pression a

De Singhal et al., J Depress Anxiety 2015, 4:4

nd
Journal of Depression and Anxiety
Journal of

DOI: 10.4197/2167-1044.1000197

ISSN: 2167-1044 Anxiety

Review Article
Research Article OpenAccess
Open Access

Adolescent Depression Prevention Programs-A Review

Meghna Singhal*, Manjula M and John Vijay Sagar K
Department of Psychology, Jain University, Bangalore, India

Abstract
In recent years, there has been an increasing focus on prevention of depression among adolescents. This review
delineates and evaluates major depression prevention programs for adolescents developed and tested world-wide,
according to the three major types, viz. universal, selective, and indicated. Overall, targeted prevention with selective
and indicated programs seem to give better results with higher effect sizes than a universal approach. School-based
cognitive-behavioural approach interventions have been found to significantly reduce depressive symptoms among
adolescents, with some evidence that the intervention provides long-lasting effects. However, further research to
ameliorate the understanding of the development and maintenance of depression is essential in order also to improve
the effects of prevention and intervention.

Keywords: Adolescent depression; Universal; Selective; Indicated
Introduction
Depression in childhood remains uncommon. When puberty
begins, the rate of depression increases sharply [1]. The prevalence
rates for depression among adolescents in India range from 3% among
school going adolescents (13-19 years) to 11.2% of school drop outs [2]
Adolescent depression is a health concern for the whole community
because it is associated with many negative outcomes [3]. Adolescent-
onset depression is also strongly associated with chronic and recurrent
depression in adulthood [4] that may be difficult to treat. Additionally,
there are many obstacles in seeking and attaining treatment for
depression in adolescents, such as perceived stigma, availability and
cost of services, and lack of trained providers. Due to these reasons,
there has been an increasing focus on preventing depression before it
becomes so serious that treatment is needed.
Types of prevention programs for adolescent depression
Prevention programs for depression are classified into three
subgroups defined according to their target population: universal,
selective, and indicated [5].
This review aims to delineate and evaluate the adolescent depression
prevention/intervention programs that have been developed and tested
worldwide.
Table 1 gives a summary of the most frequently tested universal and
targeted programs for adolescent depression, their major components,
the setting in which they were implemented, and the facilitators who
delivered the programs.
Method
For this review, an Internet search was carried out using the
search engines of PubMed, Google Scholar, and Science Direct to
locate the relevant literature from 1990 through 2014. The keywords
used in various combinations were: adolescent depression, prevention
programs, universal, selective, indicated, etc. The search was limited to
articles in the English language. Abstract of all the articles was screened,
and the relevant articles were selected. Full text articles were evaluated,
and the relevant data were extracted. Cross references from these full-
text articles also provided few more relevant articles.
Results
Universal depression prevention programs for adolescents
Universal prevention for preventing depression is provided to a
general population regardless of risk. Delivering the intervention in the
school setting with universal samples tends to result in lower attrition.
The first published, large-scale evaluation of a universal prevention
of depression (CWS-A; Table 1) in a school population was reported
by Clarke et al. [6]. Having found minimal effects from a brief, three-
session psycho-educational intervention on 9th and 10th graders,
the authors examined the impact of a five-session program (Table 2).
However, no significant benefits were found for depressive symptoms
post-intervention or at 12-week follow up, compared with an
assessment-only control group.
The Resourceful Adolescent Program (RAP [7]; Table 1) was
evaluated in New Zealand, and delivered by the teachers to 9th and 10th
graders. Participants reported significantly fewer depressive symptoms
at post-intervention but not at the 18-month follow-up [8] (Table 2).
The RAP, in Australia, delivered to a sample 12-15 year olds, resulted in
decreased depressive symptoms and hopelessness at the post-test and
at the 10-month follow-up compared with the control group [9] (Table
2) This study was estimated to have an effect size of 0.47 at post-test
and 0.34 at 10-months follow-up [10]. However, the students were not
randomly assigned to conditions.
Another universal intervention is called the Problem Solving for Life
program (PSFL [11] (Table 1). Spence et al. evaluated the effectiveness of
the PSFL program among high school students in Australia [11] (Table
2). They found that among adolescents with high levels of depressive
symptoms at baseline, a significant decrease in depressive symptoms and
increase in problem solving ability occurred for those in the treatment
group compared to the control group. The study was remarkable for
its sample size, use of diagnoses, exploration of multiple outcomes,
and substantial length of follow-up. Unfortunately, the positive effects
were present neither at 12-month follow-up nor at subsequent follow-
*Corresponding author: Meghna Singhal, PhD NIMHANS, Assistant Professor,
Department of Psychology, Jain University, Bangalore, India, Tel: +91 9900406403;
E-mail: meghnasinghal3@gmail.com
Received May 27, 2015; Accepted August 17, 2015; Published August 20, 2015
Citation: Singhal M, Manjula M, Sagar JV (2015) Adolescent Depression
Prevention Programs-A Review. J Depress Anxiety 4: 197. doi:10.4197/2167-
1044.1000197
Copyright: © 2015 Singhal M, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.

