Journal of Adolescent Health 59 (2016) S49eS60

www.jahonline.org

Review article

Interventions for Adolescent Mental Health: An Overview

of Systematic Reviews
Jai K. Das, M.D., M.B.A. a, Rehana A. Salam, M.Sc. a, Zohra S. Lassi, Ph.D. b, Marium Naveed Khan a,
Wajeeha Mahmood c, Vikram Patel, Ph.D. d, e, f, and Zulfiqar A. Bhutta, Ph.D. g, h, *
a
Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
b
Robinson Research Institute, University of Adelaide, Adelaide, Australia
c
Ziauddin University, Karachi, Pakistan
d
London School of Hygiene & Tropical Medicine, London, United Kingdom
e
Public Health Foundation of India, New Delhi, India
f
Sangath, Goa, India
g
Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
h
Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan

Article history: Received January 25, 2016; Accepted July 1, 2016

Keywords: Adolescent health; Mental health; Suicide; Depression; Anxiety; Eating disorders

A B S T R A C T

Many mental health disorders emerge in late childhood and early adolescence and contribute to the
burden of these disorders among young people and later in life. We systematically reviewed literature
published up to December 2015 to identify systematic reviews on mental health interventions in
adolescent population. A total of 38 systematic reviews were included. We classified the included reviews
into the following categories for reporting the findings: school-based interventions (n ¼ 12); community-
based interventions (n ¼ 6); digital platforms (n ¼ 8); and individual-/family-based interventions (n ¼ 12).
Evidence from school-based interventions suggests that targeted group-based interventions and cognitive
behavioral therapy are effective in reducing depressive symptoms (standard mean difference [SMD]: .16;
95% confidence interval [CI]: .26 to .05) and anxiety (SMD: .33; 95% CI: .59 to .06). School-based
suicide prevention programs suggest that classroom-based didactic and experiential programs increase
short-term knowledge of suicide (SMD: 1.51; 95% CI: .57e2.45) and knowledge of suicide prevention
(SMD: .72; 95% CI: .36e1.07) with no evidence of an effect on suicide-related attitudes or behaviors.
Community-based creative activities have some positive effect on behavioral changes, self-confidence,
self-esteem, levels of knowledge, and physical activity. Evidence from digital platforms supports
Internet-based prevention and treatment programs for anxiety and depression; however, more extensive
and rigorous research is warranted to further establish the conditions. Among individual- and family-
based interventions, interventions focusing on eating attitudes and behaviors show no impact on body
mass index (SMD: .10; 95% CI: .45 to .25); Eating Attitude Test (SMD: .01; 95% CI: .13 to .15); and
bulimia (SMD: .03; 95% CI: .16 to .10). Exercise is found to be effective in improving self-esteem (SMD:
.49; 95% CI: .16e.81) and reducing depression score (SMD: .66; 95% CI: 1.25 to .08) with no impact on
anxiety scores. Cognitive behavioral therapy compared to waitlist is effective in reducing remission (odds
ratio: 7.85; 95% CI: 5.31e11.6). Psychological therapy when compared to antidepressants have comparable
effect on remission, dropouts, and depression symptoms. The studies evaluating mental health

Conflicts of interest: The authors do not have any financial or nonfinancial competing interests for this review.
Disclaimer: Publication of this article was supported by the Bill and Melinda Gates Foundation. The opinions or views expressed in this supplement are those of the
authors and do not necessarily represent the official position of the funder.
* Address correspondence to: Zulfiqar A. Bhutta, Ph.D., Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, Toronto, Ontario M6S 1S6,
Canada.
E-mail address: zulfi[email protected] (Z.A. Bhutta).

1054-139X/Ó 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
http://dx.doi.org/10.1016/j.jadohealth.2016.06.020
S50 J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60

