Bookshelf NBK572522

Journals Library
Public Health Research

Volume 9 • Issue 8 • July 2021
ISSN 2050-4381
School-based interventions to prevent

anxiety, depression and conduct disorder
in children and young people: a systematic
review and network meta-analysis
Deborah M Caldwell, Sarah R Davies, Joanna C Thorn, Jennifer C Palmer, Paola Caro,
Sarah E Hetrick, David Gunnell, Sumayya Anwer, José A López-López,
Clare French, Judi Kidger, Sarah Dawson, Rachel Churchill, James Thomas,
Rona Campbell and Nicky J Welton
DOI 10.3310/phr09080
School-based interventions to prevent anxiety,
depression and conduct disorder in children
and young people: a systematic review and
network meta-analysis
Deborah M Caldwell ,1* Sarah R Davies ,2

Joanna C Thorn ,1 Jennifer C Palmer,1 Paola Caro,2
Sarah E Hetrick ,3 David Gunnell ,1,4
Sumayya Anwer ,5 José A López-López ,6
Clare French ,1 Judi Kidger ,1 Sarah Dawson ,1
Rachel Churchill ,5 James Thomas ,7 Rona Campbell 1
and Nicky J Welton1,4

1Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
2School for Policy Studies, University of Bristol, Bristol, UK
3Faculty of Medical and Health Sciences, University of Auckland, Auckland,
New Zealand
4National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK
5Centre for Reviews and Dissemination, University of York, York, UK
6Department of Basic Psychology and Methodology, Faculty of Psychology, University
of Murcia, Murcia, Spain

7Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre),
University College London, London, UK
*Corresponding author
Declared competing interests of authors: Sarah R Davies is the deputy managing editor for the
Cochrane Psychosocial, Developmental and Learning Problems Review Group. Sarah E Hetrick is the
joint co-ordinating editor of the Cochrane Common Mental Disorders Group and leads the Children
and Young People Satellite group. Her position is part-funded by CureKids, a philanthropic organisation
in New Zealand, and by Auckland Medical Research Foundation. David Gunnell and Nicky J Welton
are supported by the National Institute for Health Research Biomedical Research Centre at University
Hospitals Bristol NHS Foundation Trust and the University of Bristol.
Published July 2021

DOI: 10.3310/phr09080
This report should be referenced as follows:
Caldwell DM, Davies SR, Thorn JC, Palmer JC, Caro P, Hetrick SE, et al. School-based
interventions to prevent anxiety, depression and conduct disorder in children and young
people: a systematic review and network meta-analysis. Public Health Res 2021;9(8).
Public Health Research
ISSN 2050-4381 (Print)
ISSN 2050-439X (Online)
This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE)
(www.publicationethics.org/).
Editorial contact: [email protected]
The full PHR archive is freely available to view online at www.journalslibrary.nihr.ac.uk/phr. Print-on-demand copies can be
purchased from the report pages of the NIHR Journals Library website: www.journalslibrary.nihr.ac.uk
Criteria for inclusion in the Public Health Research journal

Reports are published in Public Health Research (PHR) if (1) they have resulted from work for the PHR programme, and
(2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors.
Reviews in Public Health Research are termed ‘systematic’ when the account of the search appraisal and synthesis methods
(to minimise biases and random errors) would, in theory, permit the replication of the review by others.
PHR programme
The Public Health Research (PHR) programme, part of the National Institute for Health Research (NIHR), is the leading UK funder
of public health research, evaluating public health interventions, providing new knowledge on the benefits, costs, acceptability and
wider impacts of non-NHS interventions intended to improve the health of the public and reduce inequalities in health. The scope
of the programme is multi-disciplinary and broad, covering a range of interventions that improve public health.
For more information about the PHR programme please visit the website: https://www.nihr.ac.uk/explore-nihr/funding-programmes/
public-health-research.htm
This report
The research reported in this issue of the journal was funded by the PHR programme as project number 15/49/08. The
contractual start date was in October 2016. The final report began editorial review in January 2020 and was accepted for
publication in December 2020. The authors have been wholly responsible for all data collection, analysis and interpretation, and
for writing up their work. The PHR editors and production house have tried to ensure the accuracy of the authors’ report and
would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept
liability for damages or losses arising from material published in this report.
This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions
expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR,
NETSCC, the PHR programme or the Department of Health and Social Care. If there are verbatim quotations included in this
publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect
those of the authors, those of the NHS, the NIHR, NETSCC, the PHR programme or the Department of Health and Social Care.
© Queen’s Printer and Controller of HMSO 2021. This work was produced by Caldwell et al. under the terms of a
commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for
the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals
provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising.
Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health
Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park,
Southampton SO16 7NS, UK.
Published by the NIHR Journals Library (www.journalslibrary.nihr.ac.uk), produced by Prepress Projects Ltd, Perth, Scotland
(www.prepress-projects.co.uk).
NIHR Journals Library Editor-in-Chief
Professor Ken Stein Professor of Public Health, University of Exeter Medical School, UK
NIHR Journals Library Editors
Professor John Powell Chair of HTA and EME Editorial Board and Editor-in-Chief of HTA and EME journals.
Consultant Clinical Adviser, National Institute for Health and Care Excellence (NICE), UK, and Professor of
Digital Health Care, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
Professor Andrée Le May Chair of NIHR Journals Library Editorial Group (HS&DR, PGfAR, PHR journals) and
Editor-in-Chief of HS&DR, PGfAR, PHR journals
Professor Matthias Beck Professor of Management, Cork University Business School, Department of Management
and Marketing, University College Cork, Ireland
Dr Tessa Crilly Director, Crystal Blue Consulting Ltd, UK
Dr Eugenia Cronin Senior Scientific Advisor, Wessex Institute, UK
Dr Peter Davidson Consultant Advisor, Wessex Institute, University of Southampton, UK
Ms Tara Lamont Senior Scientific Adviser (Evidence Use), Wessex Institute, University of Southampton, UK
Dr Catriona McDaid Senior Research Fellow, York Trials Unit, Department of Health Sciences, University of York, UK
Professor William McGuire Professor of Child Health, Hull York Medical School, University of York, UK
Professor Geoffrey Meads Emeritus Professor of Wellbeing Research, University of Winchester, UK
Professor James Raftery Professor of Health Technology Assessment, Wessex Institute, Faculty of Medicine,
University of Southampton, UK
Dr Rob Riemsma Reviews Manager, Kleijnen Systematic Reviews Ltd, UK
Professor Helen Roberts Professor of Child Health Research, UCL Great Ormond Street Institute of Child Health, UK
Professor Jonathan Ross Professor of Sexual Health and HIV, University Hospital Birmingham, UK
Professor Helen Snooks Professor of Health Services Research, Institute of Life Science, College of Medicine,
Swansea University, UK
Professor Ken Stein Professor of Public Health, University of Exeter Medical School, UK
Professor Jim Thornton Professor of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences,
University of Nottingham, UK
Please visit the website for a list of editors: www.journalslibrary.nihr.ac.uk/about/editors
Editorial contact: [email protected]
NIHR Journals Library www.journalslibrary.nihr.ac.uk

DOI: 10.3310/phr09080 Public Health Research 2021 Vol. 9 No. 8
Abstract
School-based interventions to prevent anxiety, depression and

conduct disorder in children and young people: a systematic
Deborah M Caldwell ,1* Sarah R Davies ,2 Joanna C Thorn ,1

Jennifer C Palmer,1 Paola Caro,2 Sarah E Hetrick ,3 David Gunnell ,1,4
Sumayya Anwer ,5 José A López-López ,6 Clare French ,1
Judi Kidger ,1 Sarah Dawson ,1 Rachel Churchill ,5 James Thomas ,7
Rona Campbell 1 and Nicky J Welton1,4
1Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
2School for Policy Studies, University of Bristol, Bristol, UK
3Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
4National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK
5Centre for Reviews and Dissemination, University of York, York, UK
6Department of Basic Psychology and Methodology, Faculty of Psychology, University of Murcia,
Murcia, Spain
7Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), University College
London, London, UK
*Corresponding author [email protected]
Background: Schools in the UK increasingly have to respond to anxiety, depression and conduct
disorder as key causes of morbidity in children and young people.
Objective: The objective was to assess the comparative effectiveness of educational setting-based
interventions for the prevention of anxiety, depression and conduct disorder in children and young people.
Design: This study comprised a systematic review, a network meta-analysis and an economic evaluation.
Data sources: The databases MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), PsycInfo®
(American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled
Trials (CENTRAL) were searched to 4 April 2018, and the NHS Economic Evaluation Database (NHS EED)
was searched on 22 May 2019 for economic evaluations. No language or date filters were applied.
Main outcomes: The main outcomes were post-intervention self-reported anxiety, depression or
conduct disorder symptoms.
Review methods: Randomised/quasi-randomised trials of universal or targeted interventions for the
prevention of anxiety, depression or conduct disorder in children and young people aged 4–18 years
were included. Screening was conducted independently by two reviewers. Data extraction
was conducted by one reviewer and checked by a second. Intervention- and component-level
network meta-analyses were conducted in OpenBUGS. A review of the economic literature and a
cost–consequence analysis were conducted.
© Queen’s Printer and Controller of HMSO 2021. This work was produced by Caldwell et al. under the terms of a commissioning contract issued by the Secretary of State
for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in
professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial
vii
reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House,
University of Southampton Science Park, Southampton SO16 7NS, UK.
ABSTRACT
Results: A total of 142 studies were included in the review, and 109 contributed to the network
meta-analysis. Of the 109 studies, 57 were rated as having an unclear risk of bias for random sequence
generation and allocation concealment. Heterogeneity was moderate. In universal secondary school
settings, mindfulness/relaxation interventions [standardised mean difference (SMD) –0.65, 95% credible
interval (CrI) –1.14 to –0.19] and cognitive–behavioural interventions (SMD –0.15, 95% CrI –0.34 to 0.04)
may be effective for anxiety. Cognitive–behavioural interventions incorporating a psychoeducation
component may be effective (SMD –0.30, 95% CrI –0.59 to –0.01) at preventing anxiety immediately post
intervention. There was evidence that exercise was effective in preventing anxiety in targeted secondary
school settings (SMD –0.47, 95% CrI –0.86 to –0.09). There was weak evidence that cognitive–behavioural
interventions may prevent anxiety in universal (SMD –0.07, 95% CrI –0.23 to 0.05) and targeted (SMD –0.38,
95% CrI –0.84 to 0.07) primary school settings. There was weak evidence that cognitive–behavioural
(SMD –0.04, 95% CrI –0.16 to 0.07) and cognitive–behavioural + interpersonal therapy (SMD –0.18,
95% CrI –0.46 to 0.08) may be effective in preventing depression in universal secondary school settings.
Third-wave (SMD –0.35, 95% CrI –0.70 to 0.00) and cognitive–behavioural interventions (SMD –0.11,
95% CrI –0.28 to 0.05) incorporating a psychoeducation component may be effective at preventing
depression immediately post intervention. There was no evidence of intervention effectiveness in targeted
secondary, targeted primary or universal primary school settings post intervention. The results for
university settings were unreliable because of inconsistency in the network meta-analysis. A narrative
summary was reported for five conduct disorder prevention studies, all in primary school settings.
None reported the primary outcome at the primary post-intervention time point. The economic evidence
review reported heterogeneous findings from six studies. Taking the perspective of a single school
budget and based on cognitive–behavioural therapy intervention costs in universal secondary school
settings, the cost–consequence analysis estimated an intervention cost of £43 per student.
Limitations: The emphasis on disorder-specific prevention excluded broader mental health interventions
and restricted the number of eligible conduct disorder prevention studies. Restricting the study to
interventions delivered in the educational setting may have limited the number of eligible university-level
interventions.
Conclusions: There was weak evidence of the effectiveness of school-based, disorder-specific prevention
interventions, although effects were modest and the evidence not robust. Cognitive–behavioural therapy-
based interventions may be more effective if they include a psychoeducation component.
Future work: Future trials for prevention of anxiety and depression should evaluate
cognitive–behavioural interventions with and without a psychoeducation component, and include
mindfulness/relaxation or exercise comparators, with sufficient follow-up. Cost implications must be
adequately measured.
Study registration: This study is registered as PROSPERO CRD42016048184.
Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health
Research programme and will be published in full in Public Health Research; Vol. 9, No. 8. See the NIHR
Journals Library website for further project information.
viii

Contents
List of tables xiii
List of figures xvii
List of abbreviations xix
Plain English summary xxi
Scientific summary xxiii
Chapter 1 Background 1
Description of the problem 1
Description of the intervention 2
Rationale for the current study 3
Aims and objectives 4
Changes to protocol, clarifications and additional analyses 4
Searching and screening 7
Analysis 7
Chapter 2 Methods for assessing effectiveness 9

Patient and public involvement 9
Methods for the systematic review of effectiveness studies 9
Criteria for considering studies for this review 9
Study design 9
Population 10
Interventions and comparators 11
Outcomes 12
Study identification, inclusion and data extraction 13
Identification of studies 13
Classification of interventions and components 14
Assessment of risk of bias in included studies 15
Methods for the evidence synthesis of effectiveness studies 15
Data preparation 15
Pairwise and network meta-analyses 15
Subgroup, metaregression and sensitivity analyses 17
Interpreting the results and evaluating evidence of effect 18
Chapter 3 Intervention and component categorisation 19