J Depress Anxiety
ISSN: 2167-1044 JDA an open access journal Volume 4 • Issue 4 • 1000197
Citation: Singhal M, Manjula M, Sagar JV (2015) Adolescent Depression Prevention Programs-A Review. J Depress Anxiety 4: 197. doi:10.4197/2167-
1044.1000197

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Conceptual
Program Components Format Target population Setting Facilitators
framework
Mood monitoring, social skills, pleasant 16 2-hour sessions
Adolescent Coping Cognitive-behavioural activities, relaxation, constructive conducted over 8 Actively depressed
with Depression therapy thinking, communication, negotiation and weeks in groups adolescents, ages
(CWD-A) problem solving, conflict resolution, and of up to 10 13-18 years
maintenance of gain adolescents School based;
primary care Trained therapists
CWD-A also includes a parent setting
15 one-hour
component to foster parental Adolescents at-risk
Adolescent Coping sessions delivered
understanding and support, and to teach for depression,
with Stress (CWS-A) to groups of 6-10
them communication and problem- ages 13-18 years
adolescents
solving skills
Cognitive restructuring (linking behaviour,
body clues, self-talk and emotions),
Stress management, problem solving, 11 weekly
Resourceful Cognitive-behavioural
building support networks, preventing sessions during a Trained teachers
Adolescents Program therapy, Interpersonal
and managing conflict, perspective 45-50 minute class Ages 12-15 years School-based or other school
(RAP) therapy
taking, building self-esteem, keeping period with 15 personnel
calm, and thinking resourcefully participants
+ 3 session parallel program for parents
(RAP-Family)
Realistic thinking, social skills training, 8 weekly Adolescents
Cognitive-behavioural Co-led by school
recognizing achievement and rewarding 90-minute who are actively
Adolescents Coping therapy, interpersonal counsellor and
self, assertiveness, interpersonal sessions in depressed/ at-risk School-based
with Emotion (ACE) skills, adolescent mental
negotiation skills and dealing with groups of 8-10 for depression,
psycho-educational health worker
conflict, and problem solving skills. participants each ages 12-15 years
Cognitive restructuring (identifying 8 weekly sessions
Problem Solving for thoughts, feelings, problem situations, during a 45-50
Cognitive-behavioural
Life (PSFL) the relations among them), minute class Ages 12-14 years School-based Trained teachers
therapy
problem-solving orientation, and period with 25-35
optimistic thinking styles participants
 Cognitive Behavioural
entails identifying and evaluating
pessimistic thoughts and teaching Members of the
12 weekly
behavioural skills for relaxation and research team,
Penn Resiliency 90-minute School based;
Cognitive-behavioural emotion regulation school personnel,
Program sessions delivered Ages 10-14 years primary care
therapy  Social problem-solving experienced
(PRP) in groups of 10-12 setting
entails addressing interpersonal and mental health
participants each
conduct problems and teaching skills practitioners
for assertiveness, decision making and
coping with conflict

Table 1: Overview of depression prevention/intervention programs.

Sample
Target sample/
Program/Authors size Outcome measures Control group Outcome (short- and long-term)
Country
(n)
CWS-A 9th and 10th graders No significant benefits at post-intervention and 12-week
380 Depressive symptoms Assessment only
Clarke et al. [6] Australia follow-up
Depression in Swedish
8th graders
Adolescents (DISA) 68 Depressive symptoms None Decreased scores at 1-year follow-up but only for girls
Sweden
Garmy et al. [19]
RAP 9th and 10th graders Significant effects at post-intervention but not at 18-month
392 Depressive symptoms Placebo-control
Merry et al. [8] New Zealand follow-up
RAP 12-15 yr olds Depressive symptoms Significant effects at post-intervention and 10-month
242 Assessment only
Shochet et al. [9] Australia Hopelessness follow-up
Depressive symptoms,
12-14 yr old 8th problem solving, negative life
PSFL Significant effects at post-intervention but not at 12-month
graders 1,500 events, social functioning, Assessment only
Spence et al. [11] follow-up or follow-up over a 4 year period
Australia attributional style, general
psychopathology
LARS and LISA 8th graders
324 Depressive symptoms Active and passive Significant effects at post-, 6- and 12-month follow-up
Pössel et al. [13] Germany
Active (Penn
PRP significantly effective in 2 out of 3 schools; overall,
PRP Enhancement
USA 3 schools Depressive symptoms PRP not significantly effective compared to both control
Gillham et al. [14] Program, PEP) and
groups over a 3 year follow-up
passive
Secondary school
beyondblue 25
students Depressive symptoms No effect at post-intervention and 2 year follow-up
Sawyer et al. [18] schools
Australia

Table 2: Evaluation of universal programs for depression.