interventions among adolescents were reported to be very heterogeneous, statistically, in their pop-
ulations, interventions, and outcomes; hence, meta-analysis could not be conducted in most of
the included reviews. Future trials should also focus on standardized interventions and outcomes for
synthesizing the exiting body of knowledge. There is a need to report differential effects for gender,
age groups, socioeconomic status, and geographic settings since the impact of mental health interventions
might vary according to various contextual factors.
Ó 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access
article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Adolescence is a period for the onset of behaviors and con- studies targeted youth (aged 15e24 years) along with adoles-
ditions that not only affect health at that time but also lead to cents, exceptions were made to include reviews targeting ado-
adulthood disorders. Unhealthy behaviors such as smoking, lescents and youth. We did not apply any limitations on the start
drinking, and illicit drug use often begin during adolescence and search date or geographical settings. We considered all available
are closely related to increased morbidity and mortality and published systematic reviews on the interventions to prevent
represent major public health challenges [1]. Many mental and treat adolescent mental health disorders. A broad search
health disorders emerge in mid- to late adolescence and strategy was used that included a combination of appropriate
contribute to the existing burden of disease among young people keywords, medical subject heading, and free text terms; the
and in later life [2]. More than 50% of adult mental disorders have search was conducted in the Cochrane Library, and PubMed. The
their onset before the age of 18 years [3,4]. Poor mental health abstracts (and the full sources where abstracts are not available)
has been associated with teenage pregnancy, HIV/AIDS, other were screened by two abstractors to identify systematic reviews
sexually transmitted diseases, domestic violence, child abuse, adhering to our objectives. Any disagreements on selection of
motor vehicle crashes, physical fights, crime, homicide, and reviews between these two primary abstractors were resolved by
suicide [2]. Globally, neuropsychiatric disorders are the leading the third reviewer. After retrieval of the full texts of all the re-
cause of years lost because of disability among 10- to 24-year- views that met the inclusion/exclusion criteria, data from each
olds, accounting for 45% of years lost because of disabilities [5]. review were extracted independently into a standardized form.
The overall prevalence of depression in adolescents is around 6% Information was extracted on (1) the characteristics of included
and that for children (younger than 13 years) is 3% [6]. Major studies; (2) description of methods, participants, interventions,
depressive disorder (MDD) is one of the leading causes of outcomes; (3) measurement of treatment effects; (4) methodo-
disability, morbidity, and mortality and is a major risk factor for logical issues; and (5) risk of bias tool. We extracted pooled effect
suicide [7]. MDD also puts adolescents and young adults at a size for outcomes reported by the review authors with 95%
greater risk for suicide as they are seven times more likely to confidence intervals (CIs). We assessed and reported the quality
complete suicide than those without MDD [8]. Suicide itself ac- of included reviews using the 11-point assessment of the
counts for 9.1% of deaths in 15- to 19-year age group and ranks as methodological quality of systematic reviews criteria (AMSTAR)
the third major cause of mortality in this age group, preceded [17]. We excluded nonsystematic reviews, systematic reviews
only by accidents and assault [9]. focusing on preventive and therapeutic mental health in-
Given the prevailing burden and impact of mental health terventions targeting population other than adolescents and
disorders in children and adolescents, it is essential that effective youth, and reviews not reporting outcomes related to mental
interventions are identified and implemented. This article is part health (Table 1).
of a series of reviews conducted to evaluate the effectiveness of Figure 1 describes the search flow. Our search identified 107
potential interventions for adolescent health and well-being. potentially relevant review titles. Further evaluation of the
Detailed framework, methodology, and other potential inter- abstracts and full texts resulted in the inclusion of 38 eligible
ventions have been discussed in separate articles [10e16]. Our reviews. We classified the included reviews into the following
conceptual framework depicts the individual and general risk categories for reporting the findings:
factors through the life cycle perspective that can have implica-
tions at any stage of the life cycle [10]. We also acknowledge the  School-based interventions (n ¼ 12)
fact that mental health interventions take a life course perspec-  Community-based interventions (n ¼ 6)
tive and that interventions earlier in life can have impacts in  Digital platforms (n ¼ 8)
adolescence; however, the focus of our review is to evaluate  Individual-/family-based interventions (n ¼ 12)
potential mental health interventions targeted toward adoles-
cents and youth only. With this focus, we aimed to systematically Table 2 describes the characteristics of the included reviews
review the effectiveness of interventions to prevent and manage while Table 3 provides the summary estimates for all the
mental health disorders among adolescents and youth. interventions.

Methods Results

We systematically reviewed literature published up to School-based interventions

December 2015, to identify systematic reviews on interventions
to prevent and manage mental health disorders in adolescent We found a total of 12 reviews reporting school-based
population. For the purpose of this review, the adolescent pop- interventions for adolescent mental health, of which one
ulation was defined as aged 11e19 years; however, since many review performed meta-analysis. AMSTAR rating ranged
 J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60 S51

Table 1
Inclusion/exclusion criteria

Inclusion criteria Exclusion criteria

Systematic review and/or meta-analysis of interventions for Nonsystematic reviews

prevention and treatment of mental health targeting adolescents Systematic reviews focusing on preventive and therapeutic mental
(11e19 years) or youth (15e24 years): health interventions targeting population other than adolescents and youth
Eating disorders Reviews not reporting outcomes related to mental health
Anxiety
Depression
Suicidal behaviors
eHealth interventions focusing on adolescent/youth mental health

between 5 and 11 with a median score of 7.5. Five of the included barriers to learning arising from social, emotional, or behavioral
reviews focused on school-based mental health promotion difficulties in an inclusive, supportive manner) have an imme-
interventions; three reviews evaluated school-based programs diate positive impact on the social and emotional well-being of
for prevention and early intervention for existing mental health young people [20]. Due to heterogeneity of design, it was not
conditions while four reviews evaluated school-based programs possible to conduct a meta-analysis, and the studies were
for suicide prevention. A review on school mental health pro- examined for effectiveness qualitatively. A review evaluating
motion programs based on the findings from 15 studies suggests solution-focused brief therapy in schools has suggested mixed
that an approach focusing on mental health promotion rather results with some promise in working with students in school
than on mental illness prevention is effective in promoting settings, specifically for reducing the intensity of students’
adolescent and youth mental health [18]. However, study pop- negative feelings, managing conduct problems, and externalizing
ulations were limited, and studies either lack clarity regarding behavioral problems [21]. These findings are based on seven
who implemented interventions or lack theoretical foundations, studies while meta-analysis could not be conducted. School-
process evaluations, or youth viewpoints [18]. Meta-analysis was based mental health interventions specifically focusing on low-
not conducted due to variations in interventions and outcomes. and middle-income countries (LMICs) suggest that the majority
Another review reported from 27 studies that school-based of the school-based life skills and resilience programs indicated
preventive health care is popular with young people and positive effects on students’ self-esteem, motivation, and
provides important mental health services [19]. However, self-efficacy. However, there were mixed results, including dif-
meta-analysis was not done due to study quality. Findings from a ferential effects for gender and age groups [19], and effect
review based on 16 studies focusing on targeted group-based estimates could not be pooled. A systematic review on the
interventions delivered in school settings suggest that nurture effectiveness of school nurse implemented mental health
groups (short-term, focused intervention which addresses screening for adolescents in schools did not find any evidence of

Figure 1. Search flow diagram. MeSH ¼ Medical Subject Heading.