Main ‘intervention-level’ classification 19
Behavioural therapy 19
Cognitive–behavioural therapy 19
Third-wave interventions 19
Interpersonal therapy 19
Mindfulness meditation and relaxation-based interventions 20
Biofeedback 20
Exercise 20
Cognitive bias modification 20
Occupational therapy 20
ix
CONTENTS
Control groups 20
Psychoeducation 20
Psychosupport and counselling 21
Usual curriculum 21
Waiting list 21
No intervention 21
Attention control 21
Component classifications 21
Behavioural 22
Cognitive 22
Third wave 22
Mindfulness 22
Relaxation 22
Physiological 22
Bias modification 22
Psychoeducation 22
Additional process and implementation classifications 23
Chapter 4 Effectiveness of educational setting-based interventions for

preventing anxiety 25
Systematic review results 25
Studies included in the review 25
Network meta-analysis results 27
Universal population, secondary setting 37
Universal population, primary setting 39
Targeted population, secondary setting 40
Targeted population, primary setting 42
Targeted population, tertiary/university setting 43
Exploring heterogeneity and small-study effects 43
Summary of main results 45
Chapter 5 Effectiveness of educational setting-based interventions for preventing

depression 47
Systematic review 47
Network meta-analysis results 48
Universal population, secondary setting 59
Universal population, primary setting 61
Targeted population, secondary setting 63
Targeted population, primary setting 64
Targeted population, tertiary/university setting 65
Exploring heterogeneity and small-study effects 66
Summary of main results 67
Chapter 6 Additional primary outcomes and secondary outcomes from studies

focusing on prevention of depression and/or anxiety 69
Additional primary outcomes 69
Self-reported psychological well-being 69
Self-reported suicidal ideation, behaviour and self-harm 70
Inequalities in health 71
Combined depression and anxiety scores and other ‘internalising’ outcomes 72
Secondary outcomes 73
Acceptability and attendance 73

Parent-reported child anxiety, depression or internalising outcomes 76

Academic attainment 76
Problem behaviours 76
Mental health-related stigma 77
Chapter 7 Effectiveness of educational setting-based interventions for preventing

conduct disorder 79
Systematic review results 79
Summary 85
Chapter 8 Economic evaluation 87

Methods 87
Narrative review 88
Intervention costing 89
Cost–consequence analysis 89
Results 90
Narrative review of previous economic evaluations 90
Intervention costs 94
Discussion 96
Review of previous economic studies 96
Cost–consequences analysis 96
Chapter 9 Summary and interpretation of key findings 99

Systematic review 99
Network meta-analyses by population and setting 99
Anxiety: universal population, secondary setting 99
Anxiety: universal population, primary setting 100
Anxiety: targeted population, secondary setting 100
Anxiety: targeted population, primary setting 100
Anxiety: tertiary/university setting 100
Depression: universal population, secondary setting 100
Depression: universal population, primary setting 101
Depression: targeted population, secondary setting 101
Depression: targeted population, primary setting 101
Depression: tertiary/university setting 101
Anxiety and depression: component network meta-analysis 101
Anxiety and depression: subgroup analyses 102
Anxiety and depression: additional primary and secondary outcomes 102
Conduct disorder 102
Interpretation of network meta-analysis results across all networks: post intervention 102
Key findings of the economic evaluation 103
Chapter 10 Discussion 105

Comparison with other studies 105
Depression and anxiety 105
Conduct disorder 107
Strengths and limitations of the study 108
Limitations relating to search strategy 108
Limitations relating to inclusion criteria 109
Limitations relating to outcomes 111
Other limitations 111
xi
CONTENTS
Implications for practice 112

Implications for research 112
Conclusions 113
Acknowledgements 115
References 117
Appendix 1 Methods for systematic review and network meta-analysis 141
Appendix 2 Results from systematic review 159
Appendix 3 Network meta-analysis results 209
Appendix 4 Full network meta-analysis and standard pairwise meta-analyses 229
Appendix 5 Further time points: results from the intervention-level network

meta-analysis 237
Appendix 6 Exploring heterogeneity and publication bias 239
Appendix 7 Additional outcomes 251
Appendix 8 Economic evaluation 267
Appendix 9 Comparison of findings with previous systematic reviews 279
xii

List of tables
TABLE 1 Protocol deviations and clarifications 4
TABLE 2 Intervention-level classifications and component classifications by

population and setting for anxiety outcome 28
TABLE 3 Results from the NMA and pairwise meta-analyses for the primary end
point of post intervention for self-reported anxiety 36
TABLE 4 Results from additive and full interaction component models: universal
secondary settings, self-reported anxiety 38
TABLE 5 Risk-of-bias sensitivity analyses for self-reported anxiety 44
TABLE 6 Intervention-level classifications and component classifications by

population and setting for depression outcome 49
TABLE 7 Results from the NMA and pairwise meta-analyses for the primary end
point of post intervention for self-reported depression 58
TABLE 8 Results from additive and full interaction component models: universal
secondary settings, self-reported depression 60
TABLE 9 Risk-of-bias sensitivity analyses for self-reported depression 67
TABLE 10 Well-being and life satisfaction: population, setting and intervention

comparison reported by study for the post-intervention time point 69
TABLE 11 Study-level summary for suicidal ideation and self-harm outcomes at

post-intervention time point 71
TABLE 12 Results from subgroup analysis by socioeconomic status 72
TABLE 13 Composite internalising outcomes at post intervention time point 72
TABLE 14 Author-reported satisfaction with the intervention 74
TABLE 15 Author-reported enjoyment and usefulness of the intervention 74
TABLE 16 Author-reported academic achievement and attainment 77
TABLE 17 Summary of post-intervention results from conduct disorder

prevention studies 85
TABLE 18 Characteristics of included studies for review of economic evaluations 91
TABLE 19 Cognitive–behavioural therapy intervention cost estimates and

consequences (SMDs), compared with usual curriculum 95
xiii
LIST OF TABLES
TABLE 20 Costs and consequences (SMD relative to usual curriculum) of a universal

secondary CBT intervention that contains cognitive and behavioural components
with and without a psychoeducation component 96
TABLE 21 Previous large-scale RCTs of school-based prevention of anxiety and

depression 106
TABLE 22 Study characteristics of included studies: anxiety 170
TABLE 23 Study characteristics of included studies: depression 176
TABLE 24 Studies not included in the anxiety or depression NMA, but which were
eligible for inclusion in review 184
TABLE 25 Studies not reporting a primary review outcome: anxiety and depression 184
TABLE 26 Study characteristics for included studies: process and delivery 185
TABLE 27 Risk-of-bias assessment for all studies reporting an anxiety and/or

depression outcome 197
TABLE 28 Author-reported facilitator fidelity and/or integrity for studies reporting

an anxiety or depression outcome 206
TABLE 29 Model fit statistics: universal population, secondary setting: anxiety 210
TABLE 30 Regression coefficients estimated from additive and full interaction

component models: universal, secondary, anxiety 211
TABLE 31 Model fit statistics: universal population, primary setting: anxiety 212

component models: universal, primary, anxiety 213
TABLE 33 Model fit statistics: targeted population, secondary setting: anxiety 214

component models: targeted, secondary, anxiety 215
TABLE 35 Model fit statistics: targeted population, primary setting: anxiety 216

component models: targeted, primary, anxiety 217
TABLE 37 Model fit statistics: targeted population, tertiary/university setting: anxiety 218
TABLE 38 Model fit statistics: universal population, secondary setting: depression 219

component models: universal, secondary, depression 220
TABLE 40 Model fit statistics: universal population, primary setting: depression 221
xiv


component models: universal, primary, depression 222
TABLE 42 Model fit statistics: targeted population, secondary setting: depression 223

component models: targeted, secondary, depression 224
TABLE 44 Model fit statistics: targeted population, primary setting: depression 225

component models: targeted, primary, depression 226
TABLE 46 Model fit statistics: targeted population, tertiary/university setting,

depression 227
TABLE 47 Results from network and pairwise meta-analyses: universal population,

secondary setting, anxiety outcome 229

primary setting, anxiety outcome 230
TABLE 49 Results from network and pairwise meta-analyses: targeted population,

secondary setting, anxiety outcome 231

primary setting, anxiety outcome 232

secondary setting, depression outcome 232

primary setting, depression outcome 234

secondary setting, depression outcome 234

primary setting, depression outcome 236
TABLE 55 Results from the intervention-level network meta-analysis: further time

points for anxiety outcome 237
TABLE 56 Results from the intervention-level network meta-analysis: further time

points for depression outcome 238
TABLE 57 Results from metaregression of intervention facilitator: universal

population, secondary setting: anxiety 243

population, primary setting: anxiety 243
xv
LIST OF TABLES
TABLE 59 Results from metaregression of intervention facilitator: targeted

population, secondary setting: anxiety 244

population, secondary setting: depression 244

population, primary setting: depression 245
TABLE 62 Results from metaregression of intervention facilitator: targeted

population, secondary setting: depression 245
TABLE 63 Results from metaregression of intervention mode of delivery: universal

population, secondary school setting: depression 245
TABLE 64 Results from metaregression of intervention mode of delivery: universal

population, secondary school setting: anxiety 246
TABLE 65 Results from subgroup analysis by focus of the intervention 246
TABLE 66 Sensitivity analysis for intracluster correlation coefficient 247
TABLE 67 Sensitivity analysis for change from baseline standard deviation 248
TABLE 68 Studies reporting that participants with suicidal behaviours or thoughts

were excluded 251
TABLE 69 Studies reporting that schools requested suicidal behaviour or thought

questions be excluded 252
TABLE 70 Socioeconomic status, sex and ethnicity as extracted from authors’

reports: universal interventions 252
TABLE 71 Socioeconomic status, sex and ethnicity as extracted from authors’

reports: targeted interventions 258
TABLE 72 Attendance data for each study as reported by study author 263
TABLE 73 Studies describing cost-effectiveness analyses of school-based interventions 271
TABLE 74 Economic evaluation: characteristics of CBT interventions with a

psychoeducation component 274
TABLE 75 Economic evaluation: characteristics of CBT + IPT interventions 276
TABLE 76 Unit costs associated with delivery of a school-based intervention

(school funder perspective) 277
TABLE 77 Characteristics of previous systematic reviews of anxiety and depression

prevention 280
TABLE 78 Lumping and splitting of control and interventions 283
xvi

List of figures
FIGURE 1 The mental health intervention spectrum for mental disorders 2
FIGURE 2 Study selection process: PRISMA flow diagram for whole systematic review 26
FIGURE 3 Network plot of all eligible studies reporting an anxiety outcome 36
FIGURE 4 Network plot for universal population, secondary setting: post-intervention

anxiety outcome 37
FIGURE 5 Network plot for universal population, primary setting: post-intervention

anxiety outcome 40
FIGURE 6 Network plot for targeted population, secondary setting: post-intervention

anxiety outcome 41
FIGURE 7 Network plot for targeted population, primary setting: post-intervention

anxiety outcome 42
FIGURE 8 Network plot for targeted population, tertiary/university setting:

post-intervention anxiety outcome 43
FIGURE 9 Network plot for all eligible studies reporting a depression outcome 58
FIGURE 10 Network plot for universal population, secondary setting: post-intervention

FIGURE 11 Network plot for universal population, primary setting: post-intervention

FIGURE 12 Network plot for targeted population, secondary setting: post-intervention

FIGURE 13 Network plot for targeted population, primary setting: post-intervention

FIGURE 14 Network plot for targeted population, tertiary/university setting:

post-intervention depression outcome 65
FIGURE 15 Conduct disorder risk-of-bias assessments by domain and study 80
FIGURE 16 Study selection process: flow diagram for review of economic evaluations 90
FIGURE 17 Comparison-adjusted funnel plot: universal population, secondary

setting – anxiety 239
FIGURE 18 Comparison-adjusted funnel plot: universal population, primary

xvii
LIST OF FIGURES
FIGURE 19 Comparison-adjusted funnel plot: targeted population, secondary

FIGURE 20 Comparison-adjusted funnel plot: targeted population, primary

FIGURE 21 Comparison-adjusted funnel plot: universal population, secondary

setting – depression 241
FIGURE 22 Comparison-adjusted funnel plot: universal population, primary

FIGURE 23 Comparison-adjusted funnel plot: targeted population, secondary

FIGURE 24 Comparison-adjusted funnel plot: targeted population, primary

xviii

List of abbreviations
ADHD attention deficit hyperactivity ICC intracluster correlation coefficient
disorder
ICD-10 International Statistical
ALPHA Advice Leading to Public Health Classification of Diseases and
Advancement Related Health Problems, Tenth
Revision
BASC Behavior Assessment System for
Children ICER incremental cost-effectiveness
ratio
BASC-TRS Behavior Assessment System for
Children – Teacher Rating Scale IPT interpersonal therapy
BEI British Education Index IQR interquartile range
CAMHS Child and Adolescent Mental LIC low-income country
Health Services
MECIR Methodological Expectations of
CBCL Child Behaviour Checklist Cochrane Intervention Reviews
CBM cognitive bias modification MesH medical subject heading
CBT cognitive–behavioural therapy MHP mental health professional
CENTRAL Cochrane Central Register of MIC middle-income country
Controlled Trials
NAM National Academy of Medicine
CHU-9D Child Health Utility-9 Dimensions
NHS EED NHS Economic Evaluation
CI confidence interval Database
CMD common mental disorder NICE National Institute for Health and
Care Excellence
CrI credible interval
NMA network meta-analysis
CYP children and young people
ODD oppositional defiant disorder
DALY disability-adjusted life-year
OR odds ratio
DECIPHer Development and Evaluation of
Complex Interventions for Public PATHS Promoting Alternative THinking
Health Improvement Strategies
df degrees of freedom PhD Doctor of Philosophy
DIC deviance information criterion PPI patient and public involvement
DSM Diagnostic and Statistical Manual of PRISMA Preferred Reporting Items for
Mental Disorders Systematic Reviews and
Meta-Analyses
ERIC Education Resources Information
Center PSHE personal, social and health
education
GP general practitioner
QALY quality-adjusted life-year
GRADE Grading of Recommendations
Assessment, Development and RAP Resourceful Adolescent Program
Evaluation
RCADS Revised Children’s Anxiety and
HIC high-income country Depression Scale
ICA intervention component analysis RCT randomised controlled trial
xix
LIST OF ABBREVIATIONS
SD standard deviation SMD standardised mean difference

SDQ Strengths and Difficulties SPARX smart, positive, active, realistic,
Questionnaire X-factor thoughts
SE standard error TIDieR Template for Intervention
Description and Replication
SES socioeconomic status
xx

