40, 0.21 ]



-1.0 -0.5 0 0.5 1.0











01 High Risk

Cardemil 2002a 10 5.80 (7.02) 5 15.60 (8.08) 15.3 -1.25 [ -2.45, -0.06 ]

Cardemil 2002b 21 7.95 (5.89) 18 7.05 (7.54) 32.4 0.13 [ -0.50, 0.76 ]

Subtotal (95% CI) 31 23 47.6 -0.46 [ -1.81, 0.88 ]



02 Low Risk

Cardemil 2002a 8 3.50 (3.66) 9 6.69 (5.25) 19.9 -0.66 [ -1.65, 0.32 ]

Cardemil 2002b 20 2.81 (2.81) 19 2.69 (2.95) 32.5 0.04 [ -0.59, 0.67 ]

Subtotal (95% CI) 28 28 52.4 -0.20 [ -0.86, 0.45 ]



Total (95% CI) 59 51 100.0 -0.27 [ -0.81, 0.28 ]



-1.0 -0.5 0 0.5 1.0










n/N n/N 95% CI (%) 95% CI

01 Targeted

Clarke 2001 13/41 13/37 12.4 -0.03 [ -0.24, 0.18 ]

Subtotal (95% CI) 41 37 12.4 -0.03 [ -0.24, 0.18 ]




02 Universal

Cardemil 2002a 1/19 2/14 12.5 -0.09 [ -0.30, 0.12 ]

Cardemil 2002b 0/41 2/37 75.0 -0.05 [ -0.14, 0.03 ]

Subtotal (95% CI) 60 51 87.6 -0.06 [ -0.14, 0.02 ]




Total (95% CI) 101 88 100.0 -0.06 [ -0.13, 0.02 ]




-0.5 -0.25 0 0.25 0.5










n/N n/N 95% CI (%) 95% CI

01 Educational





02 Psychological

Cardemil 2002a 1/19 2/14 12.5 -0.09 [ -0.30, 0.12 ]

Cardemil 2002b 0/41 2/37 75.0 -0.05 [ -0.14, 0.03 ]

Clarke 2001 13/41 13/37 12.4 -0.03 [ -0.24, 0.18 ]

Subtotal (95% CI) 101 88 100.0 -0.06 [ -0.13, 0.02 ]




Total (95% CI) 101 88 100.0 -0.06 [ -0.13, 0.02 ]




-0.5 -0.25 0 0.25 0.5





care 24 months, Outcome 07 Depressive disorder (by gender)





n/N n/N 95% CI (%) 95% CI

01 Males

Cardemil 2002a 0/7 1/9 8.1 -0.11 [ -0.39, 0.17 ]

Cardemil 2002b 0/19 1/12 17.9 -0.08 [ -0.27, 0.10 ]

Clarke 2001 6/20 2/13 7.9 0.15 [ -0.13, 0.43 ]

Subtotal (95% CI) 46 34 34.0 -0.03 [ -0.19, 0.12 ]




02 Females

Cardemil 2002a 1/12 1/5 4.2 -0.12 [ -0.50, 0.27 ]

Cardemil 2002b 0/22 1/25 54.0 -0.04 [ -0.15, 0.07 ]

Clarke 2001 7/21 11/24 7.8 -0.13 [ -0.41, 0.16 ]

Subtotal (95% CI) 55 54 66.0 -0.05 [ -0.15, 0.04 ]




Total (95% CI) 101 88 100.0 -0.05 [ -0.13, 0.03 ]




-0.5 -0.25 0 0.25 0.5





care 24 months, Outcome 08 Depressive disorder (by risk)




Study Intervention No Intervention Risk Difference (Random) Weight Risk Difference (Random)

n/N n/N 95% CI (%) 95% CI

01 High Risk

Cardemil 2002a 1/10 2/5 4.5 -0.30 [ -0.77, 0.17 ]

Cardemil 2002b 0/21 2/18 26.5 -0.11 [ -0.28, 0.05 ]

Subtotal (95% CI) 31 23 30.9 -0.13 [ -0.29, 0.02 ]




02 Low Risk

Cardemil 2002a 0/8 0/9 19.6 0.00 [ -0.20, 0.20 ]

Cardemil 2002b 0/20 0/19 49.5 0.00 [ -0.09, 0.09 ]

Subtotal (95% CI) 28 28 69.1 0.00 [ -0.09, 0.09 ]




Total (95% CI) 59 51 100.0 -0.04 [ -0.14, 0.06 ]




-0.5 -0.25 0 0.25 0.5











01 Targeted

Seligman 1999 100 1.70 (2.50) 110 2.60 (3.60) 100.0 -0.29 [ -0.56, -0.01 ]

Subtotal (95% CI) 100 110 100.0 -0.29 [ -0.56, -0.01 ]



02 Universal




Total (95% CI) 100 110 100.0 -0.29 [ -0.56, -0.01 ]



-1.0 -0.5 0 0.5 1.0









01 Educational




02 Psychological

Seligman 1999 100 1.70 (2.50) 110 2.60 (3.60) 100.0 -0.29 [ -0.56, -0.01 ]

Subtotal (95% CI) 100 110 100.0 -0.29 [ -0.56, -0.01 ]



Total (95% CI) 100 110 100.0 -0.29 [ -0.56, -0.01 ]



-1.0 -0.5 0 0.5 1.0










N

Mean(SD) N

Mean(SD) 95% CI (%) 95% CI

01 Males




02 Females




Total (95% CI) 0 0 0.0 Not estimable



-1.0 -0.5 0 0.5 1.0








N

Mean(SD) N

Mean(SD) 95% CI (%) 95% CI

01 High Risk




02 Low Risk




Total (95% CI) 0 0 0.0 Not estimable



-1.0 -0.5 0 0.5 1.0










n/N n/N 95% CI (%) 95% CI

01 Targeted

Seligman 1999 42/106 57/119 100.0 -0.08 [ -0.21, 0.05 ]

Subtotal (95% CI) 106 119 100.0 -0.08 [ -0.21, 0.05 ]




02 Universal





Total (95% CI) 106 119 100.0 -0.08 [ -0.21, 0.05 ]




-0.5 -0.25 0 0.25 0.5










n/N n/N 95% CI (%) 95% CI

01 Educational





02 Psychological

Seligman 1999 42/106 57/119 100.0 -0.08 [ -0.21, 0.05 ]

Subtotal (95% CI) 106 119 100.0 -0.08 [ -0.21, 0.05 ]




Total (95% CI) 106 119 100.0 -0.08 [ -0.21, 0.05 ]




-0.5 -0.25 0 0.25 0.5




Psychological and/or educational interventions for the prevention of depression in children and adolescents (Cochrane review)

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