Table 2

S52
Characteristics of the included reviews

Intervention Review Intervention details Setting; Number of AMSTAR Outcomes reported

HICs/LMICs included studies rating

School-based O’Mara and Lind [18] Social and emotional health and well-being, positive Mostly HICs 15 reviews d Subclinical internalizing and externalizing
interventions youth development, health promotion, mental problems, academic achievement, mood
health promotion, primary prevention disorders, anxiety, depressive symptoms,
self-concept, self-esteem, coping skills,
interpersonal skills, quality of peer and
adult relationships, self-control, problem-
solving, self-efficacy, school misbehavior,
aggressive behavior and violence,
interpersonal sensitivity, conflict resolution,
school attendance, social functioning
Mason-Jones School-based health care including comprehensive HICs 27 (RCTs and 7 Utilization of mental health services,
et al. [19] services based at schools, dedicated adolescent health observational ever considered suicide, attempted suicide
services, school-linked services based at local health studies)
centers, and servicing a number of schools and other

J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60

outreach
Cheney et al. [20] Nurture group (NG) intervention delivered in primary HICs 16 (RCTs and 8 Social and emotional well-being
and secondary school settings. NG sessions typically preepost)
include circle time meet and greet. A directed activity,
aiming to develop cooperation, listening, teamwork,
turn-taking, problem-solving, and self-esteem. Snack
time. Free time to choose an activity from the range
offered. Saying good-byes
Kim and Franklin [21] Solution-focused brief therapy on behavioral problems HICs 7 (RCT, quasi, 6 Changes in scores from Hare Self-Esteem
in schools and case Scale; Conners’ Teacher Rating Scale;
report) Conners’ Parent Rating Scale;
Feelings, Attitudes and Behaviors Scale
for Children; Substance Abuse Subtle
Screening Inventory Adolescent-2; and
Child Behavior Checklist-Youth.
Fothergill et al. [22] Screening tools being used by school nurses for the HICs None 6 Existing screening tools being applied
identification of emotional, psychological, and by school nurses to detect mental ill health
behavioral problems among adolescents in schools.
Calear and School-based prevention and early intervention HICs 42 RCTs 7 Depression
Christensen [23] programs for depression. Mostly including cognitive
behavioral therapy (CBT) delivered by a mental health
professional or graduate student over 8e12 sessions.
Other common therapeutic approaches employed
included psychoeducation and interpersonal therapy
Kavanagh et al. [24] Cognitive behavioral therapy HICs 17 RCTs 8 Outcome related to depression, anxiety,
and suicidality (actual or attempted
suicide and suicidal ideation)
Farahmand et al. [25] Day therapy programs: a multidisciplinary community- HICs 29 programs 7 Academic outcomes, behavioral outcomes,
based approach to the treatment of mental health issues conduct problems, depression, substance
use, internalizing symptoms
Katz et al. [26] School-based suicide prevention programs: HICs 16 programs 5 Students’ and school staffs’ knowledge and
awareness/education curriculum, gatekeeper training, attitudes toward suicide, suicide attempts
peer leadership training, screening, skills training,
reconnecting youth, good behavior game
De Silva et al. [27] Psychological interventions for suicide and self-harm HICs 38 controlled 6 Mapping of existing literature
prevention studies and 6
systematic
reviews
(continued on next page)
Table 2
Continued

Intervention Review Intervention details Setting; Number of AMSTAR Outcomes reported

HICs/LMICs included studies rating

Harrod et al. [28] Any intervention that (1) targeted students without HICs 8 RCTs 11 Completed suicide, suicide attempt, suicidal
known suicidal risk (i.e., primary prevention); (2) ideation, changes in knowledge, attitudes
had the prevention of suicide as one of its primary and behaviors
purposes; and (3) was delivered in the postsecondary
educational setting in any country
Harlow and Suicide prevention programs that have been evaluated HICs 11 programs 6 Suicide ideation, knowledge, attitude
Clough [29] for indigenous youth
Community-based Bungay and Music, dance, singing, drama and visual arts, taking Mostly HIC except 20 (RCTs and 5 Behavioral changes, self-confidence,
interventions Vella-Burrows [30] place in community settings or as extracurricular one in Tanzania observational) self-esteem, levels of knowledge,
activities and physical activity
Waddell et al. [31] Parent training or child social skills training and HICs 15 RCTs 6 Conduct disorder, anxiety, and depression
universal cognitive behavioral therapy (CBT)
Durlak and Primary prevention intervention designed specifically HICs 144 programs 5 Competencies, performance, successful transitions
Wells [32] to reduce the future incidence of adjustment problems