Plain English summary

A nxiety, depression and conduct disorder are the most commonly diagnosed mental disorders
among children and young people in the UK. Research suggests that preventing mental disorders
from developing before adulthood can provide the largest benefit to the individual, society and the
economy. Prevention programmes in schools are at the forefront of recent prevention attempts; studies
evaluating whether or not they work have shown a small, but positive, effect.
In this report, we combined these studies to determine which type of school-based prevention
programme was the most effective and best value for money for preventing anxiety, depression or
conduct disorder. The types of programmes we included were psychological, educational and physical.
For example, a physical intervention may be exercise, meditation or relaxation based. An educational
intervention may provide information to the young person about mental health disorders and where to
seek help. Psychological interventions typically address behavioural (actions and activities), cognitive
(thoughts, reasoning, understanding), emotional and social factors. The programmes could be universal
or targeted. Universal means that children are included regardless of whether or not they are showing
signs of problems. Targeted means that only those children at higher risk of developing a problem,
or already showing very early signs of mental health problems, are included.
When combining the results of studies, it is important that the studies include similar participants
and comparable programmes, and record the effects of the programmes in similar ways. Programme
effects are measured as ‘outcomes’ from the study. The main outcomes of interest in our report were
symptoms of anxiety, depression and conduct disorder as reported by the young people themselves
(self-reported). We were primarily interested in the outcomes immediately after the programme had
been completed.
We separated studies into primary school settings (ages 4–11 years), secondary school settings (ages
12–18 years) and tertiary settings, for example university (up to 19 years of age), and planned separate
statistical analyses for each. The findings were mixed. We found some evidence that in primary school
settings cognitive–behavioural programmes may be effective in preventing symptoms ‘of anxiety’ but
not symptoms of depression. In secondary school settings, universally delivered interventions based
on cognitive–behavioural therapy and mindfulness or relaxation may be effective at preventing anxiety
and depression. There was also evidence that exercise programmes may be effective when delivered to
young people at higher risk (targeted) in secondary schools. We were not able to run similar analyses
for the university settings. The studies evaluating prevention of conduct disorder were not similar
enough to be combined and they did not use self-reported symptoms as their outcome measure.
Instead, teachers and parents were asked to report on the students’ behaviours. We did not run
statistical analyses, but the authors of the original studies concluded that there was some evidence
that programmes were effective in primary school settings.
Very few studies assessed the cost of the anxiety, depression or conduct disorder programmes, or
whether or not they were value for money. Studies that did evaluate ‘economic evidence’ concluded
that school-based, preventative interventions are unlikely to be value for money.
Many of the studies we included were small or not rigorously designed. Previous research has suggested
that such studies are likely to overestimate the effectiveness of the interventions they evaluate.
Therefore, we need to be cautious in interpreting the results of our study. Nevertheless, there was some
evidence that school-based interventions are effective in preventing symptoms of anxiety, depression and
conduct disorder. This evidence was weak, and we recommend that further large well-designed studies
be conducted to investigate this further. Critically, these studies must also evaluate value for money.
xxi
Scientific summary
Background
Common mental disorders are a key cause of morbidity in children and young people. In the UK, the
most common among children and young people are anxiety, depressive and conduct disorders. There
is robust evidence to suggest that lifetime trajectories of common mental disorders are established
by mid-adolescence, with half of all disorders recognisable by the age of 14 years and three-quarters
recognisable by the age of 25 years. Intervening to prevent the onset of a common mental disorder
has the potential to reduce short- and longer-term negative health and social outcomes for young people.
Schools are increasingly at the forefront of the prevention agenda for children and young people in the
UK. The comparative effectiveness of the multiple competing intervention options is not known.
Objectives
The overall aim of this project was to identify the comparative effectiveness and cost-effectiveness of
interventions, component(s) or combination(s) of components for universal and targeted prevention
of anxiety, depression and conduct disorder among children and young people.
The specific objectives were to:
l conduct a systematic review of educational setting-based universal and targeted (selective and
indicated) interventions for the prevention of common mental disorders
l develop a classification scheme of preventative mental health intervention components
l conduct intervention-level and component-level network meta-analyses to identify effective
interventions and components of interventions
l conduct an economic evaluation to determine the most cost-effective component, or combinations
of components, of interventions.
Methods
We carried out a systematic review and network meta-analysis, at the whole-intervention level and by
intervention components, of educational setting-based interventions to prevent anxiety, depression and
conduct disorder in children and young people aged 4–18 years. A comprehensive search strategy was
developed with an information specialist, and the following databases were searched from inception
to 4 April 2018: MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), PsycInfo® (American
Psychological Association, Washington, DC, USA) and the Cochrane Central Register of Controlled
Trials (CENTRAL). No language or date filters were applied. Studies were eligible if they were randomised
controlled trials or quasi-randomised trials; they included participants aged between 4 and 18 years; the
intervention specifically addressed the prevention of anxiety, depression or conduct disorder; and they
were delivered in an educational setting. Study screening was conducted independently by two reviewers.
Before data extraction commenced, we consulted a young people’s patient and public involvement group
to ask the young people which mental health outcomes were of relevance to them.
Data extraction was conducted by one reviewer and checked by a second. Primary outcomes of interest
were self-reported symptoms of anxiety, depression or conduct disorder; self-reported well-being; and
suicidal ideation, behaviour and self-harm. We also extracted information relevant for assessing
xxiii
SCIENTIFIC SUMMARY
inequalities in health, such as socioeconomic status, ethnicity and sex. The primary time point for
analysis was immediately post intervention. Secondary outcomes included mental health-related stigma
(identified as important from the patient and public involvement consultation); acceptability of the
intervention; parent-reported child or young person’s disorder-specific symptoms; self-reported
problem behaviour, such as substance use; and academic attainment. Secondary follow-up time points
of 6–12, 13–24 and ≥ 25 months post intervention were also recorded.
Intervention-level network meta-analyses were performed in a Bayesian framework using OpenBUGS for
the primary outcomes at all time points. Three different random-effects network meta-analysis models
were considered: intervention level, component-level additive effects (nested within the intervention)
and a component-level full interaction model (nested within the intervention). Model fit and selection
were examined by the posterior mean of the residual deviance and the deviance information criterion.
Component-level network meta-analysis models were implemented for the primary time point only.
Component network meta-analysis results are reported only when model fit statistics were suggestive of
effect modification by components. If meta-analysis was not feasible, results are reported narratively.
We also searched the NHS Economic Evaluation Database (NHS EED) on 22 May 2019 to identify
economic evaluations, with no date restrictions. A narrative review of existing trial- and model-based
economic evaluations was conducted. Informed by the results of the intervention- and component-level
network meta-analysis, we also conducted a microcosting study for effective interventions, assigning
appropriate costs to the constituent components of the interventions when feasible, for use in a
cost–consequence analysis.
Results
A total of 11,990 citations were screened, and 1512 full-text articles were retrieved. A total of
253 reports, corresponding to 142 studies, were included in the review. Seventy-nine studies were
eligible for the anxiety prevention review, 105 for the depression prevention review and five for
the conduct disorder prevention review. There was overlap between the anxiety and depression
reviews, with 54 studies being eligible for both.
A total of 109 studies contributed to the network meta-analysis at any time point. Seventy-one studies
were included in the network meta-analysis for anxiety and 86 were included in the network meta-
analysis for depression. There was an overlap, with 48 studies contributing data to both network
meta-analyses. The evidence is not robust. Of the 109 studies included in the network meta-analysis,
57 were judged to be at unclear risk of bias for both random sequence generation and allocation
concealment. In addition, possible small-study effects were observed in the analyses for the anxiety
outcome, but not for depression. Moderate levels of heterogeneity were observed in 9 out of 10 main
analyses, and mild to moderate levels of heterogeneity were observed in one analysis. This should be
considered in the interpretation of the statistical results.
Psychological interventions were based on the principles of cognitive–behavioural therapy, interpersonal

therapy, cognitive–behavioural therapy plus interpersonal therapy, third-wave or behavioural therapies.
Other interventions were based on exercise, biofeedback, mindfulness/relaxation, bias modification or
occupational therapy. Analyses were conducted by outcome, population (universal or targeted) and school
setting. School setting broadly maps on to age grouping: primary schooling maps on to age 4–11 years,
secondary schooling to age 12–18 years and tertiary education to age ≤ 19 years. Results are reported
by time point, population and setting, and are summarised using standardised mean differences (SMDs)
and 95% credible intervals (CrIs).
At the post-intervention time point, for the prevention of anxiety in universal secondary settings, there was
evidence that mindfulness/relaxation interventions (SMD –0.65, 95% CrI –1.14 to –0.19) may be effective
xxiv

in preventing symptoms of anxiety. There was weak evidence of a small beneficial effect of cognitive–
behavioural therapy-based interventions (SMD –0.15, 95% CrI –0.34 to 0.04) compared with a usual
curriculum comparator. However, the mindfulness/relaxation studies were small and judged to be at
unclear risk of bias. Model fit statistics suggested that component network meta-analysis models were
appropriate and estimable for cognitive–behavioural interventions only. We observed that the effect of a
cognitive–behavioural intervention including a psychoeducation component was to reduce the SMD
(β –0.39, 95% CrI –0.78 to 0.01); in other words, in universal secondary settings, cognitive–behavioural
interventions including a psychoeducation component were more effective than those not containing a
psychoeducation component.
There was weak evidence of a very small effect of cognitive–behavioural therapy-based interventions
in preventing symptoms of anxiety in universal primary settings (SMD –0.07, 95% CrI –0.23 to 0.05).
In targeted secondary settings, there was evidence that exercise reduced symptoms compared with no
intervention (SMD –0.47, 95% CrI –0.86 to –0.09). However, this evidence came from a single study,
only connected to the network via a spur, that was judged to be at unclear risk of bias. There was
weak evidence that in targeted primary settings cognitive–behavioural interventions were effective in
preventing anxious symptoms (SMD –0.38, 95% CrI –0.84 to 0.07).
When outcome data were reported by study authors, we extracted these data at all follow-up time points,
which, for the purpose of analysis only, were divided into medium term (between 6 and 12 months from
the end of an intervention), longer term (between 13 and 24 months) and long term (≥ 25 months).
If a study reported two time points in our ad hoc grouping, we used the later time point in our analyses.
There was no evidence that any type of intervention, in any setting, was effective in preventing symptoms
of anxiety between 6 and 12 months. A single study reported a follow-up time point of between 13 and
24 months post intervention. There was evidence that cognitive–behavioural therapy-based interventions
were effective in targeted secondary settings (SMD –0.26, 95% CrI –0.52 to –0.01). There was no
evidence that any intervention was effective in other settings at this time point. At ≥ 25 months’ follow-up,
there was weak evidence that cognitive–behavioural interventions prevented symptoms of anxiety in
universal secondary settings (one study; SMD –0.23, 95% CrI –0.55 to 0.08) and universal primary
settings (one study; SMD –0.12, 95% CrI –0.26 to 0.02). Evidence from one study suggests that cognitive–
behavioural interventions were effective in targeted secondary settings in preventing symptoms of anxiety
(SMD –0.39, 95% CrI –0.65 to –0.14).
At the post-intervention time point, there was weak evidence of a very small effect of cognitive–behavioural
therapy-based interventions compared with usual curriculum, in preventing depressive symptoms in
universal secondary settings (SMD –0.04, 95% CrI –0.16 to 0.07). There was also weak evidence for a
small effect of cognitive–behavioural + interpersonal therapy-based interventions compared with usual
curriculum comparator (SMD –0.18, 95% CrI –0.46 to 0.08). Model fit statistics suggested that component
models were appropriate and estimable for cognitive–behavioural and third-wave interventions. The results
indicate that the impact of including a psychoeducation component in third-wave interventions was to
reduce the SMD by –0.45 (β –0.45, 95% CrI –0.87 to –0.04). There was no evidence of effect modification
by components for cognitive–behavioural interventions in universal secondary settings. In all other
populations and settings, there was no evidence from the intervention-level network meta-analysis to
suggest that any type of intervention was effective at the post-intervention time point, and no evidence
of effect modification by intervention components.
There was weak evidence, with a small effect size, that in universal secondary settings, between
6 and 12 months, cognitive–behavioural (SMD –0.02, 95% CrI –0.10 to 0.06), cognitive–behavioural +
interpersonal (SMD –0.10, 95% CrI –0.26 to 0.05) and third-wave therapy-based interventions
(SMD –0.13, 95% CrI –0.27 to 0.01) may prevent symptoms of depression, compared with the usual
usual curriculum control. In universal primary settings, there was weak evidence, with a small effect size,
that cognitive–behavioural interventions prevented depressive symptoms between 6 and 12 months,
xxv
SCIENTIFIC SUMMARY
compared with usual curriculum control (SMD –0.15, 95% CrI –0.43 to 0.09). In targeted primary settings,
there was weak evidence that cognitive–behavioural therapy-based interventions may be effective,
compared with a waiting list control (SMD –0.34, 95% CrI –0.72 to 0.05) at 6–12 months’ and at
13–24 months’ follow-up (one study; SMD –0.50, 95% CrI –0.96 to 0.05). At ≥ 25 months’ follow-up,
there was evidence that cognitive–behavioural therapy-based reduced depressive symptoms in a
universal primary setting (one study; SMD –0.27, 95% CrI –0.42 to –0.13).
Owing to a lack of model fit, suggesting possible inconsistency, we did not report network meta-analysis
results for tertiary settings.
A narrative review was conducted for conduct disorder. None of the included studies reported the
primary outcome of self-reported conduct symptoms, post intervention. Four studies were judged to
be at unclear risk of bias, and one was judged to have a low risk of bias. There was evidence from
two studies of school-only interventions and from one study of a multisystemic intervention that, on
the basis of teacher- or parent-reported outcomes, externalising behaviour was reduced post intervention.
Two studies evaluating multicomponent, multisystemic and multiphase interventions reported no evidence
that the intervention reduced externalising behaviour compared with a no intervention control (between
1 and 3 years’ follow-up). However, both these studies reported evidence that, over the longer term
(5–20 years), intervention prevented self-reported conduct disorder symptoms.
The body of evidence identified in the review of economic evidence was both small (six studies) and
heterogeneous. Identified studies were from the UK, the USA and Australia. Trial-based evaluations
suggested that the school-based interventions were unlikely to be cost-effective. There was little
empirical evidence on costs that could inform decisions on the implementation of preventative interventions.
We conducted a cost–consequence analysis based on hypothetical and highly stylised cognitive–behavioural

and cognitive–behavioural + interpersonal therapy-based universal interventions to provide an idea of the
costs that might accrue to a school budget in the first year of implementation. Taking the perspective of a
single school budget, and based on intervention costs for cognitive–behavioural interventions in universal
secondary settings, the cost–consequence analysis estimated an intervention cost of £43 per student.
We were not able to estimate longer-term costs and benefits because of a lack of follow-up data
reported in the studies.
Conclusions
The conclusions are based on the narrow set of disorder-specific preventative interventions included.
Considering the strength, robustness and possible biases in the findings, it is concluded that there is
weak evidence that school-based anxiety, depression and conduct disorder prevention interventions
may be effective. There was weak evidence from the network meta-analysis that cognitive–behavioural
therapy-based interventions were effective for preventing symptoms of anxiety and depression and
that mindfulness/relaxation and exercise interventions were effective for symptoms of anxiety post
intervention. However, evidence for mindfulness/relaxation and exercise interventions was judged to
be at unclear risk of bias and was based on only three studies. There was also weak evidence from the
component network meta-analysis that cognitive–behavioural interventions including a psychoeducation
component were effective for preventing symptoms of anxiety and depression in universal secondary
settings. The available economic literature was scarce and heterogeneous. There was a lack of robust
empirical evidence on costs and resource use to inform the economic evaluation.
Future trials should be multiarm and allow for sufficient follow-up. Studies might compare the effect
of cognitive–behavioural therapy-based interventions with and without a psychoeducation component.
Such a trial should be active or attention controlled, and comparators might include mindfulness/
relaxation or exercise interventions. Work to optimise the content of such an intervention should be
conducted in consultation with children and young people.
xxvi

