Mental Health: Universal School-Based Cognitive Behavioral Therapy Programs to Reduce Depression and Anxiety Symptoms

The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to mental health:

Werner-Seidler A, Perry Y, Calear AI, Newby JM, Christensen H. School-based depression and anxiety prevention programs for young people: a systematic review and meta-analysis. Clinical Psychology Review 2017;51;30-47.

The systematic review included 81 studies (search period through 2015). The team examined CBT programs for universal school-based programs (38 studies) and targeted school-based programs (29 studies) separately. Ten studies from the published review were excluded because they either did not evaluate CBT programs or they did not provide data for analysis.

The team examined a subset of eight universal studies from the United States and abstracted supplemental information about study, intervention, and population characteristics; and performed data analysis. Data from the subset were compared with the overall body of evidence.

The CPSTF finding is based on results from the published review, additional information from the subset of studies, and expert input from team members and the CPSTF.

Anxiety and depression are common among children and adolescents, and they can persist into adulthood, increasing risks for suicide, risk-taking behavior (e.g., substance abuse, sexual experimentation), teenage pregnancy, conduct disorder, delinquency, and poor academic outcomes (Anxiety and Depression Association of America, 2018; Weller et al., 2000; Werner-Sielder et al., 2017).

Schools can play an important role in preventing and reducing anxiety and depression. Cognitive behavioral therapy (CBT), the most commonly used therapy for anxiety and depression, helps children and adolescents change negative thoughts into more positive, effective behaviors.

Implementing CBT programs in schools supports several components of the Whole School, Whole Community, Whole Child (WSCC) Model focused on promoting students’ health (CDC, 2018).

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 38 studies of universal school-based CBT programs.

• Small decreases were reported for symptoms of depression (27 studies) and anxiety (24 studies).
• There was no difference between interventions delivered by external mental health professionals and those delivered by trained school staff.

A systematic review of economic evidence has not been conducted.

The CPSTF finding should be applicable to school aged children (aged 7-18 years) in the United States.

Additional research and evaluation are needed to answer the following questions and fill existing gaps in the evidence base. (What are evidence gaps?)

Evidence gaps identified in systematic review.

• How can advances in technology be used to improve intervention reach and availability at a population level?
• What are the infrastructure and personnel needs required to sustain programs?

The CPSTF further identified the following evidence gaps as areas for future research:

• Which strategies best balance the need for parental awareness with child confidentiality?
• What are the long-term effects of early interventions to reduce anxiety and depression symptoms?
• Are programs equally effective in public and private school settings?
• How effective are programs implemented with non-white children or children under 10 years of age?
• What are the follow-up approaches that best support the maintenance of program effects over time?

• Depression symptoms were most frequently measured with the Children’s Depression Inventory, followed by the Beck Depression Inventory.
• Anxiety symptoms were most frequently measured with the Spence Children’s Anxiety Scale, followed by the Multidimensional Anxiety Scale for Children.
• The included studies from the United States targeted adolescents (10-17 years), and were delivered by external mental health professionals (6 studies) or trained school staff (2 studies). Study populations represented a range of racial and ethnic groups.

effectiveness Review

• Analytic Framework [PDF – 478 kB]

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Werner-Seidler A, Perry Y, Calear AI, Newby JM, Christensen H. School-based depression and anxiety prevention programs for young people: a systematic review and meta-analysis. Clinical Psychology Review 2017;51;30-47.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Anticich SA, Barrett PM, Silverman W, Lacherez P, Gillies R. The prevention of childhood anxiety and promotion of resilience among preschool-aged children: a universal school based trial. Advances in School Mental Health Promotion 2013;6:93-121.

Araya R, Fritsch R, Spears M, Rojas G, Martinez V, et al. School intervention to improve mental health of students in Santiago, Chile: a randomized clinical trial. Journal of the American Medical Association Paediatrics 2013;167:1004 10.

Aune T, Stiles TC. Universal-based prevention of syndromal and subsyndromal social anxiety: a randomized controlled study. Journal of Consulting and Clinical Psychology 2009;77:867 79.

Barrett PM, Turner C. Prevention of anxiety symptoms in primary school children: preliminary results from a universal school-based trial. British Journal of Clinical Psychology 2001;40:399 410.

Barrett PM, Lock S, Farrell LJ. Developmental differences in universal preventive intervention for child anxiety. Clinical Child Psychology and Psychiatry 2005;10:539 55.

Berger R, Pat-Horenczyk R, Gelkopf M. School-based intervention for prevention and treatment of elementary-students’ terror-related distress in Israel: a quasi-randomized controlled trial. Journal of Traumatic Stress 2007;20:541 51.

Bouchard S, Gervais J, Gagnier N, Loranger C. Evaluation of a primary prevention program for anxiety disorders using story books with children aged 9 12 years. Journal of Primary Prevention 2013;34:345 58.

Calear AL, Christensen H, Mackinnon A, Griffiths KM, O’Kearney R. The YouthMood Project: a cluster randomized controlled trial of an online cognitive behavioral program with adolescents. Journal of Consulting and Clinical Psychology 2009;77:1021 32.