J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60

in currently normal populations, including efforts
directed at the promotion of mental health
Farahmand Community-based mental health and behavioral HICs 33 (RCTs and 4 Psychological, behavior, achievement, school
et al. [33] programs observational) connectedness, antisocial behavior,
interpersonal, social skills community
or prosocial activities, physical health
Bower et al. [34] Effectiveness of interventions for child and adolescent HICs RCTs and pree 7 Clinical outcomes, social, educational, satisfaction
mental health problems in primary care, and post studies with treatment, costs, attitudes, knowledge,
interventions designed to improve the skills of diagnostic and treatment behavior, costs
primary care staff
Digital platforms Clement et al. [35] It was a mass media intervention, defined as an HICs 22 RCTs 11 Discrimination or prejudice outcome measures
intervention that uses a channel of communication
intended to reach large numbers, and is not
dependent on person-to-person contact, for example,
newspapers, billboards, pamphlets, DVDs, television,
radio, cinema, some Web- and mobile phoneebased
media, street art, and ambient media
Musiat and Computerized cognitive behavioral therapy (cCBT) HICs 101 (observational 4 Cost-effectiveness, geographic flexibility, time
Tarrier [36] interventions studies) flexibility, waiting time for treatment, stigma,
therapist time, effects on help-seeking and
treatment satisfaction
Montgomery Media-based cognitive behavioral therapies HICs 11 RCTs 11 Behavioral disorders, therapist time
et al. [27]
Clarke et al. [38] Online mental health promotion and prevention HICs 28 observational 6 Anxiety, depression
interventions studies
Calear and Christensen BRAVE for ChildrendONLINE and BRAVE for Teenagersd HICs 4 programs 9 Anxiety and depression
2010 [39] ONLINE: based on cognitive behavioral therapy (CBT),
these programs consist of 10 weekly sessions for
children and adolescents; two booster sessions
presented 1 and 3 months after the intervention, and
five or six parent sessions. The programs present
information on managing anxiety, recognizing the
physiological symptoms of anxiety, graded exposure,
and problem-solving techniques.
Project CATCH-IT is a free, Internet-based training
program based on behavioral activation, CBT, and
interpersonal psychotherapy.
(continued on next page)

S53
Table 2

S54
Continued

Intervention Review Intervention details Setting; Number of AMSTAR Outcomes reported

HICs/LMICs included studies rating

MoodGYM is a free, interactive, Internet-based program

designed to prevent and decrease symptoms of
depression in young people.
Grip op je dip online is a free, Dutch language, CBT-based
program aimed at 16- to 25-year-olds. Based on the
face-to-face Grip op je dip course, the online program
consists of six moderated chat sessions attended by six
to eight participants.
Kauer et al. [40] Online services in facilitating mental health help-seeking HICs 18 (RCTs and 9 Help-seeking, mental health
observational
studies)
Martin et al. [41] Networked communication: e-mail and/or Web-based HICs 12 (RCTs and 9 Clinical outcomes (e.g., symptom alleviation),
electronic diary; videoconference; and virtual reality. observational patient-level impacts (e.g., improved health
studies) behaviors), patient and health care

J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60

professional satisfaction and costs
Farrer et al. [42] A range of broad technology types including the Internet, HICs 27 RCTs 9 Depression, anxiety
audio, virtual reality, video, stand-alone computer
programs, and/or a combination of these
Individual-/family- Pratt and Eating disorder awareness, promotion of healthy eating HIC 12 RCTs 8 BMI, Eating Attitude Test, Eating Disorder
based Woolfenden [43] attitudes and behaviors, as well as eating disorder Inventory, Sociocultural Attitudes Towards
interventions awareness and coping with general adolescent issues, Appearance Questionnaire, social perception
training in media literacy and advocacy skills profile, body image assessment
Ekelend et al. [44] Gross motor, energetic activity, for example, running, Mostly HIC except 23 RCTs 8 Self-esteem
swimming, ball games and outdoor play of moderate one in Nigeria
to high intensity, or strength training, in contrast to
“ordinary” physical activity (e.g., routine physical
education (PE) classes, walking to school, or playtime
activities of low intensity) for at least a duration of
4 weeks
Lubans et al. [45] Three types of physical activity programs (i.e., outdoor HICs 15 (RCTs, quasi, 9 Social and emotional well-being
adventure, sport and skill-based and physical fitness and preepost)
programs)
Cooney et al. [46] Exercise was defined as “planned, structured and Mostly HICs except 39 RCTs 11 Depression, acceptability of treatment,
repetitive bodily movement done to improve or one in Thailand, number of participants completing the
maintain one or more components of physical fitness” one in Brazil interventions; quality of life; cost; adverse
events
Larun et al. [47] Interventions that included vigorous physical activity HICs 16 RCTs 11 Anxiety or depression symptoms
of clearly specified quality with a minimum duration post-treatment
of 4 weeks
James et al. [48] (1) The relative efficacy of CBT versus non-CBT active HICs 41 RCTs 11 Remission, reduction in anxiety symptom,
treatments; (2) the relative efficacy of CBT versus acceptability
medication and the combination of CBT and
medication versus placebo; and (3) the long-term
effects of CBT
Cox et al. [49] Any psychological therapy with any antidepressant HICs 11 RCTs Remission from depressive disorder,
medication; a combination of interventions acceptability, suicide-related serious
(psychological therapy plus antidepressant adverse events, dropouts
medication) with either psychological therapies or
antidepressant medication alone; a combination of
interventions (psychological therapy plus
antidepressant medication) compared with either
intervention (psychological therapy or
antidepressants) plus a placebo; and a combination
(continued on next page)
 J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60 S55

existing screening tools to detect mental ill health among

AMSTAR ¼ assessment of the methodological quality of systematic reviews criteria; BMI ¼ body mass index; HIC ¼ high-income country; LMIC ¼ low- and middle-income country; RCT ¼ randomized controlled
adolescents in schools [22].

symptoms, improvement in other symptoms

depressive symptoms, dropouts, secondary
A systematic review of 28 school-based prevention and early

readmissions, time to relapse, functioning,

Treatment efficacy, treatment acceptability,

psychological functioning, acceptability,

remittance, improvement in depressive
intervention programs for depression has shown some support

Measures of symptoms and functioning

Prevention of a second or next episode, for the implementation of depression prevention and early