J Depress Anxiety
ISSN: 2167-1044 JDA an open access journal Volume 4 • Issue 4 • 1000197
Citation: Singhal M, Manjula M, Sagar JV (2015) Adolescent Depression Prevention Programs-A Review. J Depress Anxiety 4: 197. doi:10.4197/2167-
1044.1000197
ups over a 4-year period. This discounted the possibility of any delayed
beneficial effects from the intervention. Certain factors potentially
limiting the effect size of the intervention in this study included: the
large group format, teacher implementation, and significant attrition
(about 30% dropout by 12-month follow-up).
A German universal depression prevention program called ‘Desire
for a Realistic View and Ease in Social Aspects of Everyday Life’
(Lust An Realistischer Sicht & Leichtigkeit Im Sozialen Alltag, LARS
& LISA [12]) has been found to show significant, positive effects for
8th graders at post-test and 6- and 12-month follow-ups [13] (Table
2). Results indicated that participants with initial minimal depressive
symptoms showed no increase in symptom levels, but such a significant
increase was found in the control group. Spence and Shortt [10] have,
in retrospect, estimated the effect sizes for this study to be 0.49 at post-
test and 0.44 at 6-month follow-up. The results for the group with sub-
syndromal scores were non-significant at post-test, but significant at
6-month follow-up with an effect size of 0.50. There were, however, no
significant changes in dysfunctional automatic thoughts or the social
network as a consequence of the intervention. Therefore it is unclear
what the active ingredients in the intervention are.
Gillham et al. evaluated the Penn Resiliency Program as a universal
intervention program implemented by teachers in three schools [14]
(Table 2). This study included both an active and a passive control
group. The results for the entire sample showed no effects of the
program. PRP prevented the debut of depression compared to the
passive control groups, but not compared to the active control group.
PRP did also not reduce the levels of depressive symptoms over a 3-year
follow-up period. The effects of the interventions seem to depend on
if they were administered by members of the research team or others
(such as teachers). The study was influenced by low recruitment rates
(15 -22% participated) at all schools, and the drop-out rates were high
in the follow-up period.
Based on the PRP, Op Volle Kracht (‘On Full Power’; OVK) has
been developed in Netherlands and its effectiveness is currently being
studied in Dutch adolescents (ages 12-14 years) as a universal school-
based prevention program [15].
Internet interventions promoting behaviour change are gaining
popularity and an evidence base. MoodGYM, an automated CBT-
based Internet program designed to reduce and prevent symptoms
of depression and anxiety in adolescents has been tested extensively.
In a school-based sample of 1,477 teens, MoodGYM was effective at
reducing depressive symptoms and preventing the onset of significant
depressive symptoms in male, but not female, participants [16].
Internet interventions are low-cost, highly scalable, and convenient
for participants, which makes them prime candidates for worldwide
prevention efforts [17].
One of the largest universal prevention programs that has ever been
implemented in school settings is the ‘beyondblue’ program [18] (Table
2). The program had a 3-year implementation period. It consisted
of four specific components: a psycho-educational component, a
component focusing on improving the quality of the social interaction
between school members, increased access to health care information,
and a component focused on forming forums where young people,
their families and school employees could exchange information to
help them identify problems and seek help. Twenty-five secondary
schools matched for socioeconomic status were randomised to either
intervention or control groups. The results indicated that there was
no effect in reducing the level of depressive symptoms among the
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Page 3 of 7
adolescents. The results did not change at two years follow-up. Further
analysis indicated that the participants with higher depression scores
had higher drop-out rates, which could have influenced the results.
In a recent pilot study, the CWS program was adapted for Swedish
adolescents, called Depression in Swedish Adolescents (DISA) [19]
(Table 2). The program was delivered to a universal sample of 8th
graders in five groups of students by school tutors. The students scored
lower on measures of recent depressive symptoms at the 1-year follow-
up. However, this improvement was only significant for females. The
tutors highlighted the advantages of offering the program on a voluntary
basis. They also highlighted practical issues, such as the course being
quite time consuming, and emphasised the importance of having full
support from the school administration when implementing this sort
of program. However, absence of a control group was a limitation of
this study.
Evaluation of universal programs
A universal prevention program may positively affect the social
environment of at-risk adolescents [20]. It has been argued that selective
programs may have larger effects for individual participants, but
universal programs have multiple smaller effects on a larger number of
participants, which may, in turn, have an enormous effect on the larger society
[21]. Furthermore, adolescents with more developed skills in a particular area
may serve as models for peers who have less developed skills [22].
On the other hand, a few questions remain unanswered. For
example, longer-term follow-up data, which has become the gold
standard in clinical research, is not yet available for any of the universal
programs presented here. Attempts to replicate the findings have found
short term effects, but no effects on the long term [8,23,24]. Some
differences related to the effects have also been identified depending on
the kind of facilitators administering the interventions.
Unfortunately, most of the programs named in this review are based
on adult models that have been adapted to an adolescent population, and
thus, developmental psychopathology has not typically been considered in
treatment development and implementation. The LARS & LISA universal
prevention program represents an exception to this pattern.
A further problem with universal prevention programs is their
diversity, that is if and under what circumstances these programs may
be integrated into the everyday adolescent experience. The universal
programs mentioned in this review are all school-based prevention
programs; thus the deciding factor for the applicability of these
interventions will depend on whether they can be led by teachers and
be integrated into school curricula. The integration of a cognitive-
behavioural program into the school setting has been complicated thus
far by the fact that the implementation requires broad background
knowledge of therapeutic methods. An important future goal, thus, is
the adaptation of current programs to fit the needs of the school setting.
Selective depression prevention programs for adolescents
Selective prevention targets individuals at risk for depression as a
function of family factors such as parental depression, environmental
factors such as poverty, or personal characteristics such as a negative
cognitive style. Selective programs have greater attrition than universal
prevention programs.
Numerous studies have utilised the Penn Prevention Program
(PPP) for selective and indicated samples [25,26] (Table 3). For example,
the PPP was delivered to children aged 10-13 years with depressive
symptoms and/or family conflict, and a decrease in symptoms was
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Target sample/ Sample size