Chaplin TM, Gillham JE, Reivich, K, Elkon AG, Samuels B, et al. Depression prevention for early adolescent girls: a pilot study of all girls versus co-ed groups. Journal of Early Adolescence 2006;26:110 26.

Clarke GN, Hawkins W, Murphy M, Sheeber L. School-based primary prevention of depressive symptomatology in adolescents: findings from two studies. Journal of Adolescent Research 1993;8: 183 204.

Essau CA, Conradt J, Sasagawa S, Ollendick TH. Prevention of anxiety symptoms in children: results from a universal school-based trial. Behavior Therapy 2012;43:450 64.

Garaigordobil M. Effects of a psychological intervention on factors of emotional development during adolescence. European Journal of Psychological Assessment 2004;20:66.

Gillham JE, Hamilton J, Freres DR, Patton K, Gallop R. Preventing depression among early adolescents in the primary care setting: A randomized controlled study of the Penn Resiliency Program. Journal of Abnormal Child Psychology 2006;34:203 19.

Gillham JE, Reivich KJ, Freres DR, Chaplin TM, Shatte AJ, et al. School-based prevention of depressive symptoms: a randomized controlled study of the effectiveness and specificity of the Penn Resiliency Program. Journal of Consulting and Clinical Psychology 2007;75:9 19.

Hains AA, Szyjakowski M. A cognitive stress-reduction intervention program for adolescents. Journal of Counseling Psychology 1990;37:79.

Hains AA. Comparison of cognitive-behavioral stress management techniques with adolescent boys. Journal of Counseling and Development 1992;70:600 5.

Hains AA, Ellmann SW. Stress inoculation training as a preventative intervention for high school youths. Journal of Cognitive Psychotherapy 1994;8:219 32.

Hiebert B, Kirby B, Jaknavorian A. School-based relaxation: attempting primary prevention. Canadian Journal of Counselling 1989;23:273 87.

Horowitz JL, Garber J, Ciesla JA, Young JF, Mufson L. Prevention of depressive symptoms in adolescents: A randomized trial of cognitive-behavioral and interpersonal prevention programs. Journal of Consulting and Clinical Psychology 2007;75:693 706.

Johnstone J, Rooney RM, Hassan SA, Kane RT. Prevention of depression and anxiety symptoms in adolescents: 42 and 54 months follow-up of the Aussie optimism program-positive thinking skills. Frontiers in Psychology 2014;5:364.

Keogh E, Bond FW, Flaxman PE. Improving academic performance and mental health through a stress management intervention: Outcomes and mediators of change. Behaviour Research and Therapy 2006;44:339 57.

Kraag G, Van Breukelen GJ, Kok G, Hosman C. ‘Learn Young, Learn Fair’, a stress management program for fifth and sixth graders: longitudinal results from an experimental study. Journal of Child Psychology and Psychiatry 2009;50:1185 95.

Lock S, Barrett PM. A longitudinal study of developmental differences in universal preventive intervention for child anxiety. Behaviour Change 2003;20:183 99.

Lowry-Webster HM, Barrett PM, Dadds MR. A universal prevention trial of anxiety and depressive symptomatology in childhood: preliminary data from an Australian study. Behaviour Change 2001;18: 36 50.

Merry S, McDowell H, Wild CJ, Bir J, Cunliffe R. A randomized placebo controlled trial of a school-based depression prevention program. Journal of the American Academy of Child and Adolescent Psychiatry 2004;43:538 47.

Miller LD, Short C, Garland E, Clark S. The ABCs of CBT (cognitive behavior therapy): evidence-based approaches to child anxiety in public school settings. Journal of Counseling and Development 2010;88: 432 9.

Miller LD, Laye-Gindhu A, Bennett JL, Liu Y, Gold S, et al. An effectiveness study of a culturally enriched school-based CBT anxiety prevention program. Journal of Clinical Child and Adolescent Psychology 2011a;40:618 29.

Miller LD, Laye-Gindhu A, Liu Y, March JS, Thordarson DS, et al. Evaluation of a preventive intervention for child anxiety in two randomized attention-control school trials. Behaviour Research and Therapy 2011b;49:315 23.

Pattison C, Lynd-Stevenson RM. The prevention of depressive symptoms in children: the immediate and long-term outcomes of a school-based program. Behaviour Change 2001;18:92 102.

P ssel P, Horn AB, Groen G, Hautzinger M. School-based prevention of depressive symptoms in adolescents: A 6-month follow-up. Journal of the American Academy of Child and Adolescent Psychiatry 2004;43:1003 10.

P ssel P, Seemann S, Hautzinger M. Impact of comorbidity in prevention of adolescent depressive symptoms. Journal of Counseling Psychology 2008;55:106 17.

P ssel, P, Adelson JL, Hautzinger M. A randomized trial to evaluate the course of effects of a program to prevent adolescent depressive symptoms over 12 months. Behaviour Research and Therapy 2011;49: 838 51.