Disease-specific symptoms, general

intervention programs in schools [23]. Most of these programs

Symptoms, knowledge, attitude

were based on cognitive behavioral therapy (CBT) and delivered
by a mental health professional or graduate student over 8e12
sessions. Indicated programs, which targeted students exhibiting
elevated levels of depression, were found to be the most effective
AMSTAR Outcomes reported

in reducing depressive symptoms with effect sizes ranging from

.21 to 1.40. Meta-analysis was not conducted. It was found that
morbidity

and cost CBT delivered to young people in secondary schools can reduce
the symptoms of depression (standard mean difference
[SMD]: .16; 95% CI: .26 to .05) and anxiety (SMD: .33; 95%
CI: .59 to .06) [24]. School-based therapeutic mental health
programs specifically targeting adolescents with existing mental
rating

health disorders in LMICs suggested negative effects for pro-

11

11

8
11

grams that targeted externalizing problems and were delivered

selectively to youth with existing problems. Distinctive charac-
included studies

observational

teristics of low-income, urban schools, and nonschool environ-

8 RCTs and
Number of

ments were emphasized as potential explanations for the

studies
25 RCTs

52 RCTs

findings [25].
9 RCTs

7 RCTs

School-based suicide prevention programs focused on

awareness/education curricula, screening, gatekeeper, peer
leadership, and skills training [26,27]. Interventions for primary
prevention of suicide in university and other postsecondary
HICs/LMICs

educational settings suggest that classroom-based didactic and

Setting;

experiential programs increased short-term knowledge of sui-

HICs

HICs

HICs
HICs

HICs

cide (SMD: 1.51; 95% CI: .57e2.45) and knowledge of suicide

prevention (SMD: .72; 95% CI: .36e1.07) with no evidence of an
effect on participant’s suicide-related attitudes or behaviors;
however, these findings are limited by the overall low quality
[28]. Promising interventions that need further research include
skills training assertiveness training, relaxation
antidepressant medication) with a placebo or

Mental health services providing specialist care,

Behavioral therapy, behavioral activation, social

school-based prevention programs with a skills training

Any type of pharmacotherapy or psychological
of interventions (psychological therapy plus

provision, which provide an alternative to

beyond the capacity of generic outpatient

component, individual CBT interventions, interpersonal psy-

therapies, other psychological therapies

chotherapy, and attachment-based family therapy [26,27]. A

systematic review evaluating suicide prevention programs tar-
geting indigenous youth (aboriginals) suggested that more
Evidence-based psychotherapies

inpatient mental health care

controlled study designs using planned evaluations and valid

outcome measures are needed in research on indigenous youth
suicide prevention [29].
treatment as usual
Intervention details

Community-based interventions
therapy

We report findings from six systematic reviews evaluating

various community-based interventions targeting adolescents
and youth; meta-analysis was conducted in two reviews.
AMSTAR ratings ranged between 4 and 7 with a median score of
Deenadayalan et al. [54]

5. Evidence from 20 studies evaluating community-based crea-

Shinohara et al. [51]

Shepperd et al. [53]

tive activities (including music, dance, singing, drama, and visual

Weisz et al. [52]

arts) suggests some positive effect on behavioral changes, self-

Cox et al. [50]

confidence, self-esteem, levels of knowledge, and physical ac-

Review

tivity [30]. The interventions used in the studies were diverse,

and the research was heterogeneous, and hence overall synthesis
of the results was not attempted. Another review based on 15
studies on community-based parent training and social skills
training for preventing depression suggested significant re-
Intervention

ductions in symptom and/or diagnostic measures at follow-up

Continued

[31]. However, meta-analysis was not conducted. Evidence

Table 2

from a review evaluating primary prevention mental health

trial.

programs for adolescents suggests that individually focused

S56 J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60

Table 3
Summary estimates for adolescent mental health interventions

Interventions Comparison Outcomes and estimates

(number of reviews)