Program/Authors Outcome measures Control group Outcome (short- and long-term)
Country (n)
PPP Depressive symptoms,
10-13 year olds Significant effects at post-intervention and every 6 months
Jaycox et al. [25] 143 explanatory styles, family Assessment only
USA till 2 years. But not at 3-year follow-up
Gillham et al. [26] conflict
Lower income Latino
Modified PRP 49 (study 1); Depressive symptoms, negative Significant effects for all measures, except self-esteem, at
and African American
Cardemil et al. [32] th th 106 (study 2) cognitions, self-esteem post-intervention and 24-month follow-up
5 -8 graders
CWS-A 13-19 yr olds Parental depression, depressive Significant preventive effects at 18- and 24-month follow-
94 Usual care
Clarke et al. [27] Australia symptoms, suicide, functioning up; however, effects were diminished
CWS-A 13-17 yr olds Parental depression, depressive
316 Usual care Decreased incidence of depression at 9 months
Garber et al. [28] USA symptoms
Family Significant effects at post-intervention; at 11-months
Parenting, coping skills,
Bereavement 7-17 yr olds follow-up, decreased internalising and externalising
72 caregiver mental health, Self study
Program (FBP) USA problems for girls and those who had higher problem
stressful events
Sandler et al. [29] scores at baseline
Parental depression, parenting
Written
Family intervention 9-15 yr olds skills, coping skills, depressive Significant effects at post-intervention and at 24-month
111 information
Compas et al. [33] USA symptoms, externalising follow-up
comparison
symptoms
Table 3: Evaluation of selective programs for depression.

found post-treatment and every 6-months, till 2 years, but not at 3-year
follow-up. The effect sizes were highest for children that reported the
highest levels of symptoms, and for those that reported the highest
levels of parental conflict. The follow-up at 2 years indicated that the
interventions had a significant prevention effect, as the intervention
group reported significantly lower depression scores compared to the
control group.
A study by Clarke et al. used a combination of selective and indicated
approaches [27] (Table 3). Adolescents whose parents had been treated
for depression and who had elevated symptoms of depression that
fell short of depressive disorder were randomised to intervention
using the Coping with Stress program (CWS-A) or to usual care. The
intervention consisted of cognitive restructuring, specifically targeting
parent-related beliefs, was delivered to groups of 6–10 adolescents by
a trained therapist. The results provided indication of a significant
preventive effect for several outcome variables, including depression,
suicide symptoms, and functioning. The effect size was moderate (0.41),
representing a reduction in the risk of developing depression by more
than five times that of the control group. The significant preventive effect
persisted at the 18- and 24-month follow-ups, however, at a diminished
level, suggesting that the program’s effect had faded over time.
In an extension of this work, Garber et al. mounted a four-
site effectiveness replication trial [28] (Table 3). Assessments were
conducted at baseline, after the 8-week intervention, and after the
6-month continuation phase. At month 9, the intervention resulted in
reduced incidence overall (21.4% in the experimental group vs. 32.7%
in usual care), and especially so for adolescents whose parents were not
depressed at baseline.
Targeting children and adolescents whose parent died less than 2
years ago, Sandler et al. developed a multi-component intervention, the
Family Bereavement Program (FBP), directed at strengthening children’s
coping, strengthening the quality of parenting by the surviving parent,
and promoting the surviving parent’s own adjustment [29] (Table 3).
Results indicated that the FBP led to improved parenting, coping, and
caregiver mental health and to reductions in stressful events at post-
test. At 11-month follow-up, the FBP led to reduced internalising and
externalising problems, but only for girls and those who had higher
problem scores at baseline.
Evaluation of the FBP in a randomised experimental trial found
a reduction in girls’ level of depressive symptomatology 11 months
following the intervention [30] and a reduction in parents’ depressive
symptomatology up to six years after participation [31]. At the six-year
follow-up, the odds of the bereaved spouse having a moderate or higher
level of depression were 2.38 times higher in the control group than
in the FBP group after controlling for the baseline level of depressive
symptoms.
Cardemil et al. delivered 12-weekly group sessions of Modified
Penn Resiliency Program (PRP) to low income Latino and African-
American children [32] (Table 3). In the modified PRP, the ethnicity of
the children was changed in the examples, and it focused on problems
specific to low-income families and single-parent homes. Beneficial
effects were reported for depressive symptoms and negative cognitions
but not for self-esteem at post-test and 24-months follow-up for Latino
children. The intervention gave significant results for the groups with
higher levels of symptoms at the start. The effect size was reported as
1.19 at post intervention and 0.90 at 6-months follow-up. The effect sizes
for the low symptom group were .067 at post-test and 0.79 at 6-months
follow-up, which was interpreted as a trend toward prevention. The
intervention also seemed to have a positive effect both for groups
with low and high symptoms. No effects were found for participants
with an African-American background. One possible explanation for
this may be that the Latin-American groups reported higher levels of
depressive symptoms. The sample size was small, particularly in the
Latin-American group with only 49 participants distributed across the
interventions and control group.
Compas et al. delivered a family-based intervention to parents with
a history of depression and their children [33]. Groups of four families
at a time received eight sessions weekly and then four follow-up sessions
monthly. The intervention provided the families information about
depression, the effect of stress and depression on functioning, and ways
to reorganise and manage stress. Within the group format, there was
also emphasis on working with parents to improve parenting skills and
with children to improve coping skills. In a randomized trial of 111
families, significant differences in child- and parent-reported anxiety
and depression scores and other dimensions of functioning were found
at 24-month follow-up. Incidence was reduced in the intervention
group (14.3%) compared with the control group (32.7%). This study
had a high retention rate and involved systematic implementation at
two different sites with good fidelity of intervention delivery. The results
suggest that this intervention has a preventive effect on depressive
symptomatology and on incidence of depression.