To ensure high-quality information for decision-makers and commissioners, it is imperative that

future trials should be rigorously designed, with long-term follow-up, and that the cost implications
of interventions are adequately measured.
Study registration
This study is registered as PROSPERO CRD42016048184.
Funding
This project was funded by the National Institute for Health Research (NIHR) Public Health Research
programme and will be published in full in Public Health Research; Vol. 9, No. 8. See the NIHR Journals
Library website for further project information.
xxvii
Chapter 1 Background
P arts of this chapter are reproduced or adapted from Caldwell et al.1 © 2019 The Author(s).
Published by Elsevier Ltd. This is an Open Access article distributed in accordance with the terms
of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix,
adapt and build upon this work, for commercial use, provided the original work is properly cited.
See: http://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting
changes to the original text.
Description of the problem
Common mental disorders are a key cause of morbidity in children and young people (CYP). Globally,
depressive disorders are the third largest cause of adolescent disability-adjusted life-years (DALYs)
lost, and anxiety disorders are the fifth cause of DALYs lost for adolescent girls.2 In the UK, the most
common mental disorders among CYP are anxiety, depressive and conduct disorders. NHS Digital
figures from 2017 suggest that 7.2% of 5- to 19-year-olds have an anxiety disorder, 2.1% a depressive
disorder and 4.6% a conduct disorder.3 In this report, we will refer to anxiety, depressive and conduct
disorders as ‘common mental disorders’ (CMDs), as these are the disorders with the highest prevalence
among CYP in the UK. Although the prevalence of CMDs tends to increase with age, it is noted that
rates of anxiety and depressive disorders have increased among CYP in the UK over the last 20 years,
in contrast to the stability of diagnoses for conduct and hyperactivity disorders.3–5 However, as many
CYP or their guardians do not seek help,6,7 these figures may represent an underestimate.8,9
Children and young people with a mental health disorder are more likely to engage in risky behaviours,
such as smoking and substance use; are more likely to self-harm; and are more likely to be excluded from
school.10–16 Although the causes are multifactorial, with genetic and environmental factors contributing
to susceptibility, the distribution of CMDs is socially and economically patterned.17 For example, young
people with a common mental disorder are nearly twice as likely as those without a disorder to be living
with a lone parent, more than twice as likely to have unemployed parents and more likely to have parents
with low incomes and fewer qualifications and living in social housing.11 Evidence from the UK Millennium
Cohort18 suggests that children from low-income families are four times more likely to have a mental
health problem than those from higher-income families. Longitudinal evidence suggests a linear relationship
between the frequency of disorder episodes and the likelihood of adverse social outcomes. In a cohort
of CYP aged 16–21 years from New Zealand,19 the odds of later welfare dependence were 1.34 [95%
confidence interval (CI) 1.09 to 1.64] times higher among those reporting 1–4 episodes of depression
than among those reporting no episodes of major depression. The odds among those reporting ≥ 10 episodes
were 2.42 (95% CI 1.31 to 4.45) times higher than among those reporting none.
Although there is ongoing debate about the drivers of increased prevalence,20 there is robust evidence
to suggest that lifetime trajectories of CMDs are established by mid-adolescence,21 with half of all
disorders recognisable by age 14 years and three-quarters by age 25 years.22 The Royal College of
Psychiatrists has stated that greater personal, social and economic benefits can be generated by
intervening early in the life course than by intervening at any other time.22 However, Child and
Adolescent Mental Health Services (CAMHS) worldwide are under-resourced.23 In the UK, the Local
Government Association estimates that > 338,000 children were referred to CAMHS in 2017, but
fewer than one-third had received treatment within the year.24 Even in the advent of optimal access
and treatment, one economic modelling study has suggested that < 30% of the burden of CMDs could
be alleviated by treatment alone.25
1
BACKGROUND
Description of the intervention
Against this background, there has been a growing focus on the primary prevention of CMDs among
CYP. Primary prevention aims to prevent the onset of disease before clinically relevant symptoms are
detectable and, therefore, targets a seemingly ‘healthy’ population. According to the National Academy
of Medicine (NAM) (formerly known as the Institute of Medicine), primary prevention encompasses
the prevention of disorder-specific symptoms, reduction of preclinical symptoms and prevention (or delay)
of disorder onset.26 The NAM definition of primary prevention also refers to universal, selective and
indicated prevention26,27 and is distinguished from mental health promotion (Figure 1). Universal
prevention addresses whole populations regardless of their risk status or susceptibility to a CMD.
Selective prevention targets subgroups with higher than average risk of developing a mental disorder;
risk can be defined as biological, psychological or social factors. Indicated prevention focuses on
individuals with detectable, but subclinical, symptoms of a CMD. Increasingly, the boundary between
indicated prevention and ‘early intervention’ is being blurred by clinicians.28 The NAM framework views
mental health promotion as a focus on encouraging mental health and the enhancement of well-being,
rather than the prevention of illness.
In the UK, schools are at the forefront of the prevention agenda. For example, the green paper
Transforming Children and Young People’s Mental Health Provision29 calls for mental health leads to be
embedded in schools and a greater role for schools in cross-sectoral support teams. The 2019 green
paper Advancing our Health: Prevention in the 2020s30 takes this further, with subsequent policy
announcements giving schools statutory responsibility for children’s mental health and well-being.
Across the UK, school-based education is compulsory between the ages of 5 and 16 years,31 with
further statutory provision for 16- to 18-year-olds in England. In 2019, 8.82 million pupils were
enrolled in England,32 698,000 in Scotland,33 234,550 in Wales34 and 330,000 in Northern Ireland.35
Multiple systematic reviews examining school-based preventative interventions for CMDs have been
published in recent years, and taken together the results suggest a small but positive effect of psychological
and educational interventions. For example, for the prevention of anxiety and depression, Werner-Seidler
et al.36 evaluated both universal and targeted (selective and indicated) interventions in school settings
Treatment
ation
orde ent for

entif ic
tm
rs
Ind
n
tio
know ard trea

Case id
ica
Ma
en
ted
ev
n dis
int
m
er in
Pr
-t ion
en
d
g
n t
an
Stan
Se lo duc e)
c
lec ith : re enc

e
tiv w l r
e ce goa cur
n
ia t ( re
pl en nd
m m a
Co eat pse
tr la )
re ation
Unive r e h abilit
rsal ng
cludi
e r c a re (in
Aft
FIGURE 1 The mental health intervention spectrum for mental disorders. Reproduced with permission from Reducing
Risks for Mental Disorders: Frontiers for Preventive Intervention Research.26 Copyright © National Academy of Sciences.
All rights reserved.

and found a small beneficial effect on both depression (Hedges’ g 0.23, 95% CI 0.19 to 0.28) and
anxiety (Hedges’ g 0.20, 95% CI 0.14 to 0.25). Johnstone et al.37 focused on universal interventions in
school settings and observed a positive effect on symptoms of depression (Hedges’ g 0.17, 95% CI
0.06 to 0.28), but not on anxiety (Hedges’ g 0.09, 95% CI –0.07 to 0.26). Stockings et al.38 included
multiple settings in their review, and included both universal and targeted populations. They concluded
that universal (Cohen’s d –0.11, 95% CI –0.16 to –0.05) and targeted interventions (Cohen’s d –0.33,
95% CI –0.46 to –0.20) to prevent depression are effective in the short term. They observed that
universal prevention had a positive effect on anxiety (Cohen’s d –0.16, 95% CI –0.27 to –0.06), but
that indicated prevention did not (Cohen’s d –0.01, 95% CI –0.27 to 0.26). Rasing et al.39 focused on
targeted interventions only, in any setting, and concluded that depression symptoms were reduced
[standardised mean difference (SMD) –0.25, 95% CI –0.38 to –0.12], but not anxiety (SMD –0.19,
95% CI –0.36 to 0.03).
Much research into the prevention of conduct disorder has focused on indicated parenting programmes
to prevent antisocial/disruptive behaviour in young children. Meta-analyses of indicated parenting
programmes suggest that they have a positive effect. For example, Piquero et al.40 report a medium
effect size for preventing antisocial behaviour (Hedges’ g 0.37; p < 0.001). Meta-analyses of school-
based universal interventions have focused on reducing broader ‘externalising’ or general behaviour
problems, rather than on the prevention of conduct disorder. For example, Lipsey and Wilson41 found
that both universal school-based interventions (Hedges’ g 0.21; p < 0.05; Q76 212; p < 0.05) and indicated
interventions (Hedges’ g 0.29; p < 0.05; Q108 300; p < 0.05) had a small beneficial effect in terms of
preventing outcomes of disruptive behaviour.
Rationale for the current study
It can be argued that no two preventative interventions are exactly alike, as they are made up
of combinations of components, each delivered with differing degrees of fidelity and intensity,
to slightly different populations and settings. However, in a standard meta-analysis, intervention
complexity and variation are overlooked when studies are combined to form a single comparator for
analysis (e.g. ‘CMD intervention’ compared with control). This ‘lumping’, or conflating, of potentially
disparate interventions can induce statistical heterogeneity. Estimates of statistical heterogeneity
(variability across intervention effects) in meta-analyses of preventative CMD interventions can be
substantial. Although heterogeneity may be inevitable in public health meta-analyses,42 it should
nevertheless be minimised because of the consequences for policy recommendations and decision-
making.43 For example, in a random-effects meta-analysis, the precision (certainty) with which the
average intervention effect is estimated decreases as heterogeneity increases, that is CIs are wider.
The need to ‘lump’ interventions, and control conditions, can be avoided by using a network meta-
analysis (NMA).44 A NMA combines direct and indirect estimates of intervention effect to allow the
simultaneous comparison of multiple interventions in a single evidence synthesis. Crucially, a NMA
retains the distinct identity of each intervention analysed.45 It also enables the ranking of interventions
according to the probability that each is the best, or worst, for a given outcome. The effect of intervention
components (individually or in combination) can be modelled in a meta-analysis using metaregression
methods.46 Work since 201447–49 has highlighted the importance and feasibility of NMAs in public health,
and how they can be used to explore and minimise heterogeneity in evidence syntheses. A component-
level NMA is ideally suited to synthesising preventative CMD interventions, as the complexity of
interventions can be incorporated, while providing the coherent and quantitative assessment of
effectiveness necessary for decision-making.
3
BACKGROUND
Aims and objectives
The overall aim of this project was to identify the most effective and cost-effective intervention
component(s), or combination of components, for the universal and targeted prevention of common
mental health problems among CYP. For the purposes of this project, CMDs were defined as anxiety,
depressive and conduct disorders. This focus was clarified in a protocol update (see the following
section and Table 1 for details).
This aim was addressed by the following objectives:
l consult with CYP and their parents/guardians to inform the outcomes of interest for the
systematic review
l conduct a systematic review of educational setting-based (1) universal and (2) targeted interventions
for the primary prevention of anxiety, depression and conduct disorder that have been evaluated in
randomised controlled trials (RCTs)
l develop a classification scheme, or taxonomy, of components used in preventative mental
health interventions
l conduct intervention-level and component-level NMAs to identify effective interventions and
components of interventions
l conduct an economic evaluation to determine the most cost-effective component, or combinations
of components, of targeted and universal interventions by condition and setting.
Changes to protocol, clarifications and additional analyses
The protocol was updated in October 2018, to reflect decisions made at the searching and screening
stages of the review. These are listed in Searching and screening, with full details and accompanying
rationale reported in Table 1 Further changes and clarifications were made at the analysis stage and
are listed in Analysis for transparency.
TABLE 1 Protocol deviations and clarifications
Proposal or
Deviation or original Review stage and
clarification protocol Date change Rationale
Project began: October 2016
Deviation Proposal and November Searching: reduced The proposal stated that 12 databases would be
protocol 2016 number of databases searched. In consultation with an information
searched specialist, we derived a more efficient approach
involving three stages:
1. Databases – we followed the Cochrane

MECIR guidance50,51 for searching, which
states that CENTRAL, MEDLINE and
EMBASE™ (Elsevier, Amsterdam, the
Netherlands) should always be searched as a
mandatory first step. In addition, the MECIR
guidance states that it is highly desirable that
specialist databases are searched. In the
updated protocol, we ordered the databases
in terms of how likely they were to yield
relevant papers, based on databases used in
existing reviews.52 As the condition being
reviewed was CMDs we chose to search
PsycInfo® (American Psychological Association,
Washington, DC, USA) in the first instance