School-based School-based CBT Symptoms of depression: effect size range: .21 to 1.40
interventions (n ¼ 12) CBT in secondary schools Depression (SMD: L.16; 95% CI: L.26 to L.05)
Anxiety (SMD: L.33; 95% CI: L.59 to L.06)
Classroom instructions Knowledge of suicide (SMD: 1.51; 95% CI: .57 to 2.45)
Knowledge of suicide prevention (SMD: .72; 95% CI: .36 to 1.07)
Community-based Person-centered programs Social acceptance at 3-month follow-up (SMD: .03; 95% CI: .10 to .04)
interventions (n ¼ 6) Affective education (SMD: .33; 95% CI: .18 to .48)
Aggregate of positive mental health outcome (SMD: .03; 95% CI: .19 to .25)
Person plus environment interventions Aggregate of positive mental health outcome (SMD: .27; 95% CI: .16 to .37)
Environment-only interventions Aggregate of positive mental health outcome (SMD: .38; 95% CI: .15 to .60)
Digital platforms (n ¼ 8) Mass media Discrimination: effect size range: SMD .85 to .17
Prejudice: effect size range: SMD 2.94 to 2.40
Individual-/family-based Media literacy and advocacy approach Internalization or acceptance of societal ideals relating to appearance
interventions (n ¼ 12) at a 3- to 6-month follow-up (SMD: L.28; 95% CI: L.51 to L.05)
Eating attitudes and behaviors and BMI at 12- to 14-month follow-up (SMD: .10; 95% CI: .45 to .25)
adolescent issues Eating Attitude Test at 6- to 12-month follow-up
(SMD: .01; 95% CI: .13 to .15)
Eating Disorder Inventory “bulimia” at 12- to 14-month
follow-up (SMD: .03; 95% CI: .16 to .10)
Self-esteem approach Close friendship at 3-month follow-up (SMD: .01; 95% CI: .09 to .06)
Exercise alone Self-esteem (SMD: .49; 95% CI: .16 to .81)
Exercise as a part of a comprehensive intervention Self-esteem (SMD: .51; 95% CI: .15 to .88)
Exercise compared to control Depression (SMD: L.62; 95% CI: L.81 to L.42)
Dropouts (RR: 1.00; 95% CI: .97 to 1.04)
Exercise compared to psychological therapies Depression (SMD: .03; 95%CI .32 to .26)
Exercise compared to antidepressant Depression (SMD: .11; 95% CI: .34 to .12)
Vigorous exercise versus no intervention Anxiety scores (SMD: .48; 95% CI: .97 to .01)
Depression score (SMD: L.66; 95% CI: L1.25 to L.08)
Vigorous exercise to low intensity exercise Anxiety scores (SMD: .14; 95% CI: .41 to .13)
Depression scores (SMD: .15; 95% CI: .44 to .14)
Exercise with psychosocial interventions Anxiety scores (SMD: .13; 95% CI: .43 to .17)
Depression scores (SMD: .10; 95% CI: .21 to .41)
Waitlist versus CBT for anxiety Anxiety remission (OR: 7.85; 95% CI: 5.31 to 11.6)
Participants lost to follow-up: (OR: .93; 95% CI: .58 to 1.51)
Psychological therapy versus antidepressant Remission (OR: .62; 95% CI: .28 to 1.35)
medications for depression Dropouts (OR: .61; 95% CI: .11 to 3.28)
Suicidal ideation (SMD: L3.12; 95% CI: L5.91 to L.33)
Depression symptoms (SMD: .16; 95% CI: .69 to 1.01)
Combination therapy versus antidepressant Remission (OR: 1.50; 95% CI: .99 to 2.27)
medication for depression Dropouts (OR: .84; 95% CI: .51 to 1.39)
Suicidal ideation (OR: .75; 95% CI: .26 to 2.16)
Depression symptoms (SMD: .27; 95% CI: 4.95 to 4.41)
Functioning (SMD: .09; 95% CI: .11 to .28)
Combination therapy versus psychological therapy Remission (OR: 1.61; 95% CI: .38 to 6.90)
Dropouts (OR: 1.23; 95% CI: .12 to 12.71)
Suicidal ideation (SMD: .60; 95% CI: 2.25 to 3.45)
Depression symptoms (SMD: .28; 95% CI: 1.41 to .84)
Combination therapy versus psychological Dropouts (OR: .98; 95% CI: .42 to 2.28)
therapy plus placebo Remission (OR: 2.15; 95% CI: 1.15 to 4.02)
Depression symptoms (SMD: L.52; 95% CI: L.78 to L.26)
Antidepressants compared to placebo to Number of relapsed recurred (OR: .34; 95% CI: .18 to .64)
relapse and recurrence Suicide-related behaviors (OR: 1.02; 95% CI: .14 to 7.39)
Dropouts (OR: 1.02; 95% CI: .38 to 2.79)
Behavioral therapy compared to all other Response (RR: .97; 95% CI: .86 to 1.09)
psychological therapies Remission (RR: .91; 95% CI: .8 to 1.04)
Response at follow-up (RR: .77; 95% CI: .59 to 1.01)
Depression severity (SMD: .03; 95% CI: .2 to .15)
Dropouts (RR: 1.02; 95% CI: .65 to 1.61)
Evidence-based youth-focused psychotherapy Effect size (SMD: .31; 95% CI: .16 to .44)
versus usual clinical care
Evidence-based parent-/family-focused Effect size (SMD: .16; 95% CI: .01 to .33)
psychotherapy versus usual clinical care
Multisystem approaches Effect size (SMD: .35; 95% CI: .19 to .52)
Combinations Effect size (SMD: .29; 95% CI: .06 to .52)

Bold indicates significant impact. Italics indicate nonsignificant impact.

BMI ¼ body mass index; CBT, cognitive behavioral therapy; CI ¼ confidence interval; OR ¼ odds ratio; RR ¼ relative risk; SMD ¼ standard mean difference.
 J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60 S57