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ISSN: 2167-1044 JDA an open access journal Volume 4 • Issue 4 • 1000197
Citation: Singhal M, Manjula M, Sagar JV (2015) Adolescent Depression Prevention Programs-A Review. J Depress Anxiety 4: 197. doi:10.4197/2167-
1044.1000197

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Target sample/ Sample size

Program/Authors Outcome measures Control group Outcome (short- and long-term)
Country (n)
CWS-A High school students Active and Significantly reduced incidence of depression at
341 Depressive symptoms
Stice et al. [37] Australia passive 2-year follow-up
Modified Penn Optimism
8-15 yr olds Depressive symptoms, family Significant effects at post-test, 3- and 6-month
Program 220
China conflict, explanatory style follow-ups
Yu and Seligman[38]
Teaching Kids to Cope At least 13 yrs of age Significant effects at post-test and 12-month
107 Depressive symptoms Usual care
Puskar et al. [39] Australia follow-up
Grade 9 students;
ACE Depressive symptoms, negative Significant effects at post-test and 6-month
Mean age 14.5 yrs 82 Wait-list
Kowalenko et al. [40] automatic thoughts, coping skills follow-up
Australia
11-12 yr olds
PRP Depressive symptoms, attributional
271 Usual care Significant effects for girls at post-test
Gillham et al. [41] style
US
Depressive symptoms, negative
Coping Skills Program 13-18 yr olds Psycho- Significant effects at post-test and 3-months
120 cognitions, academic stress, coping
Singhal et al. [43] India education follow-up
skills, social problem solving
Table 4: Evaluation of indicated programs for depression.

Evaluation of selective programs
Overall, we can see that the selective prevention programs effect
a larger range of outcomes related to externalizing symptoms and
behavioural difficulties [29,31,33], anxiety [33], depressive symptoms
[29,31,33], and clinical depression [33]. The interventions do also seem
to have the larger effect when directed towards specific risk factors
associated with a depressive disorder.
The results from selective prevention programs are, however,
unclearly related to variables like gender and symptom level [31], age
[34], and whether the parents report or the children or adolescents
report themselves [35].
Moreover, not all selective programs have included parental
samples, even though the risk factors have been selected based on parent
factors. An important gap in research remains if only factors related
to adolescents are subjected to intervention and the studies are not
designed to effect changes in parental indices (e.g., psychopathology)
that conferred risk upon adolescents in the first place. Based on this
reason it is possible to question the selective programs as having a
somewhat biased focus on the capacity and skills of the adolescent.
In this vein, it is interesting to see that studies with a stronger
focus on the parents generally seemed to have a positive effect on the
adolescents [29,33], but it is difficult to evaluate the results because none
of the programs mentioned here had a condition that only included
improving the parents’ functioning.
That the above mentioned studies have yielded varied results may
be because our models for depression are inadequate. If our present
understanding of depression is inadequate, it will be difficult to develop
good prevention strategies and interventions. Selective interventions
seem to work better than universal programs, and it is possible in
the near future, for example, to include genetic factors in selective
prevention, because genetic components have been shown to be
important for depression. Newer research has indicated that a different
combination of alleles may influence the risk for developing depression
when faced with adversity [36]. However, this would involve some kind
of a genetic screening, which is considered ethically controversial.
Indicated depression prevention programs for adolescents
Indicated prevention programs are provided to individuals with
sub-clinical signs or symptoms of depression, and thus are a classic
‘early interventions’. They ensure that those receiving the intervention
are at greatest risk. Similar to selective prevention, indicated prevention
programs usually are conducted in small groups.
Stice et al. used the CWS-A program (Table 1) with high school
students with elevated depressive symptoms [37] (Table 4). The students
were randomised into one of four conditions: a cognitive-behavioural
(CB) group intervention, a supportive-expressive group intervention,
a CB bibliotherapy intervention, and an educational brochure control
condition. At two-year follow-up, onset of major and minor depression
was significantly lower for the CB group (14%) and CB bibliotherapy
participants (3%) than for brochure controls (23%).
Yu and Seligman targeted Chinese youth with depressive symptoms
or family conflict and delivered Modified Penn Optimism Program
(10 weekly, 2-hour sessions), adapted for use with Chinese youth [38]
(Table 4). Significantly reduced depressive symptoms, mediated by
improvement in explanatory styles, at post-test, 3- and 6-month follow-
ups were found.
Puskar et al. examined the effectiveness of a Teaching Kids to
Cope Program in a group of adolescents [39] (Table 4). Students from
three schools who had elevated symptoms of depression were invited
to participate. The intervention, a 10-week psycho-educational group
intervention that uses a combination of behavioural and cognitive
techniques, was delivered during school time by nurses with psychiatric
mental health experience. Results indicated a significant effect for the
intervention group, with a drop in depression scores after intervention
that was maintained to 12 months.
Kowalenko et al. administered the Adolescents Coping with
Emotion (ACE; Table 1) program to Grade 9 female students at-risk for
depression [40] (Table 4). Results revealed significantly lower depressive
scores, significantly higher coping scores, and significant reduction in
negative automatic thoughts. All the effects were observed both at post-
intervention and at 6-month follow-up.
Gillham et al. assessed the effectiveness of the PRP in adolescents
with elevated depressive symptoms in a primary care setting [41]
(Table 4). The adolescents in the intervention condition evidenced an
improvement in the attribution style of positive events. The effects of
attribution style for negative life events and depressive symptoms were
moderated by gender. The program significantly reduced depressive
symptoms for girls who had an effect size of 0.31, but not significantly
for the boys. The authors report that the intervention did not prevent
depressive disorders per se but did prevent depression, anxiety and
adjustment disorders when these were combined, and then only in the