TABLE 1 Protocol deviations and clarifications (continued )
Proposal or
2. Systematic reviews – the second stage of

our search strategy involved searching for
existing systematic reviews. In addition to the
reviews identified via the database searches,
we also searched Epistemonikos, which is a
database of systematic reviews. The reference
lists from reviews were downloaded and
screened for potentially relevant studies.
These were added to our list of titles and
abstracts to screen for inclusion in the review
3. Scoping – finally, we conducted an informal
scoping search of ERIC to check if any additional
records (over and above those identified by the
above strategy) could be identified. The scoping
search did not identify additional studies.
We therefore determined that this was an
appropriate place to stop the search. In
response to peer-review comments on the draft
NIHR report, the ERIC scoping search was
formalised in June 2020. It was combined with a
search of the BEI, and is reported in Appendix 1
Deviation Proposal and December Screening: change In the original proposal, we stated that the
protocol 2016 to inclusion criteria relevant age range would be 5–25 years. To
increase relevance to school settings in the UK,
the lower age limit was changed to age 4 years.
Studies were included if the majority of children
were aged ≥ 5 years, or if the mean age was
approximately 5 years with a ‘small’ standard
deviation. Studies in which the majority of
children were < 4 years of age were excluded
Deviation Proposal and December Screening: change In the original proposal, we stated that the relevant
protocol 2016 to inclusion criteria age range would be 5–25 years. The original upper
age limit was selected to allow sufficient time for
multiple follow-ups in tertiary settings, and was not
intended to reflect age at baseline (entry to trial).
This approach was difficult to operationalise during
pilot data extraction, as studies had a wide age
range at baseline, spanning the upper age limit
(e.g. ages 18–28 years at baseline). Therefore,
this was modified to include studies in which the
majority of participants were aged ≤ 19 years
at baseline
Clarification Proposal and December Screening: ‘Community’ was defined in the protocol
protocol 2016 clarification of inclusion criteria as ‘school affiliated’ and the
inclusion criteria examples ‘after-school and holiday clubs, church
groups, youth clubs and student unions’ given
as an illustration. During screening, ‘school
affiliated’ was operationalised as ‘attached or
linked to a specific school setting’. Studies that
used schools as the source of recruitment but
that were conducted ‘off-site’ at home or in
other community settings were not eligible
for inclusion. Multisetting studies that were
primarily based in schools were included. This
was to ensure that the school was not simply be
the point of recruitment for an intervention that
was then (entirely) carried out elsewhere
continued
5
BACKGROUND
Proposal or
Project paused: April 2017 to February 2018
Clarification Protocol April 2018 Data extraction: The original proposal listed CMDs as
clarification to obsessive–compulsive disorder, phobia,
conditions included post-traumatic stress, panic disorder, anxiety,
depression and conduct disorder. We stated in
the proposal that we anticipated focusing on the
most common: anxiety, depression and conduct
disorder. However, the original protocol did not
reflect this anticipated focus clearly enough, and
a clarification was needed. After staff absence,
to ensure efficiency and expedite the review, a
modification was made to the protocol to ensure
that the explicit focus was on anxiety, depression
and conduct disorder. At the stage this decision
was made, data extraction for depression and
conduct disorder studies had not started, but
was under way for anxiety
Clarification Protocol January Analysis: Educational settings were divided into

2019 clarification of UK-specific primary, secondary and tertiary
analysis plans groupings for the purposes of analysis, and
studies were grouped on the basis of the mean
age (or range) and mapped to a primary,
secondary or tertiary setting for analysis. This
was not made explicit in the original protocol,
which implied that the intervention should be
delivered in one of these settings. This would
not have been practical from an international
perspective, owing to differences in educational
systems (e.g. middle and junior-high schools).
Studies were grouped on the basis of the mean age
(or range) and mapped to a UK-equivalent primary,
secondary or tertiary setting for analysis
Deviation Protocol January Analysis: change to We planned to analyse ‘inequality’ as a main

2019 analysis plan outcome. However, few studies reported
inequality as a primary outcome; instead, we
carried out post hoc subgroup analyses by SES,
sex and ethnicity. These characteristics were
selected post hoc, on the basis of the most
commonly reported study characteristics
Deviation Protocol January Analysis: change to In the protocol, we stated that we would
2019 analysis plan conduct metaregression by intervention
intensity, defined as total session time (number
of sessions × duration in minutes). However, we
determined that this would not be meaningful
in a NMA with differing classes of intervention.
It would have been possible to conduct the
metaregression in a subgroup analysis of
psychological therapies only
Deviation Protocol May 2019 Analysis: change to In response to reviewer comments on Caldwell
outcome measure et al.,1 we added a post hoc composite
‘internalising’ outcome for inclusion in the NMA.
We defined internalising outcomes as combined,
or total, scores from depression and anxiety
symptom scales. For example, the ‘internalising’
subscale of the SDQ or the total score from
the DASS

Proposal or
Deviation Protocol June 2019 Analysis: change to Parental reporting of child symptoms was a
analysis plan secondary outcome and, as such, it was not
anticipated that we would conduct a NMA.
However, based on external evidence of a
discrepancy between CYP and parent reports,
and that some included studies reported only
a parent outcome, we conducted a post hoc
analysis of parent-reported outcomes
Clarification Protocol October Analysis: change to In the protocol, we stated that a cost-effectiveness
2019 analysis plan analysis would be conducted if there was sufficient
evidence to build and populate a model. If this
were not the case, then a cost–consequence
analysis would be conducted. We did not identify
sufficient evidence to build and populate a
model; therefore, we did not conduct a
cost-effectiveness analysis. We did, however,
conduct a cost–consequence analysis. This,
therefore, does not constitute a change from
protocol, but we report it here for transparency
BEI, British Education Index; CENTRAL, Cochrane Central Register of Controlled Trials; DASS, Depression, Anxiety and
Stress Scale; ERIC, Education Resources Information Center; MECIR, Methodological Expectations of Cochrane
Intervention Reviews; SDQ, Strengths and Difficulties questionnaire; SES, socioeconomic status.
Searching and screening
l The number of databases searched was reduced from the original proposal. Instead, we followed
Cochrane Methodological Expectations of Cochrane Intervention Reviews (MECIR) conduct
guidelines50,51 on the selection of primary databases and applied approaches for optimising
search strategies.52–54
l The protocol stated that the relevant age range for inclusion was 5–25 years. This was difficult to
operationalise in practice, and changes were made to the age limits so that the report covers the
age range 4–18 years.
l We clarified the intended intervention setting as ‘educational-setting based’. In the original proposal,
we stated that the review would be conducted for ‘school and community based . . . prevention
interventions’, and defined ‘community’ as ‘school affiliated’ settings. The clarification here pertains
to the definition of ‘school affiliated’, which was operationalised as ‘formally attached or linked to a
specific school setting’.
l A further clarification relates to the definition of CMDs. In this review, CMDs were defined in
reference to their prevalence. The updated protocol clarified that the clinical conditions of interest
were anxiety, depressive and conduct disorders, as these are the most common across the included
age groups.
Analysis
l The educational setting for each study was categorised as UK-specific primary, secondary and
tertiary groupings for the purposes of analysis only. This was not made explicit in the original
protocol, which implied that the intervention should be delivered in one of these settings.
l We planned to analyse ‘inequality’ as a main outcome. However, owing to a lack of data, this was
not possible; instead, we considered subgroup analyses by socioeconomic status (SES), sex and
ethnicity. These characteristics were selected post hoc, based on participant characteristic data that
had been extracted.
7
BACKGROUND
l We planned to conduct a metaregression of intervention intensity, in which intensity was defined as

total session time (number of sessions × duration in minutes). However, we determined that this
would not be meaningful in a NMA with differing classes of intervention, and so the analysis was
not conducted.
l In response to reviewer comments on Caldwell et al.,1 we added a post hoc analysis for a composite
internalising symptoms outcome (which combined depression and anxiety symptom scores).
l A post hoc NMA of parent-reported child symptoms was conducted.
l In the protocol, we stated that a cost-effectiveness analysis would be done if there was sufficient
evidence to build and populate a model. As an alternative, we planned a cost–consequence analysis.
We found that there was insufficient evidence for a cost-effectiveness analysis, and so a
cost–consequence analysis is reported.

Chapter 2 Methods for assessing

effectiveness
I n this chapter, we describe the methods and process applied for the systematic review and NMA.
The protocol for the study was registered with PROSPERO (CRD42016048184). Changes from the
protocol and clarifications relating to inclusion criteria are listed in Chapter 1 and are described in
detail in Table 1. They are also briefly noted throughout this chapter.
Patient and public involvement
As part of the systematic review process, we consulted with the Advice Leading to Public Health
Advancement (ALPHA) research advisory group of young people aged 14–21 years, facilitated by the
Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer)
Centre at Cardiff University.55 The aim was to identify health and social outcomes of importance to
young people that could be considered in the systematic review. On the basis of this focus group,
we included a post hoc outcome looking at the impact of prevention interventions on the stigma
associated with mental disorders. We also met with members of The Caerphilly County Borough
Parent Network to explore their views on young people’s mental health and the role of schools in
preventing and identifying problems.56 There were no outcomes from that focus group that fed directly
into this report.
Methods for the systematic review of effectiveness studies
Criteria for considering studies for this review

In the absence of direct head-to-head evidence comparing interventions, indirect comparisons can
be made across a connected network of interventions. For example, the effect of intervention C
against intervention B (BC) can be obtained indirectly from the effect of C against intervention A (AC),
minus the effect of B against A (AB). The combination of indirect and direct evidence across a network
of intervention comparisons is known as a NMA.
The following eligibility criteria were specified to address the key consistency assumption required
for a valid NMA. In a three-intervention network, the consistency assumption requires the true BC
intervention effect estimated in the B versus C trials to be the same as the BC intervention effect
estimated by the A versus C and A versus B trials (had they also included the B and C arms).57 For this
to hold, one should check that the populations included across all trials in the analysis are comparable
to each other, with respect to any potential effect-modifying characteristics.58 This requirement has
been conceptualised as ‘joint randomisability’ of the interventions for the target population.59 ‘Joint
randomisability’ implies that a hypothetical, multiarm trial of every included intervention would be
reasonable, in principle, and that all participants would be randomisable to any of the interventions
included.60 This requires clearly and specifically defined inclusion criteria, to ensure the included
studies, populations and interventions are sufficiently comparable. Further details on NMA are provided
in Methods for the evidence synthesis of effectiveness studies.
Study design
Parallel-group RCTs and quasi-randomised controlled trials were eligible for inclusion. We defined
quasi-randomised trials as those for which allocation was based on a pseudo-random sequence, such as
the order in which participants were recruited or their date of birth. Both individually randomised and
cluster randomised trials were eligible for inclusion. We did not plan to exclude crossover trials, but
only the first period was considered eligible for inclusion.
9
METHODS FOR ASSESSING EFFECTIVENESS
Population
We followed the NAM’s definition of primary prevention, which refers to universal, selective and indicated
populations (see Figure 1).27 Briefly, universal prevention addresses whole populations not defined on the
basis of risk; selective prevention is targeted at subgroups with a higher than average risk of developing
a mental disorder; and indicated prevention is targeted at high-risk subgroups and/or individuals
with detectable, but subclinical, symptoms of a mental disorder. In the first instance, we used author-
reported classifications of the intended prevention level. However, when interventions were delivered
to a whole class or school with the same at-risk characteristic (such as schools in low-income areas),
they were combined with universal prevention. Studies were excluded if the intervention was described
by the author as indicated prevention, but baseline symptoms scores were suggestive of clinically
meaningful symptom levels (see Definition of disorder).
Age
As noted in Chapter 1, the eligible age range was modified during the screening stage of the review.
Further details of this change to protocol are provided in Table 1.
Studies including participants between the ages of 4 and 18 years (age at study recruitment), in full- or
part-time education, were eligible for inclusion. The lower age limit was set in accordance with the de
facto school starting age in England and Wales. However, owing to global differences in school starting
age, we determined that studies implemented in preschool settings would be eligible for inclusion if
(1) the mean age of participants was 5 years or (2) the majority of enrolled children were aged 5 years
at the time of the baseline assessment. The upper age limit reflects the minimum age of entry to higher
(tertiary) education in England and Wales. However, studies were eligible for inclusion if the mean
age of participants at baseline was ≤ 19 years. Studies targeted at young people not in education or
training were excluded.
Definition of disorder
The original proposal listed CMDs among CYP as obsessive–compulsive disorder, phobia, post-
traumatic stress, panic disorder, anxiety, depression and conduct disorder. However, we anticipated
focusing on anxiety, depression and conduct disorder, as they are the most common, and we expected
the greatest number of studies for these conditions. The structure and connectivity of a network are
important considerations in a NMA, as estimates can be obtained only for connected networks, and
sparsely populated networks with few participants can lead to imprecise estimates.57 Further details of
this clarification to the original protocol are provided in Table 1.
Studies were included if they were explicitly aimed at the primary prevention of anxiety, depression
and/or conduct disorder as operationalised according to categorical or clinically referenced definitions
of disorder [e.g. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)].61 This was
to differentiate studies addressing related mental health constructs, such as emotional health or
well-being, which were excluded (see Interventions and comparators). Studies were eligible if they
focused on either prevention of disorder onset or prevention of symptoms.
However, studies that addressed individual symptoms, or combinations of symptoms, associated with
anxiety, depression and conduct disorder, but without explicitly linking these to a clinically identifiable
disorder, were excluded. For example, interventions to prevent insomnia, rumination or low self-esteem
were excluded, even though these symptoms are associated with depressive and/or anxiety disorders,
and interventions to prevent truancy, bullying or aggressive behaviour were excluded, even though
these behaviours are associated symptoms of conduct disorder. Studies were included only if they
addressed the whole condition, not individual symptoms or combinations of associated symptoms.
We consulted trial registrations and protocols, when available, for further information.
10