mental health promotion efforts and attempts to help negotiate Individual-/family-based interventions
stressful transitions yield significant mean effects on reducing
problems and increasing competencies [32]. Evidence from We included 12 systematic reviews focusing on individual- or
community-based mental health delivery programs specifically family-based interventions, of which 10 reviews performed
targeting mental health promotion of young people in LMICs meta-analysis. AMSTAR rating ranged between 6 and 11 with a
suggests positive impacts on mental health outcomes; however, median score of 11. One review focused on interventions for
pooled analysis could not be conducted [19]. Another review eating disorders; four reviews focused on physical activity and
evaluating community-based mental health and behavioral exercise interventions; six reviews focused on CBT, psychother-
programs for low-income urban youth suggested that person- apy, behavioral, and pharmacological interventions for anxiety
only interventions had a nonsignificant impact on improving and depression; while two reviews focused on home-based
mental health (measured by an aggregate outcome measure; multisystemic interventions.
SMD: .03; 95% CI: .19 to .25) while person plus environmental A systematic review on the effectiveness of eating disorder
interventions (SMD: .27; 95% CI: .16e.37) and environment-only programs for adolescents focused on eating disorder awareness,
interventions had a significant positive impact (SMD: .38; 95% CI: healthy eating attitudes and behaviors, media literacy and
.15e.60) [33]. One review reporting the impact of treatment of advocacy skills, and promoting self-esteem [43]. All included
adolescent mental health disorders in primary care settings studies were conducted in high-income countries (HICs). In-
suggests some preliminary evidence that treatments by terventions focusing on eating attitudes and behaviors showed
specialist staff working in primary care were effective, although no impact on body mass index at 12- to 14-month follow-up
quality of included studies was variable. Meta-analysis could not (SMD: .10; 95% CI: .45 to .25), Eating Attitude Test at 6- to
be conducted. Some educational interventions showed potential 12-month follow-up (SMD: .01; 95% CI: .13 to .15), and bulimia
for increasing skills and confidence of primary care staff, but at 12- to 14-month follow-up (SMD: .03; 95% CI: .16 to .10).
controlled evaluations were rare, and few studies reported the Combined data from two eating disorder prevention programs
actual change in professional behavior or patient health out- based on a media literacy and advocacy approach showed a
comes [34]. significant reduction in the internalization or acceptance of
societal ideals relating to appearance at a 3- to 6-month follow-
up (SMD: .28; 95% CI: .51 to .05). Two studies focusing on
Digital platforms for mental health interventions self-esteem approach showed no impact on close friendships
(SMD: .01; 95% CI: .09 to .06) and social acceptance
We report findings from eight systematic reviews evaluating (SMD: .03; 95% CI: .10, .04) at 3-month follow-up. There is not
impact of digital platforms for mental health disorders. None of enough evidence to suggest any harm from any of the prevention
the included reviews conducted meta-analysis. AMSTAR rating programs included in the review.
ranged between 4 and 11 with a median score of 9. A review Four systematic reviews evaluated the impact of exercise and
evaluating the impact of mass media interventions from two physical activity on mental health outcomes among adolescents
studies suggests an impact ranging from SMD .85 to .17 on and youth. Exercise alone was evaluated in eight studies showing
discrimination while the impact on prejudice ranged between significant impact on self-esteem (SMD: .49; 95% CI: .16e.81).
SMD 2.94 and 2.40. The studies were very heterogeneous, Exercise as a part of other comprehensive interventions was
statistically, in their populations, interventions, and outcomes, evaluated in four studies and showed a significant improvement
and hence meta-analysis could not be conducted [35]. Evidence in self-esteem (SMD: .51; 95% CI: .15e.88). However, these con-
pertaining to mass media suggests that mass mediaebased clusions are based on several small number of trials reporting
behavioral treatments have a moderate effect while computer- poolable data with lack of long-term follow-up data [44].
ized CBT for mental health suggests that such interventions are Another review reporting the effects of physical activity pro-
cost-effective and often cheaper than usual care [36,37]. grams (including outdoor adventure, sport and skill-based and
Another review evaluating online youth mental health promo- physical fitness program) included 15 studies. Due to small
tion and prevention interventions indicates that there is some number of studies and large heterogeneity in terms of study
evidence that skills-based interventions presented in a module- length, sample size, assessment of outcomes, and participants,
based format can have a significant impact on adolescent meta-analysis was not conducted. Some studies suggested pos-
mental health; however, an insufficient number of studies limit itive impacts on social and emotional well-being; however, due
this finding. The results from online interventions indicate sig- to mixed findings and the high risk of bias, the efficacy of physical
nificant positive effect of computerized CBT on adolescents’ and activity programs could not be concluded [45]. Evidence on the
emerging adults’ anxiety and depression symptoms [38]. These use of exercise for depression compared to no treatment suggests
findings are based on 20 studies; however, meta-analysis could significant impact in reducing depression from 35 trials
not be conducted in this review due to heterogeneity in studies. (SMD: .62; 95% CI: .81 to .42) while there was no impact on
Evidence from four Internet-based prevention and treatment dropouts (relative risk [RR]: 1.00; 95% CI: .97e1.04). Exercise
programs for anxiety and depression suggests early support for when compared to psychological therapy and pharmacological
the effectiveness; however, more extensive and rigorous treatment found no significant difference on depression
research is warranted to further establish the conditions (SMD .03; 95% CI: .32 to .26 and SMD: .11; 95% CI: .34 to
through which effectiveness is enhanced, as well as to develop .12, respectively) [46]. Vigorous exercise when compared to no
additional programs to address gaps in the field [39]. Three intervention led to reduced depression score (SMD: .66; 95%
reviews evaluating the acceptability and feasibility of mental CI: 1.25, .08) with no impact on anxiety scores (SMD: .48;
health resources among youth suggested that young people 95% CI: .97, .01) while vigorous exercise when compared to low
regularly use and are generally satisfied with online mental intensity exercise and psychosocial interventions showed com-
health resources [40e42]. parable results. However, the small number of studies and the
S58 J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60