J Depress Anxiety
ISSN: 2167-1044 JDA an open access journal Volume 4 • Issue 4 • 1000197
Citation: Singhal M, Manjula M, Sagar JV (2015) Adolescent Depression Prevention Programs-A Review. J Depress Anxiety 4: 197. doi:10.4197/2167-
1044.1000197
high-symptom participants (although this was already targeted to a
high-risk group). They concluded that the effects of their program were
‘small and inconsistent’. The study had a high drop-out rate with nearly
a third dropping out over the 2-year period.
In the most comprehensive study to date, Sheffield et al. evaluated
the impact of universal, indicated and a combination of both approaches
using a cognitive-behavioural approach [42]. The 34 participating
schools from two sites in Australia were randomised to one of four
conditions: a universal program, an indicated program for students
with elevated symptoms of depression, a universal program followed
by an indicated program for high-risk students and a no-intervention
control group. Disappointingly, there was no difference in outcome for
any of the interventions compared with the no-intervention control
group. There was a significant decline in depression scores in high-
risk students irrespective of condition, although this group remained
more depressed than their low-risk counterparts. However, the study
had several methodological strengths, including a large sample size of
2,470 participants, an independent research team, a randomization to
different conditions of interventions, long term follow-up (12 months)
and a low drop-out rate.
In the only published Indian study to have utilised indicated samples,
the researchers developed and tested a program that was informed by
an empirical investigation of the risk factors for depression unique to
the Indian cultural context [43] (Table 4). Adolescents with subclinical
depression across two schools comprised the intervention and control
groups. The intervention group received the 8-weekly Coping Skills
Program in same-gender groups, whereas the control group received
one interactive psycho-educatory session. The intervention group
evidenced clinically significant reductions in depressive symptoms,
negative cognitions, and academic stress, and increased social problem
solving and coping skills, at both post-intervention and follow-up. No
corresponding changes were found in the control group.
Evaluation of indicated programs
Several of the interventions reviewed above show an effect at
post-test and at 6-months follow-up. However, these effects seem to
disappear long term, with a few exceptions [25,37]. Sheffield et al. [42]
found no effects in their study, while Gillham et al. [41] found small
and inconsistent effects. Overall, aiming the interventions at groups
that have elevated symptoms seems to work better, especially in terms
of yielding higher effect sizes, than offering it to a general group.
There is suggestion that indicated interventions make participants
feel stigmatised, but there is limited research that has actually examined
this issue in a quantitative manner. In one study, students were asked
about how stigmatised they felt being selected for an indicated
intervention [44]. It was found that the program delivery was associated
with significantly greater levels of embarrassment, but effect sizes were
small and neither the universal nor the indicated program was associated
with marked stigma in absolute terms. In fact, the indicated program
was evaluated more positively by both participants and program leaders
and effect sizes for these measures of satisfaction were moderate to large.
In another study, the authors took measured steps to overcome stigma,
such as masking the nature of selection of at-risk students, describing
the intervention as a positive-skill building experience, and not using
the word ‘depression’ anywhere in the study [43]. The participants in
this study reported not being embarrassed to do the program, not being
teased by peers for being singled out for participation, and not being
criticised at home or school for participating. The satisfaction with the
program was rated to be moderate to high.
J Depress Anxiety
ISSN: 2167-1044 JDA an open access journal
Page 6 of 7
Summary and Future Directions
To sum up the evidence overall, it has been found that group
cognitive-behavioural approach interventions can significantly reduce
depressive symptoms among adolescents, with some evidence that the
intervention provides long-lasting effects.
Targeted prevention with indicated and selective programs
overall seem to be significantly more effective with higher effect sizes
than universal programs. One reason for this finding could be in the
universal samples, control participants often do not show high enough
level of depressive symptoms at follow-up to demonstrate a preventive
effect for the intervention. On the other hand, selective and indicated
programs choose participants on the basis of risk status and are thus
likely to have higher level of depressive symptoms at baseline, which also
demonstrate an increase over time.
Also, the programs reviewed above have variable lengths of follow-
up, from 2 months to 24 months. Programs that claim to prevent