Studies in indicated populations were eligible if participants had subclinical mental disorder symptoms
as identified by a screening instrument, an interview or a teacher referral. Subclinical symptoms could
be defined in reference to diagnostic criteria such as the International Statistical Classification of Diseases
and Related Health Problems, Tenth Revision (ICD-10)- or DSM-5-categorised disorders, or ‘in research’
via use of a disorder-specific screening instrument, for example the Children’s Depression Inventory
or Revised Children’s Manifest Anxiety Scale. The boundary between indicated prevention and early
intervention (treatment) is debated,26,27 with no definitive diagnostic threshold. Studies were excluded
if baseline measures were suggestive of clinically meaningful symptoms in > 40% of participants, even
if the study had been defined as indicated prevention by the author. Young people at risk of comorbid
mental health disorders were eligible for inclusion. However, we excluded studies for which > 40%
of participants had an identifiable or pre-existing mental disorder. To ensure a clinically homogeneous
population for analysis, studies in which the whole population had a diagnosis of attention deficit
hyperactivity disorder (ADHD) or an autism spectrum disorder were excluded, as these form distinct
diagnostic categories.
Setting
As noted in Chapter 1, the operationalisation of setting was clarified from the original proposal.
Full details are provided in Table 1.
Interventions implemented in an educational setting were eligible for inclusion. For the purposes of
analysis, this was operationalised as being primary, secondary or tertiary educational settings. However, to
accommodate global differences in educational systems, we did not restrict to interventions implemented
in these settings if the age eligibility criteria were met. For example, an intervention delivered in a
kindergarten setting would be eligible for inclusion if the mean age of participants was 5 years, or the
majority of enrolled children were aged 5 years at the time of the baseline assessment. Interventions
implemented in school-affiliated settings (e.g. after-school and holiday clubs) were eligible for inclusion
if they were implemented on school grounds. This clarification from the original protocol is explained in
Table 1. Studies that used schools as the source of recruitment but for which the intervention was not
school based were excluded.
Health service settings, such as primary care and outpatient and inpatient settings, were excluded.
Interventions implemented in young offender institutions and for looked-after children in residential care
were also excluded. Interventions implemented in low-income countries (LICs), middle-income countries
(MICs) or high-income countries (HICs) were eligible, as defined by 2017 World Bank classifications.62
Interventions and comparators
Inclusion criteria
Interventions were eligible for inclusion if they addressed a universal, selective or indicated population,
and the primary study aim was to prevent anxiety, depression or conduct disorder.
Eligible intervention types included psychological and psychosocial, educational or physical interventions
that were implemented in educational settings, either individually or in groups. Inclusion was not restricted
by mode of delivery. Interventions were included if delivered by peer educators, teachers, youth workers,
clinicians, health visitors, school nurses or counsellors. However, digital and online interventions were
eligible for inclusion only if they were primarily delivered in the education setting or were a clear adjunct
to a wider programme delivered in the school/educational setting (e.g. as homework).
All relevant non-pharmacological control interventions were considered eligible for inclusion, for
example standard provision/usual curriculum, waiting list, no intervention, attention control or ‘placebo’
interventions, and other active psychological and psychosocial, educational or physical interventions.
Further details on active and control interventions are provided in Chapter 3.
11
Exclusion criteria
The following intervention exclusion criteria were informed by the need to ensure the validity of the
NMA. The key assumption underpinning a NMA is described in the Cochrane handbook59 as ‘transitivity’,
but is also known as the consistency assumption. Regarding the interventions included in the network,
transitivity requires ‘all competing interventions of a systematic review to be jointly randomizable’59
and that intervention A is ‘similar’ when it appears in the A versus B and A versus C studies.
Assessment of transitivity for public health interventions is not straightforward. To ensure the validity
of the NMA, we included only interventions for which the primary aim in a given study was to prevent
anxiety, depression or conduct disorder. Unless the study was explicitly focused on disorder-specific
prevention, then mental health promotion, awareness, literacy or information interventions were not
eligible for inclusion. Social and emotional well-being and positive psychology interventions to improve
mental well-being were also excluded, as research suggests that well-being is a separate construct to
mental ill health.63,64 When possible, we consulted trial protocols or registrations if this was ambiguous
in the publication. Interventions designed to target prevention of behaviours or social problems that
might be on the causal pathway to a mental disorder (e.g. prevention of stress, anti-bullying interventions,
substance abuse prevention) were also excluded. Similarly, classroom management and school readiness
interventions were not eligible. ‘Parenting’ interventions such as parent management training or parenting
skills interventions were not eligible for inclusion. However, interventions that took place in schools, with
a parenting component, were eligible if the parenting component was not > 50% of the whole intervention.
Outcomes
According to the NAM classification of primary prevention, the overall, longer-term aim of preventative
interventions ‘is the reduction of the occurrence of new cases’26 of mental disorders. However, it also
recognises the importance of shorter-term prevention in terms of reducing symptoms, which, in turn, may
delay or reduce the risk of the onset of the disorder. All are considered beneficial at a population level and
are ‘worthwhile goals of prevention’.26 In this report, we focus on the effect of prevention interventions on
symptoms of anxiety, depression and conduct disorder. The main outcome was prevention or reduction of
disorder-specific symptoms for self-reported anxiety, depression and conduct disorder.
All validated disease-specific measurement scales for CYP were eligible for inclusion. When studies
reported multiple outcome measures, we applied a prespecified hierarchy to select the most
appropriate outcome for analysis from each study (see Appendix 1). We did not exclude studies
reporting a composite mental health scale from the systematic review [e.g. the Strengths and
Difficulties Questionnaire (SDQ)]; however, they were not combined with disorder-specific scales in
the main NMA. In a change from protocol (see Table 1), a post hoc analysis for composite ‘internalising’
symptom scales was conducted. For example, measurement scales reporting a total or combined score
across depression and anxiety symptoms, such as a total Revised Children’s Anxiety and Depression
Scale (RCADS) score, or a composite outcome such as the SDQ ‘emotional symptoms’ subscale, were
included in this post hoc outcome.
The following additional primary and secondary outcomes were also specified a priori. However, in the
absence of a core outcome set65 or guidelines for the selection of measurement scales for school-based
mental health interventions,66 we determined that an inclusive approach to additional primary and
secondary outcomes was appropriate. Therefore, we did not specify how these outcomes should be
measured in advance, or which scales should be used. Instead, we extracted outcomes as reported by
the study authors.
Additional primary outcomes were as follows:
l self-reported well-being, as defined by study author(s)

l self-reported suicidal ideation, behaviour and self-harm, as reported by study author(s)
l intervention impact on inequalities in health, as defined by study author(s).
12

The primary time point of interest was immediately post intervention. However, as sustainability of
intervention effect is an important question for public mental health,67 we also report results for
mid-term (6–12 months) and longer-term (13–24 months) follow-ups. If studies had a follow-up of
≥ 25 months, these results were also extracted.
Secondary outcomes of interest were as follows:
l Mental health-related stigma, as defined by study author(s). During our initial patient and public
involvement (PPI) focus groups, reducing the stigma associated with mental health problems was
identified as an important outcome for young people.
l Acceptability of an intervention to young people, as reported by the study author(s).
l Parent-reported prevention or reduction of disorder-specific symptoms, as reported by the
study author(s).
l Self-reported problem behaviour, such as substance use or involvement in violence.
l Academic attainment, as defined by the study author(s).
Study identification, inclusion and data extraction
Identification of studies
As noted in Chapter 1, the approach to searching was modified from that of the original proposal.
Full details and explanation are reported in Table 1.
The revised search strategy involved three stages, which might be considered to combine the ‘known
items’ and ‘law of diminishing returns’ approaches described by Booth,52 to optimise searching.
First, working with an information specialist (SDa) and following the Cochrane MECIR guidance on
conducting searches,50,51 we searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled
Trials (CENTRAL) and PsycInfo electronic databases. The search strategies for each electronic database
are described in Appendix 1. The final searches were carried out on 4 April 2018. Searches were not
restricted by language, country or date of publication.
Second, in addition to the database searches, we conducted searches of Epistemonikos (www.

epistemonikos.org; Epistemonikos Foundation, Santiago, Chile) to identify published systematic
reviews of interventions for the prevention of CMDs among CYP. Epistemonikos was searched on
16 November 2016. The reference lists from these reviews were added to the results of the database
searches, ready for screening.
Finally, after screening, we conducted an informal scoping search of the Education Resources
Information Center (ERIC) database. This was to check whether further relevant studies could be
located, cross-referencing with those already identified from the previously mentioned approaches.
If scoping revealed further relevant studies, a formal search was planned. In response to reviewer
comments on the draft version of this report, the ERIC scoping searches were formalised and extended
to the British Education Index (BEI). Further details are reported in Appendix 1.
Screening for study inclusion/exclusion was independently assessed by two reviewers (SRD, JCP, DMC,
PC); disagreement was resolved by a third reviewer if necessary (SRD, JCP, DMC, PC, SEH). Owing
to the volume of potentially relevant studies retrieved, reasons for study exclusion were recorded at
full-text screening only.
We used a standardised data extraction form in Microsoft Excel® (Microsoft Corporation, Redmond,
WA, USA) to extract information from included studies. Data were extracted by one reviewer and
checked by a second (SRD, CF, PC, JCP, DMC). Discrepancies were discussed and a consensus reached.
13
Disagreements were resolved by a third reviewer if necessary. The following information was extracted
from the papers:
l Study design and the target CMD of intervention (i.e. anxiety, depression or conduct disorder);
whether the intervention was universal or targeted (indicated or selected); and number of
participants recruited, randomised and assessed (or clusters, if a cluster RCT).
l Details of participants (country, intervention setting, age, sex, ethnicity).
l Details of intervention as reported by trial author. Narrative description of components and delivery
process for experimental and control interventions. This included number of sessions; intervention
dose (calculated as intensity of intervention: total session time × duration in minutes); whether the
intervention was group or individual, face to face or digital; who facilitated the intervention; and
intervention fidelity measures.
l Outcome(s) assessed and all follow-up time points.
l Risk-of-bias assessment, including additional assessment for cluster trials.
l Mean total symptom score and standard deviation (SD) at baseline and follow-up time points for
primary measurement scale, change from baseline or mean difference between arms; details on
whether results were for completers only or use of methods for handling missing data such as last
observation carried forward; and intracluster correlation coefficient (ICC), the statistical model used
to account for clustering (if any).
Study authors were contacted for additional data, if necessary.
Classification of interventions and components

Eligible interventions were psychological and psychosocial, educational, or physical interventions.
Following previous studies,68–72 and based on author-reported descriptions, the content of psychological
and psychosocial interventions was classified into four broad intervention types: cognitive–behavioural,
behavioural, third wave and interpersonal. Physical interventions were further classified as exercise
or biofeedback. Further categories identified were a combined mindfulness/relaxation intervention,
psychoeducational and psychosupportive interventions, and occupational therapy. Control interventions
were classified into four categories: no intervention, waiting list, usual curriculum and attention
controls.72–74 A full description of all interventions is given in Chapter 3.
We also conducted an intervention component analysis (ICA)75 to identify features of intervention

content and process, influenced by the why, what, who, how, when and how much domains of the
Template for Intervention Description and Replication (TIDieR).76 We applied the constant comparative
method,77 whereby the intervention descriptions reported by authors were used to develop a coding
scheme to classify the components of each intervention and control. If necessary, descriptions were
supplemented by intervention manuals and/or correspondence with the study author. ICA is an
iterative and inductive process. One reviewer (SRD) developed and piloted a list of provisional
component codes based on published studies.46,68,72,78 The components were discussed with a second
reviewer and a preliminary coding exercise was then undertaken on a sample of interventions by a
wider group (SRD, DMC, JK and SEH), and the coding scheme was further refined based on discussion.
The refined coding scheme was then applied inductively by one researcher (SDa) and audited by
another (DMC). Iterative coding refinements were made until application failed to reveal any new
information and the component categories could be described as ‘saturated’.
The working definitions of each intervention and control classification and the classifications of
intervention components are provided in Chapter 3.
14

Assessment of risk of bias in included studies
Two reviewers independently used the Cochrane Risk of Bias tool79 to assess whether there was a
high, low or unclear risk of bias in the following domains: random sequence generation, allocation
concealment, blinding of participants and personnel, blinding of outcome assessor, incomplete outcome
data, selective outcome reporting and other sources of bias (including cluster-specific issues such as
contamination, recruitment bias and unit-of-analysis errors). All eligible studies were included in the
NMA regardless of their risk-of-bias classification, and sensitivity analyses examined the impact of
excluding studies deemed to be at high and unclear risks of bias for random sequence generation and
allocation concealment.
Methods for the evidence synthesis of effectiveness studies
Data preparation
For continuous outcomes, data were extracted for number randomised to each intervention arm at
baseline, and baseline mean and SD, and number assessed at follow-up, and follow-up mean and SD
(for each time point listed previously). If the mean change from baseline was reported, then this was
extracted, together with the standard error (SE) for the mean change from baseline (if reported).
Data were extracted for complete cases. However, if authors reported means and SEs from an appropriate
model accounting for participant dropout or non-response, this was preferred.
For analysis, we used the standardised mean change from baseline, as a variety of outcome
measurement scales were used across the studies. An adjustment for small sample size was applied,
following the formula for Hedges’ g.80 For studies that did not report mean change from baseline, we
derived this from reported baseline and follow-up means and SDs.81 Here we assumed a correlation
coefficient of 0.7, based on previous analyses.82 This value was explored in sensitivity analyses.
Results are summarised using SMDs and 95% credible intervals (CrIs).
For dichotomous outcomes, data were extracted for available cases unless authors clearly reported
events and number of participants following the intention-to-treat principle. Dichotomous outcomes
were summarised using odds ratios (ORs) and 95% CrIs.
If key statistics (e.g. SDs) were not available in the published report, we contacted trial authors for
further information. In cases of non-response, or if missing data were not available, we did not impute
the data and these studies were excluded from the NMA (but not the systematic review).
For cluster randomised trials that did not account for the effect of clustering, we followed the advice
in the Cochrane handbook (section 16.3.4)81 for calculating an approximate sample size. We reviewed
reported ICCs from all included papers and used an ICC estimate of 0.03, which is the mean of the
values reported and is similar to ICCs used in previous public health systematic reviews.68,83–85 This value
was also explored in sensitivity analyses.
Pairwise and network meta-analyses

Both standard pairwise meta-analyses and NMAs were conducted. A NMA was planned for each
primary outcome and for the primary time point only.
A NMA allows data on multiple interventions to be pooled in a single analysis.86 It is considered a