P ssel, P, Martin NC, Garber J, Hautzinger M. A randomized controlled trial of a cognitive-behavioral program for the prevention of depression in adolescents compared with nonspecific and no-intervention control conditions. Journal of Counseling Psychology 2013;60:432 8.

Quayle D, Dziurawiec S, Roberts C, Kane R, Ebsworthy G. The effect of an optimism and lifeskills program on depressive symptoms in preadolescence. Behaviour Change 2001;18:194 203.

Raes F, Griffith JW, Van der Gucht K, Williams J. School-based prevention and reduction of depression in adolescents: a cluster-randomized controlled trial of a mindfulness group program. Mindfulness 2014;5:477 86.

Rivet-Duval E, Heriot S, Hunt C. Preventing adolescent depression in Mauritius: a universal school-based program. Child and Adolescent Mental Health 2001;16:86 91.

Roberts CM, Kane R, Bishop B, Cross D, Fenton J, et al. The prevention of anxiety and depression in children from disadvantaged schools. Behaviour Research and Therapy 2010;48:68 73.

Rooney R, Roberts C, Kane R, Pike L, Winsor A, et al. The prevention of depression in 8- to 9-year-old children: a pilot study. Australian Journal of Guidance and Counselling 2006;16:76 90.

Rose K, Hawes DJ, Hunt CJ. Randomized controlled trial of a friendship skills intervention on adolescent depressive symptoms. Journal of Consulting and Clinical Psychology 2014;82:510 20.

Ruini C, Belaise C, Brombin C, Caffo E, Fava GA. Well-being therapy in school settings: a pilot study. Psychotherapy and Psychosomatics 2006;75:331 6.

Ruini C, Ottolini F, Tomba E, Belaise C. Albieri E, et al. School intervention for promoting psychological well-being in adolescence. Journal of Behavior Therapy and Experimental Psychiatry 2009; 40:522 32.

Spence SH, Sheffield JK, Donovan CL. Long-term outcome of a school based, universal approach to prevention of depression in adolescents. Journal of Consulting and Clinical Psychology 2005;73:160 7.

Stallard P, Skryabina E, Taylor G, Phillips R, Daniels H, et al. Classroom-based cognitive behaviour therapy (FRIENDS): a cluster randomised controlled trial to Prevent Anxiety in Children through Education in Schools (PACES). The Lancet Psychiatry 2014;1:185 92.

Wong N, Kady L, Mewton L, Sunderland M, Andrews G. Preventing anxiety and depression in adolescents: a randomised controlled trial of two school based internet- delivered cognitive behavioural therapy programmes. Internet Interventions 2014;1:90 4.

Refer to the existing systematic review for information about the search strategy:

Werner-Seidler A, Perry Y, Calear AI, Newby JM, Christensen H. School-based depression and anxiety prevention programs for young people: a systematic review and meta-analysis. Clinical Psychology Review 2017;51;30-47.

Anxiety and Depression Association of America. Facts and Statistics. Silver Spring (MD): 2018. [Cited 10/1/18]. Available from URL: https://adaa.org/about-adaa/press-room/facts-statistics.

Centers for Disease Control and Prevention. Whole School, Whole Community, Whole Child (WSCC). Atlanta (GA): 2018. [Cited 1/30/19]. Available from URL: https://www.cdc.gov/healthyschools/wscc/index.htm.

Weller EB, Weller RA. Depression in adolescents growing pains or true morbidity? [Review][20 refs]. Journal of Affective Disorders 2000;61:Suppl-13.

Werner-Seidler A, Perry Y, Calear AI, Newby JM, Christensen H. School-based depression and anxiety prevention programs for young people: a systematic review and meta-analysis. Clinical Psychology Review 2017;51;30-47.

The following considerations for implementation are drawn from studies included in the existing evidence review, the broader literature, and expert opinion.

• Based on the needs of the student population, school administrators may prefer universal programs. They are easier to schedule and allow for early identification of mental health issues.
• Confidentiality of student information should be a priority, and policies should be clearly communicated to parents and students, especially when there will be group sessions.
• Parents should be notified when students participate in programs or receive mental health services (though this must be balanced with student confidentiality).
• Students should have access to additional mental health services in case issues arise (either on-site or by referral).
• Referral processes should be in place and consistently followed by staff who detect possible child maltreatment or risk of harm to self or others.
• Schools should decide whether trained school personnel or external mental health professionals will deliver program components (balancing potential effects against resource limitations).
  • School staff may be familiar with the student population and school environment, and there may be greater opportunities for program sustainability. They may not, however, have mental health training that would prepare them to handle additional issues.
  • External mental health professionals are professionally trained for mental health issues, but they may not be as familiar with individual students, and additional funding may be required.
• Schools should decide whether universal CBT programs, targeted CBT programs for at-risk individuals, or both, are best suited for their student population. Some schools may prefer a stepped approach to deliver universal CBT programs first followed by targeted CBT programs for at-risk, symptomatic individuals who do not respond to the universal program. Other schools may prefer to deliver one program only.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the proportion of children and adolescents who get appropriate treatment for anxiety or depression — EMC‑D04
• Increase the proportion of children and adolescents who get preventive mental health care in school — EMC‑D06