depression require a longer follow-up than what most programs actually
do. This is because not only do the program participants take time to
assimilate the skills taught, but also because it may take time for control
participants to show increases in depressive symptoms.
However, there is high variability in the findings of the studies
reviewed above. One explanation for the varying results is that our
models are incomplete in regards to understanding depression. Further
research to ameliorate the understanding of the development and
maintenance of depression is essential in order also to improve the
effects of prevention and intervention. The existing research accentuated
cognitive variables such as those that contribute to predicting
depression, but based on the findings from the prevention studies, it is
probably not the complete picture. Many of the interventions used in
above mentioned programs are generated from cognitive therapy, which
often focuses on intrapersonal factors. Another possible approach is to
include the focus on interpersonal factors in order to enhance the effect
of the prevention programs.
It does, however, seem decisive that future emphasis on prevention is
based on an empirical and solid theoretical foundation. If interventions
are to be implemented, they should be based on actual knowledge of
what works and such interventions should be rigorously evaluated.
Interventions that are theoretically informed, efficacious, and cost-
effective would stand to benefit lakhs of adolescents worldwide who are
affected by depression.
References
1. Costello EJ, Erkanli A, Angold A (2006) Is there an epidemic of child or
adolescent depression? J Child Psychol Psychiatry 47: 1263-1271.
2. Nair MKC, Paul MK, John R (2004) Prevalence of depression among
adolescents. Ind J Pediatr 71: 523-52.
3. Stolberg R, Clark DC, Bongar B (2002) Epidemiology, assessment, and
management of suicide in depressed patients, Handbook of Depression and its
Treatment. Guildford: NY 581-601.
4. Lewinsohn PM, Rohde P, Klein DN, Seeley JR (1999) Natural course of
adolescent major depressive disorder I: Continuity into young adulthood. J Am
Acad Child Adolesc Psychiatry 38: 56-63.
5. Mrazek PJ, Haggerty RJ (1994) Reducing risks for mental disorders: Frontiers
for preventive research. Washington DC: National Academy Press.
6. Clarke GN, Hawkins W, Murphy M, Sheeber L (1993) School-based primary
prevention of depressive symptomatology in adolescents: Findings from two
studies. J Adolesc Res 8: 183-204.
7. Shochet IM, Whitefield K, Holland D (1997) Resourceful adolescent program:
Group leader’s manual. Brisbane, Australia.
Volume 4 • Issue 4 • 1000197
Citation: Singhal M, Manjula M, Sagar JV (2015) Adolescent Depression Prevention Programs-A Review. J Depress Anxiety 4: 197. doi:10.4197/2167-
1044.1000197
8. Merry S, McDowell H, Wild CJ, Bir J, Cunliffe R (2004) A randomized placebo-
controlled trial of a school-based depression prevention program. J Am Acad
Child Adolesc Psychiatry 43: 538-547.
9. Shochet IM, Dadds MR, Holland D, Whitefield K, Harnett PH, et al. (2001) The
efficacy of a universal school-based program to prevent adolescent depression.
J Clin Child Psychol 30: 303-315.
10. Spence SH, Shortt AL (2007) Research Review: Can we justify the widespread
dissemination of universal, school-based interventions for the prevention of
depression among children and adolescents? J Child Psychol Psychiatry 48:
526-542.
11. Spence SH, Sheffield JK, Donovan CL (2003) Preventing adolescent
depression: an evaluation of the problem solving for life program. J Consult
Clin Psychol 71: 3-13.
12. Pössel P, Horn AB, Seemann S, Hautzinger M (2004) Trainingsprogramm
zur Prävention von Depressionen bei Jugendlichen LARS&LISA: Lust An
Realistischer Sicht & Leichtigkeit Im Sozialen Alltag Hogrefe: Göttingen.
13. Pössel P, Horn AB, Groen G, Hautzinger M (2004) School-based prevention
of depressive symptoms in adolescents: a 6-month follow-up. J Am Acad Child
Adolesc Psychiatry 43: 1003-1010.
14. Gillham JE, Reivich KJ, Freres DR, Chaplin TM, Shatte AJ, et al. (2007) School-
based prevention of depressive symptoms: A randomized controlled study of
the effectiveness and specificity of the Penn Resiliency Program. J Consult
Clin Psychol 75: 9-19.
15. Tak YR, Van Zundert RM, Kuijpers RC, Van Vlokhoven BS, Rensink HF (2012)
A randomized controlled trial testing the effectiveness of a universal school-
based depression prevention program ‘Op Volle Kracht’ in the Netherlands.
BMC Public Health 12: 21-29.
16. Calear AL, Christensen H, Mackinnon A, Griffiths KM, O’Kearney R (2009) The
YouthMood Project: a cluster randomized controlled trial of an online cognitive
behavioral program with adolescents. J Consult Clin Psychol 77: 1021-1032.
17. Muñoz RF (2010) Using evidence-based internet interventions to reduce health
disparities worldwide. J Med Internet Res 12: e60.
18. Sawyer MG, Pfeiffer S, Spence SH, Bond L, Graetz B, et al. (2010) School-
based prevention of depression: A randomized controlled study of the Beyondblue
Schools Research Initiative. J Child Psychol Psychiatry 51: 199-209.