‘core method’ by Cochrane59 and is routinely used in National Institute for Health and Care Excellence
(NICE) technology appraisals and guidelines.87,88 For the novice, the Cochrane handbook81 provides an
accessible introduction; for further depth, we recommend consulting tutorials and introductory papers
on NMA.44,45,60,89–92 However, we describe the fundamentals in the following paragraphs.
15
A NMA requires that the intervention comparisons made in RCTs can be displayed pictorially as a
network of comparisons that are ‘connected’ (i.e. there is a path from any one intervention to another
formed by RCT evidence).59,93 In the absence of direct head-to-head evidence comparing interventions,
indirect comparisons can be made via common comparator(s) across the network. For example, the
effect of intervention C against intervention B can be obtained from the effect of C against A, minus
the effect of B against A. The combination of indirect and direct evidence across a network of
intervention comparisons is known as a NMA.
The validity of a NMA assumes that there are no differences between studies in factors that might interact
with the intervention effect (effect modification). This is the same assumption made in a pairwise meta-
analysis,57 but in a NMA applies across intervention comparisons. It is therefore important to consider
separate analyses according to factors that may be potential effect modifiers. In the first instance, separate
analyses were conducted by population (universal or targeted) and setting (primary, secondary or tertiary
education). Separate analyses were run for the main outcomes of self-reported anxiety, self-reported
depression and self-reported conduct disorder symptoms. Following research suggesting common
mechanisms and pathways within internalising and externalising disorders (transdiagnostic factors),94–97
we ran analyses across (1) all studies aiming to prevent depression and/or anxiety and (2) studies aiming
to prevent conduct disorder. That is, studies contributing to either the depression or anxiety outcome
analyses could be studies that aimed to prevent (1) anxiety (2) depression or (3) anxiety and depression.
Studies contributing to the analysis of the conduct disorder outcome were only those aiming to prevent
conduct disorder. We explore this decision further in a subgroup analysis (see Subgroup, metaregression
and sensitivity analyses). A visual check of the inclusion/exclusion characteristics of trials in each network
was conducted, to ensure that potential effect modifiers were evenly distributed across studies.
Network plots were drawn in Stata® version 15 (StataCorp LP, College Station, TX, USA) to allow visual
inspection of network connectedness.98
For the primary time point of post intervention only, we considered three NMA models, each allowing
for increasing specificity of intervention detail:46,82
1. Intervention-level model – interventions were analysed as ‘clinically meaningful units’.48 For example,
cognitive–behavioural therapy (CBT) was analysed as a distinct intervention to psychoeducation or
third wave-based interventions.
2. Additive model – components nested within intervention. A main intervention effect was estimated
(as per the intervention-level model), plus additional effects for specific components within each
intervention. For example, we estimated an overall CBT effect, which represents the effect for CBT
interventions with components that were common across all the included CBT interventions, and
also estimated the additional effect of CBT interventions containing a psychoeducation component,
a mindfulness component and so on.
3. Full interaction model – components nested within intervention: under this model, each unique
combination of intervention and components was considered as a separate intervention. For example,
CBT with cognitive + behavioural + psychoeducation components was considered a distinct
intervention to CBT with cognitive + behavioural + psychoeducation + relaxation components.
For follow-up time points, where we anticipated finding fewer studies, we ran the intervention-level
model only as prespecified in the protocol. Intervention-level analyses were implemented in a Bayesian
framework using OpenBUGS software (version 3.2.3). Component analyses were implemented in
WinBUGS99 (version 1.4.3; MRC Biostatistics Unit, Cambridge, UK). Statistical details are reported
in Appendix 1. Data and WinBUGS code can be obtained by contacting the corresponding author.
Vague prior distributions were specified for intervention effect and heterogeneity parameters (see
Appendices 1 and 3). We assessed convergence for the intervention-level NMA based on three chains
using the Brooks–Gelman–Rubin diagnostic tool and history plots in OpenBUGS. Specific convergence
details for each model and population/setting analysis are reported in the model fit tables in Appendix 3,
Table 29–46.
16

Random-effects models were run for the main outcomes, assuming a common between-study SD
(known as ‘homogeneous variance’).100 However, we assessed both fixed- and random-effects models
on the basis of model fit. Heterogeneity was evaluated by examining the posterior median between-
study SD (τ) and 95% CrIs from the random-effects model, and by comparing model fit of the fixed-
and random-effects models. Model fit was measured by the posterior mean of residual deviance. In
addition, we examined the deviance information criterion (DIC), which penalises model fit with model
complexity. Differences of ≥ 5 points in posterior mean residual deviance and the DIC were considered
meaningful, with lower values preferred.101 Model fit statistics are reported in Appendix 3.
As described previously, a key assumption for a valid NMA is that of consistency between the direct
and indirect evidence. If the effect estimates from the direct and indirect evidence in a network do
not agree, this is known as inconsistency. The strict inclusion/exclusion criteria described previously
were specified to avoid inconsistency, but they do not guarantee consistency. For this reason, the
statistical agreement of the evidence was formally checked. Consistency was assessed by comparing
the goodness of fit of a model assuming consistency with that of one allowing for inconsistency
(i.e. a model that provides effect estimates based on direct evidence only). A common between-study
SD was also assumed for these inconsistency models.57
Pairwise meta-analyses were also conducted when head-to-head evidence was available. The method
of estimation is similar to the NMA, except that the consistency assumption is removed such that
intervention effects for separate comparisons are unrelated and separate intervention effects can
be estimated.57 Estimates are reported for the post-intervention time point only and are from a
random-effects model that assumes that the heterogeneity parameter is common across intervention
comparisons. This better reflects the assumption made in the NMA and, therefore, allows a fair
comparison of the intervention effect estimates obtained from both approaches.
Subgroup, metaregression and sensitivity analyses

Metaregression and subgroup analyses were performed in OpenBUGS following the Evidence
Synthesis Technical Support Unit code available from the NICE Decision Support Unit’s website and
described in Dias et al.102,103 Subgroup analyses were conducted to assess whether or not intervention
effects differed by intended focus of the intervention, for example if interventions addressing anxiety
had a larger effect on anxiety outcomes than interventions intended to focus on depression but which
also recorded anxiety outcomes.
Metaregression was planned for the intervention-level NMA and main outcomes only, to examine if
intervention effects differed by mode of intervention delivery and who facilitated intervention delivery:
l Mode of intervention delivery – interventions were categorised as being delivered face to face or via a
computer/internet. To explore whether or not intervention effects were modified by mode of delivery,
we fitted a metaregression model for face-to-face (covariate value = 0) and computer/internet
(covariate = 1) interventions. A random-effects NMA model was fitted. However, the regression
coefficient for the covariate was assumed to be a fixed effect across studies. The between-study SD
was assumed to be common for face-to-face and computer/internet interventions. Vague priors
were specified.
l Who facilitated intervention delivery – interventions were categorised as being facilitated by a
teacher or a mental health professional (MHP). There was considerable variation within the category
of ‘MHP’ and it should be regarded as a simplification. Here, MHP included school counsellors,
qualified psychotherapists and graduate and post-doctoral psychology students. Graduate and post-
doctoral students included those studying general psychology, educational psychology or counselling
psychology, when specified. We fitted a metaregression model that enabled us to estimate the
intervention effect at each value of the covariate (0 or 1), for each intervention, comparing the
effect of each facilitator (e.g. CBT-teacher vs. CBT-MHP vs. usual care). To allow for networks
containing multiarm studies with more than two interventions facilitated by a teacher or MHP,
17
a hierarchical model was fitted. In this hierarchical model, a regression coefficient for each
intervention was assumed to come from a normal distribution with a common mean and between-
intervention SD. The between-intervention SD was assumed to be common for each value of the
covariate. Vague priors were specified.
We explored the potential for small-study effects using comparison-adjusted funnel plots.98
Sensitivity analyses were conducted for the intervention-level NMA, main outcomes and primary
time point only. Analyses explored the robustness of results to the following:
l Excluding studies deemed to have a high/unclear risk of bias on the domains of random sequence
generation and allocation concealment.
l The ICC value of 0.03 for cluster randomised trials. Sensitivity analyses were conducted assuming
an ICC of 0.01 and 0.06.
l The correlation value of 0.7 assumed for calculating change from baseline SD. Sensitivity analyses
were conducted assuming a correlation of 0.6 and 0.8.
Interpreting the results and evaluating evidence of effect

As described previously, summary effect estimates and their 95% CrIs from the NMA are reported.
In interpreting these statistical findings, we followed the guidance from the Cochrane handbook
(section 15.3) that interpretation of results from a meta-analysis should not rely on statements of
‘statistical significance’ or thresholds implying ‘significance’.104 Instead, we interpret the strength of
statistical evidence on a graduated scale from weaker to stronger evidence of an intervention effect.105,106
In Chapter 9, we also provide a summary of these statistical findings for the primary outcomes of
anxiety, depression and conduct disorder symptoms at the primary time point of post intervention.
This interpretation forms the basis of the conclusions for the report. The criteria used are based on the
considerations outlined in Chapters 14107 and 15104 of the Cochrane handbook. These considerations
are informed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE)
domains of imprecision, inconsistency (heterogeneity), risk of bias and publication bias. It is not a
formal application of the GRADE rating system, which necessitates up- or downgrading of the evidence
on the basis of the assessments to form an overall assessment of ‘quality’.107
Specifically, our interpretation of the evidence is not solely based on the magnitude and direction of
the summary point estimate, but also incorporates an evaluation of all of the following:
l the precision of the effect estimate, as described by the 95% CrI

l the extent of the between-study heterogeneity observed in each analysis, as described by τ and its
95% CrI
l the risk-of-bias assessment
l the possibility of non-reporting biases or evidence of small-study effects.
18

Chapter 3 Intervention and component

categorisation
I n this chapter, we describe the intervention classifications and the components used in the NMAs
reported in Chapters 4 and 5.
Main ‘intervention-level’ classification
The main ‘intervention-level’ classifications were assigned based on the trial authors’ descriptions and
classifications used in previous systematic reviews.36–39,68,108–113 Many interventions to prevent anxiety
and depression have been adapted from existing clinical interventions for treatment which, in turn, are
grounded in identifiable therapeutic traditions. In adapting therapeutic interventions for a prevention
context, some developers have retained the reference to the underlying therapy on which they are
based, for example cognitive–behavioural therapy. Although these preventative interventions focus on
the same techniques, exercises and skills that underpin the clinical ‘therapeutic’ intervention, the term
‘therapy’ may be considered a misnomer in a preventative context. As such, it may be preferable and
more accurate to consider these preventative interventions as ‘interventions based on the principles of
CBT’. However, for conciseness and consistency with the trial literature we retain the use of ‘therapy’
when using intervention abbreviations throughout the report (e.g. CBT).
Behavioural therapy
Behavioural therapy is a group of allied techniques that focus on behavioural models of psychology
and seek to modify overt maladaptive behaviours. In the current review, we categorised interventions
based on behavioural activation, self-monitoring, role-playing, exposure to feared stimuli or scheduling
pleasant activities as being behavioural in nature.
Cognitive–behavioural therapy
Cognitive–behavioural therapy can be considered a family of allied techniques, based in both behavioural
and cognitive models of psychology, that utilise a set of overlapping cognitive and behavioural techniques.
CBT is based on the proposition that a person’s behaviour is influenced by their cognitive activity (and
vice versa), and that cognitions can be monitored and altered (cognitive restructuring). In turn, emotions
and behaviour can be modified via this cognitive change. CBT interventions for treatment of CMDs
typically include a psychoeducation component; however, in preventative interventions, this may not
always be present.
Third-wave interventions
This was a composite category. Third-wave psychotherapies emphasise mindfulness, acceptance and
flexibility. They tend to focus on a person’s relationship to their cognitions and emotions, encouraging an
acceptance of thoughts, rather than modifying their content. Interventions that described themselves as
mindfulness-based CBT, acceptance and commitment therapy or dialectical behavioural therapy were
included in this classification. Third-wave preventative interventions were distinguished from mindfulness
meditation or relaxation interventions that did not explicitly address cognitions or behaviours.
Interpersonal therapy
From a treatment perspective, interpersonal therapy (IPT) is based on the relationship between mood
symptoms and interpersonal relationships. It seeks to relieve symptoms via resolving interpersonal
conflict and difficulties. In the preventative context, IPT addresses the relationship between young
people significant adults (e.g. teachers, parents), with regard to avoiding/resolving conflict via improved
coping communication skills. The techniques used attempt to improve interpersonal skills may include
role play, problem-solving exercises and practising effective communication.
19
INTERVENTION AND COMPONENT CATEGORISATION
Mindfulness meditation and relaxation-based interventions

In the present review, mindfulness/relaxation is a composite category and is distinct from third-wave
interventions. Relaxation includes breathing exercises, muscle relaxation and yoga from the Iyengar
or Hatha traditions (as opposed to more vigorous traditions). Mindfulness meditation interventions
were included in this category if they focused solely on meditation or relaxation without incorporating
aspects of traditional ‘talking’ psychotherapeutic approaches.
Biofeedback
Biofeedback is a mind–body intervention that uses physiological monitoring devices or equipment
to learn to control physiological responses, such as heart rate. Users may monitor their heart rate
variability using pulse oximetry, for example while completing a standard deep-breathing exercise.
The feedback received helps the participant learn how to influence the negative, or undesired, response
(e.g. a stress response). Smartphone applications and ‘consumer wearables’ have been developed for
monitoring stress, anxiety and sleep problems.
Exercise
In this review, we classified an exercise intervention as a cardiovascular intervention designed to
raise heart rate and breathing to (at least) a moderate intensity level, for example dancing, running
and team sports.
Cognitive bias modification

Cognitive bias modification (CBM) relates to a group of approaches, including attention and
interpretation bias training, that aim to retrain cognitive distortions. CBM evolved from a visual
attention task (a dot-probe task), in which a participant is exposed to a series of threatening and
neutral stimuli via computer, such as angry and neutral faces, and the speed of their response to a
‘probe’ is measured (e.g. where on the screen the angry or neutral face was displayed). In individuals
with a CMD, attention tends to be selectively directed towards the negative image and response
times to the probe are slower. CBM for the treatment of anxiety disorders seeks to ‘retrain’ this
selective attention bias towards the positive stimulus. In preventative interventions for CYP, CBM
tasks may be embedded in engaging and user-friendly formats such as interactive video games
(‘CBM gamification’).
Occupational therapy
Occupational therapy interventions are based on engaging CYP in meaningful daily activities or
‘occupations’. Interventions are skill based and aim to enable CYP to successfully engage with, and
participate in, developmentally appropriate everyday events. For example, an intervention might focus
on a favourite activity to increase self-esteem, or schoolwork may be modified to create a positive
learning environment and reduce stress.
Control groups
On the basis of previous research,68,72–74 we distinguished the following separate control groups.
We note that, in the included trials, psychoeducation and psychosupport were sometimes considered
as active interventions in their own right. Their inclusion under a ‘control group’ heading does not
affect the findings.
Psychoeducation
Often a component of CBT-based interventions, psychoeducation can also be used as a distinct
intervention. It typically involves a systematic approach to providing background information, for
example what the cause or symptoms of a mental disorder are and advice regarding the mental
disorder and/or explaining the approaches that can help to mitigate symptoms. Written materials or
presentations may be provided.
20