clinical diversity of participants, interventions, and methods of approach has shown to be most effective, and participants could
measurement limit the ability to draw conclusions [47]. benefit from the involvement of at least one health professional
Six systematic reviews reported findings on interventions for from a psychology or psychiatric background. Further high-level,
anxiety and depression among adolescents and youth. A review high-quality research using standardized outcome measures is
on the effectiveness of CBT for anxiety disorders included required to support these findings and determine key parame-
41 studies. CBT compared to waitlist was effective in reducing ters, such as an optimal frequency and duration for day therapy
remission (odds ratio [OR]: 7.85; 95% CI: 5.31e11.6). There was programs [54].
nonsignificant impact on participants lost to follow-up (OR: .93;
95% CI: .58e1.51) [48]. A review evaluating the impact of psy- Discussion
chological therapies and antidepressant medication, alone and
in combination, for the treatment of depressive disorder for We report findings from a total of 38 systematic reviews with
adolescents included 11 studies. Findings suggest that psycho- an AMSTAR rating ranging between 7 and 11 and a median score
logical therapy when compared to antidepressants had com- of 8. Evidence from school-based interventions suggests that
parable effect on remission (OR: .62; 95% CI: .28e1.35), dropouts targeted group-based interventions and CBT were found to be
(OR: .61; 95% CI: .11e3.28), and depression symptoms (SMD: .16; effective in reducing depressive symptoms and anxiety. School-
95% CI: .69 to 1.01) while psychological therapy significantly based suicide prevention programs suggest that classroom-
reduced suicidal ideation (SMD: 3.12, 95% CI: 5.91 to .33) based didactic and experiential programs increased short-term
when compared to antidepressant. Combination therapy was knowledge of suicide and knowledge of suicide prevention
also found to be comparable to antidepressant medications for with no evidence of an effect on suicide-related attitudes or
remission (OR: 1.50; 95% CI: .99e2.27), dropouts (OR: .84; 95% behaviors. Community-based creative activities had some posi-
CI: .51e1.39), suicidal ideation (OR: .75; 95% CI: .26e2.16), tive effect on behavioral changes, self-confidence, self-esteem,
depression symptoms (SMD: .27; 95% CI: 4.95 to 4.41), and levels of knowledge, and physical activity. Evidence from digital
functioning (SMD: .09; 95% CI: .11 to .28). Combination ther- platforms supports Internet-based prevention and treatment
apy was also found to be comparable to psychological therapy programs for anxiety and depression; however, more extensive
for remission (OR: 1.61; 95% CI: .38e6.90), dropouts (OR: 1.23; and rigorous research is warranted to further establish the con-
95% CI: .12e12.71), suicidal ideation (SMD: .60; 95% CI: 2.25 to ditions. Among individual- and family-based interventions,
3.45), and depression symptoms (SMD: .28; 95% CI: 1.41 to interventions focusing on eating attitudes and behaviors showed
.84). Psychological therapy when compared to combination no impact on body mass index, Eating Attitude Test, and bulimia.
therapy was effective in reducing remission (OR: 2.15; 95% Exercise was found to be effective in improving self-esteem and
CI: 1.15e4.02). Combination therapy significantly reduced reduced depression score with no impact on anxiety scores. CBT
depression symptoms (SMD: .52; 95% CI: .78 to .26) compared to waitlist was effective in reducing remission. Psy-
compared to psychological therapy plus placebo [49]. Another chological therapy when compared to antidepressants had
review evaluating the impact of interventions for relapse and comparable effect on remission, dropouts, and depression
recurrence of depressive disorders included nine trials. Findings symptoms. Most of the evidence is from HICs, limiting the
suggest reduction in number of relapsed recurred (OR: .34; 95% generalizability of the findings for LMICs. Meta-analysis could
CI: .18e.64) with no impact on suicide-related behaviors (OR: not be conducted in many of the included reviews due to het-
1.02; 95% CI: .14e7.39) and dropouts (1.02; 95% CI: .38e2.79) erogeneity in their populations, interventions, and outcomes.
[50]. However, there is considerable diversity in the design of One of the limitations of our review was that the scope of our
trials, making it difficult to compare outcomes across studies review was limited to interventions targeting adolescents and
[50]. Behavioral therapy when compared to all other psycho- youth only; however, mental health interventions take a life
logical therapies is reported to be equally effective for depres- course perspective. Mental health disorders are linked in
sion response (RR: .97; 95% CI: .86e1.09); remission (RR: .91; different ways and levels, exerting a dimensional effect between
95% CI: .8e1.04); response at follow-up (RR: .77; 95% CI: environmental, genetic factors and other biological mechanisms
.59e1.01); depression severity (SMD: .03; 95% CI: .2e.15); [55e57]. Evidence from recent literature suggests interventions
and dropout (RR: 1.02; 95% CI: .65e1.61) [51]. Another review to support parenting offer much scope for improving mental
evaluating the performance of evidence-based youth psycho- health among children and adolescents later in life [58e62].
therapies compared with usual clinical care suggests that psy- Evidence suggests that early childhood development (ECD)
chotherapies outperform usual care (SMD: .31; 95% CI: .16e.44), interventions including stimulation in early childhood, preschool
but the advantage is modest and moderated by youth, location, level interventions, and ECD consultations have shown to be
and assessment characteristics [52]. effective in improving health behaviors, conduct problems, and
Evidence suggests that home-based multisystemic therapy social skills and are also low-cost interventions delivered in
resulted in improved externalizing symptoms, and they spent home and at school [63e67]. Evidence also suggests that ECD
fewer days out-of-school and out-of-home placement. Intensive and parenting interventions can be implemented effectively in
home-based crisis intervention using the “Homebuilders” model LMICs’ schools and community settings; however, evidence for
(components include relationship building, reframing problems, scaling-up and sustainability of mental health promotion in-
anger management, communication, setting treatment goals, terventions in LMICs needs to be strengthened [68].
and CBT) did not show any impact when compared to routine There are challenges pertaining to adolescent mental health
inpatient care [53]. Day therapy programs for adolescents with due to the associated stigma. Furthermore, there are gaps related
mental health disorders (including anxiety disorders, social to monitoring the health behavior of adolescents, even with
phobia, and behavioral issues) suggest that it may be an effective multicountry surveys, for example, most of the data are gathered
intervention for adolescents with mental health disorders. A among older adolescents. More widespread developmentally
multimodal and multidisciplinary group-based treatment appropriate surveys of younger adolescents may help identify
 J.K. Das et al. / Journal of Adolescent Health 59 (2016) S49eS60 S59

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