19. Garmy P, Jakobsson U, Carlsson KS, Berg A, Clausson EK (2015) Evaluation
of a school-based program aimed at preventing depressive symptoms in
adolescents. J Sch Nurs 31: 117-125.
20. Spence SH (1998) Preventive interventions, Comprehensive Clinical
Psychology, Children & Adolescents: Clinical formulation and treatment.
Amsterdam: Elsevier.
21. Gillham JE, Shatté AJ, Freres DR (2000) Preventing depression: A review of
cognitive-behavioural and family interventions. Appl Prev Psychol 9: 63-88.
22. Lowry-Webster HM, Barrett PM, Dadds MR (2001) A universal prevention trial
of anxiety and depressive symptomatology in childhood: Preliminary data from
an Australian study. Beh Change 18: 36-50.
23. Harnett PH, Dadds, MR (2004) Training school personnel to implement a
universal school-based prevention of depression program under real-world
conditions J Sch Psychol 42: 343-357.
24. Rivet-Duval E, Heriot S, Hunt C (2011) Preventing Adolescent Depression in Mauritius:
A Universal School-Based Program. Child Adolesc Ment Health 16: 86-91.
25. Jaycox LH, Reivich KJ, Gillham J, Seligman ME (1994) Prevention of depressive
symptoms in school children. Behav Res Ther 32: 801-816.
26. Gillham JE, Reivich KJ, Jaycox LH, Seligman MEP (1995) Prevention of
depressive symptoms in school children: Two-year follow-up. Psychol Sci 6:
343-351.
J Depress Anxiety
ISSN: 2167-1044 JDA an open access journal
Page 7 of 7
27. Clarke GN, Hornbrook M, Lynch F, Polen M, Gale J, et al. (2001) A randomized
trial of a group cognitive intervention for preventing depression in adolescent
offspring of depressed parents. Arch Gen Psychiatry 58: 1127-1134.
28. Garber J, Clarke GN, Weersing VR, Beardslee WR, Brent DA, et al. (2009)
Prevention of depression in at-risk adolescents: a randomized controlled trial.
JAMA 301: 2215-2224.
29. Sandler IN, Ayers TS, Wolchik S, Tein JY, Kwok OM, et al. (2003) The Family
Bereavement Program: Efficacy evaluation of a theory-based preventive
intervention for parentally bereaved children and adolescents. J Consult Clin
Psychol 71: 587-600.
30. Schmiege SJ, Khoo ST, Sandler IN, Ayers TS, Wolchik SA (2006) Symptoms of
internalizing and externalizing problems: Modeling recovery curves after death
of a parent. Am J Prev Med 31: 152-160.
31. Sandler I, Ayers TS, Tein JY, Wolchik S, Millsap R, et al. (2010) Six-year follow-
up of a preventive intervention for parentally bereaved youths: a randomized
controlled trial. Arch Pediatr Adolesc Med 164: 907-914.
32. Cardemil EV, Reivich KJ, Beevers CG, Seligman ME, James J (2007) The
prevention of depressive symptoms in low-income, minority children: two-year
follow-up. Behav Res Ther 45: 313-327.
33. Compas BE, Forehand R, Keller G, Champion JE, Rakow A, et al. (2009)
Randomized controlled trial of a family cognitive-behavioral preventive intervention
for children of depressed parents. J Consult Clin Psychol 77: 1007-1020.
34. Beardslee WR, Wright EJ, Salt P, Drezner K, Gladstone TR, et al. (1997)
Examination of children’s responses to two preventive intervention strategies
over time. J Am Acad Child Adolesc Psychiatry 36: 196-204.
35. Sandler IN, West SG, Baca L, Pillow DR, Gersten JC, et al. (1992) Linking
empirically based theory and evaluation: The family bereavement program. Am
J Community Psychol 20: 491-521.
36. Koefoed P, Woldbye PD, Hansen TO, Eplov LF, Christiansen SH, et al. (2012)
Association of the leucine-7 to proline-7 variation in the signal sequence of
neuropeptide Y with major depression. Acta Neuropsychiatr 24: 81-90.
37. Stice E, Rohde P, Gau JM, Wade E (2010) Efficacy trial of a brief cognitive-
behavioral depression prevention program for high-risk adolescents: effects at
1- and 2-year follow-up. J Consult Clin Psychol 78: 856-867.
38. Yu DL (2002) Seligman MEP. Preventing depressive symptoms in Chinese
children Prev Treat 5: 9.
39. Puskar K, Sereika S, Tusaie-Mumford K (2003) Effect of the Teaching Kids
to Cope (TKC) program on outcomes of depression and coping among rural
adolescents. J Child Adolesc Psychiatr Nurs 16: 71-80.
40. Kowalenko N, Rapee RM, Simmons J, Wignall A, Hoge R, et al. (2005) Short-
term effectiveness of a school-based early intervention program for adolescent
depression. J Clin Child Psychol Psychiatry 10: 493-507.
41. Gillham JE, Hamilton J, Freres DR, Patton K, Gallop R (2006) Preventing
depression among early adolescents in the primary care setting: A randomized
controlled study of the Penn Resiliency Program. J Abnorm Child Psychol 34:
203-219.
42. Sheffield JK, Spence SH, Rapee RM, Kowalenko N, Wignall A, et al. (2006)
Evaluation of universal, indicated, and combined cognitive-behavioral
approaches to the prevention of depression among adolescents. J Consult Clin
Psychol 74: 66-79.
43. Singhal M, Manjula M, Vijay Sagar KJ (2014) Development of a school-based
program for adolescents at-risk for depression in India: results from a pilot
study. Asian J Psychiatr 10: 56-61.
44. Rapee RM, Wignall A, Sheffield J, Kowalenko N, Davis A, et al. (2006)
Adolescents’ reactions to universal and indicated prevention programs for
depression: perceived stigma and consumer satisfaction. Prev Sci 7: 167-177.
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