Psychosupport and counselling

Often a component of other interventions, psychosupportive interventions are also used in a stand-alone
format. In the current report, we combined psychosupportive and counselling-based interventions
into one category. Here it refers to a non-specific, possibly therapeutic, intervention that could include
listening, signposting to further services, or forming an attachment or therapeutic alliance.
Usual curriculum
If an active intervention took place during a regular timetabled class and participants in the control
group continued to receive the regular class curriculum, the control intervention was classified as
standard provision or ‘usual curriculum’. This included a variety of different classes and could have
included a ‘well-being’ or health lesson or a standard timetabled academic lesson (such as history
or mathematics).
Waiting list
If participants in the control group were explicitly told (e.g. via informed consent processes) that they
would receive the active intervention at a later date, the control condition was categorised as a waiting
list. Although participants were also likely to be receiving usual curriculum or a no-intervention control,
the use of an explicit waiting list design takes precedence in our categorisation.
No intervention
A no-intervention control categorisation was used to differentiate between a control condition in which
participants received something and a control condition in which participants were not involved in any
structured activity. This classification was applied when the active intervention was held outside regular
timetabled classes (e.g. after school) and the participants were not described as being in a waiting list control.
Attention control
A control was classified as attention control if it was a de novo intervention provided to the
participants for the purpose of the research study.
Component classifications
As described in Chapter 2, ICA is a subjective process. We defined an intervention component as a

potentially active ingredient or constituent part of a main ‘therapy-level’ intervention. In a NMA,
components can be included as indicator variables in a network metaregression; as such, they are
pragmatic classifications related to the techniques used, and may not pertain to psychotherapeutic
schools or traditions. We did not assume the presence of a component based on the therapy-based
intervention-level classification assigned by study authors, but on the details provided about what was
done. For example, if an author stated that the intervention was CBT based, we did not assume that it
contained a psychoeducation, cognitive or behavioural component unless it was clearly stated in the
paper (or intervention manual if applicable). We coded only what was clearly reported, and discuss this
further in the limitations section of the discussion (see Chapter 10).
Component classifications should also be read independently from the similar-sounding main
intervention-level classifications mentioned previously. For example, an intervention-level CBT
classification may be defined by the following illustrative combinations of components, depending on
what was reported:
l CBT intervention 1 – psychoeducation + cognitive + behavioural + relaxation + exercise

l CBT intervention 2 – cognitive + behavioural
l CBT intervention 3 – psychoeducation + cognitive.
21
INTERVENTION AND COMPONENT CATEGORISATION
Behavioural
A behavioural component was one in which techniques included helping participants to practise and
acquire new skills to cope or manage difficult emotions, moods or behaviours. This component includes
strategies used in behavioural activation, social skills exercises (including how to make friends, be a
good friend and support your friends), role play, assertiveness training, interpersonal work and activity
scheduling and contingency management including goal-setting, planning and decision-making activities,
problem-solving and exposure. Following Hetrick et al.,68 this component was initially subdivided into
four further subcomponents: (1) social skills training, (2) problem-solving, (3) exposure and (4) ‘other’
behavioural categories. However, this resulted in unconnected networks, so results are reported for a
‘lumped’ behavioural component only.
Cognitive
This component label was applied when an intervention included strategies or techniques designed
to identify and replace cognitive distortions with more accurate and adaptive ones, for example
recognising and understanding thoughts and feelings, using positive self-talk and challenging negative
self-talk and thoughts.
Third wave
During the ICA, we observed that standard CBT, third wave interventions and mindfulness/relaxation
interventions were often based on combinations of the same components. We included a third wave
component category to ensure differentiation between these ‘therapy-level’ interventions. The component
definition is the same as described previously for the intervention level analysis.
Mindfulness
Mindfulness techniques included guided meditation, colouring and drawing, and exercises to practise
being in the moment and being free from judgemental thoughts and distractions. On completion of the
component coding, we observed that a mindfulness component was always present in conjunction with
a relaxation component.
Relaxation
Separate mindfulness and relaxation components were specified to allow for relaxation techniques that
were not defined as meditation or mindfulness. This included strategies such as progressive muscle
relaxation, abdominal breathing exercises, cue-controlled relaxation, and identification of physiological
arousal (‘body clues’) approaches.
Physiological
A component was coded as physiological if it involved the process of displaying involuntary or
subthreshold physiological processes, usually by electronic instrumentation, and learning to voluntarily
influence those processes by making changes in cognition.
Bias modification
This component was present only in the main therapy-level intervention, CBM, as described previously.
However, on completion of coding, it was retained as a separate component, as the four studies
that could be described as evaluating a CBM intervention were assessed as containing different
combinations of components:
l study 1114 – bias modification

l study 2115 – behavioural + relaxation + physiological + bias modification
l study 3116 – behavioural + physiological + bias modification
l study 4117 – cognitive + bias modification.
Psychoeducation
Psychoeducation was also included as a component of broader interventions. The definition applied at
the component level is the same as described previously for the intervention-level analysis.
22

Additional process and implementation classifications

We also extracted information on the following implementation and process components of interventions:
number of sessions, duration of intervention (minutes), mode of delivery (face to face or digital), group
or individual delivery, who the facilitator was and whether or not training was provided, and whether or
not intervention fidelity was monitored. The characteristics of interventions, the components and process
details are provided in Chapters 4 and 5 and in Appendix 2. We did not include the process components in
the NMA owing to concerns regarding a lack of power and network connectedness.82
23
Chapter 4 Effectiveness of educational

setting-based interventions for preventing
anxiety
P arts of this chapter are reproduced or adapted from Caldwell et al.1 © 2019 The Author(s). Published by
Elsevier Ltd. This is an Open Access article distributed in accordance with the terms of the Creative
Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon
this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/
licenses/by/4.0/. The text below includes substantial additions and formatting changes to the original text,
as well as changes to the reporting approach.
In this chapter, we report the systematic review and NMA results for studies reporting an anxiety
outcome only. Studies reporting a depression outcome are reported in Chapter 5 and additional and
secondary outcomes are reported in Chapter 6.
Systematic review results
Studies included in the review

The overall Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram
for the whole review is reported in Figure 2. A total of 11,990 citations were screened, and 1512 full-text
articles were retrieved for further screening. Of these, 142 studies were identified as eligible for inclusion
in either the anxiety, depression or conduct disorder reviews. Fifty-four studies reported both an anxiety
and a depression outcome. The full list of included studies can be found in Appendix 2.
Of the 142 studies eligible for the review, 79 included a self-reported anxiety outcome; the details are
reported in this chapter. Studies reporting a depression or conduct disorder outcome are reported
separately in Chapters 5 and 7. Among the studies reporting an anxiety outcome, the primary focus of
38 studies was the prevention of anxiety whereas 13 were focused on the prevention of depression and
28 addressed both anxiety and depression. Subgroup analyses examining whether or not intervention
effects differed by intended focus of the intervention are reported in Exploring heterogeneity and
small-study effects.
Study characteristics are reported in Appendix 2. Included studies were published between 1982 and
2018, and randomised between 22 and 5030 participants (median 184 participants). There were
43 cluster randomised studies, of which four reported cluster-adjusted means and SDs and 35 reported
model-based estimates. Thirty-six were individually randomised trials. Seventy-three studies reported a
post-intervention end point, 38 reported a follow-up of between 6 and 12 months and seven reported
a follow-up of between 13 and 24 months. Studies could report more than one follow-up time point;
details of studies reporting multiple time points are in Appendix 2.
Forty-four studies were classified as universal and 35 were classified as targeted (27 indicated, eight
selective). Twenty-seven studies were implemented in primary schools, 45 in secondary schools, five in
tertiary education and two across multiple settings (i.e. two or more settings). Seventy studies were
conducted in HICs, with eight conducted in MICs and one in a LIC. Of the studies conducted in HICs,
five were conducted in lower-income settings, as specified by the trial authors. Categorisation of LICs
and MICs was based on 2017 World Bank classifications.62
25
EFFECTIVENESS OF EDUCATIONAL SETTING-BASED INTERVENTIONS FOR PREVENTING ANXIETY
Records identif ied through Additional records identif ied

database searching through other sources
(n = 10,766) (n = 2438)
Records after duplicates removed

(n = 11,990)
Title/abstract screened Records excluded

(n = 11,990) (n = 10,478)
Full-text articles assessed Full-text articles excluded

for eligibility (n = 1259)
(n = 1512) • Not anxiety/depression/conduct
disorder, n = 753
• Not prevention, n = 156
• Not educational setting, n = 126
• Not RCT, n = 180
Articles included in review
• Wrong population, n = 44
(n = 253)
Articles awaiting Studies included in

classif ication systematic review
(n = 18) (n = 142)
• Anxiety, n = 79a
• Depression, n = 105a
• Conduct disorder, n = 5
Studies included in NMAb

(n = 109)
• Anxiety, n = 71a
• Depression, n = 86a
FIGURE 2 Study selection process: PRISMA flow diagram for whole systematic review. a, Not mutually exclusive.
Some studies reported both anxiety and depression outcomes. Of 142 studies, 54 reported both anxiety and depression
outcomes. Seven did not report either. Forty-eight of 109 studies contributing to the NMA reported both an anxiety and
a depression outcome. b, Study was included in the NMA at any of the follow-up time points. Note that references to the
main study publication and articles awaiting classification are listed in Appendix 2.
Risk-of-bias assessment
Study-level risk-of-bias assessments are reported in Appendix 2. Thirteen of the 79 studies reporting an
anxiety outcome were assessed as being at low risk of bias for both random sequence generation and
allocation concealment. A further 13 studies reported a suitable randomisation approach, but did not
report sufficient details of allocation concealment to allow assessment (i.e. unclear). Fifty studies were
judged as having unclear risk of bias for both random sequence generation and allocation concealment.
Two studies were judged to have an unclear risk of bias for randomisation and a low risk of bias for
allocation concealment. One study was judged to have a low risk of bias for randomisation and a high
risk of bias for allocation concealment.
26

Seventy-three studies were judged to be at high or unclear risk of bias for participant blinding.
The six studies judged to have a low risk of bias for participant blinding used active controls or
alternative interventions. Study protocols and/or trial registrations were available for 23 studies, of
which 20 were considered to have a low risk of bias, and three an unclear risk of bias, for selective
outcome reporting. For cluster randomised trials, we also considered how recruitment, randomisation
and analysis were conducted under the Cochrane Risk of Bias tool heading of ‘other bias’. Of 43 cluster
RCTs, 19 were judged to be at high risk for ‘other bias’.
Interventions and components identified in the review

Table 2 reports the interventions and components identified for studies reporting a self-reported
anxiety outcome. Seventeen studies compared three or more interventions. Sixty-two studies included
an intervention based on CBT, eight included a relaxation/mindfulness-based intervention, one included
an intervention based on CBT + IPT, three included a ‘third-wave’ intervention, four used methods of
biofeedback, two included an exercise intervention and two used CBM approaches. One study used
an occupational therapy-based intervention. With regard to non-active comparators, 27 studies were
waiting list controlled, 17 were ‘usual curriculum’ controlled, 16 had a no-intervention control and
14 used an attention control.
Table 2 also reports the combinations of components identified across all studies reporting an anxiety
outcome (at any time point) by population and setting. Components are reported by intervention arm
level, and not at the trial level. When there are multiarm trials (i.e. three or more arms) with multiple
‘active’ interventions, intervention components are reported on separate lines. There were 99 active
intervention arms, of which 67 had a psychoeducation component. Seventy-eight interventions had a
cognitive component, 75 had a behavioural component, eight had a mindful component, four had
third-wave components, 60 had a relaxation component, six had a physiological component, four
arms had an exercise component and four had a bias modification component.
Further intervention process and delivery characteristics are reported in Appendix 2. The number
of sessions implemented ranged from 2 to 120 [mean 11.13 (SD 13.44) sessions]. As a proxy for
intervention dose, we calculated the intervention intensity as total session time (number of
sessions × duration in minutes). This ranged from 135 to 10,800 minutes [mean 740.15 (SD 1295.60)
minutes]. A total of 90% of interventions were delivered to whole classrooms or small groups.
Forty-three per cent of interventions were delivered by a MHP, school counsellor or student psychologist,
and 10% were delivered by miscellaneous external professionals. Twenty-two per cent of studies
used interventions delivered by teachers. Fifteen per cent of studies involved a combination of both
teaching and a MHP/psychology professional. Four studies implemented interventions via computer.
Two studies could not be classified.
Network meta-analysis results
Of the 79 studies reporting an anxiety outcome, 71 (n = 33,377 participants) contributed data to the
NMA for anxiety (across all settings and time points). Forty-eight of these studies also reported a
depression outcome and contributed to the depression NMA reported in Chapter 5. The network plot
for all studies reporting an anxiety outcome across all populations and settings is reported in Figure 3.
Analyses were conducted separately by population, setting and follow-up time point. Three models were
compared for each analysis: a main effects (intervention-level) model, an additive component model and a
full interaction component model for the primary time point of immediately post intervention. The longer-
term follow-ups of 6–12, 13–24 and ≥ 25 months are reported for the standard intervention-level NMAs
only. When data were available from head-to-head trials, we conducted pairwise meta-analyses. The
results are reported alongside NMA results in Table 3. Full NMA and pairwise results are reported in
Appendix 4.
27
28

TABLE 2 Intervention-level classifications and component classifications by population and setting for anxiety outcome
Classification
Intervention level Component level, for active intervention only
Third
Study Focusa Armb 1 Armb 2 Armb 3 Armb 4 Psychoeducation Cognitive Behavioural Mindfulness wave Relaxation Physiological Exercise BM
Universal secondary setting
Araya et al.118 2013 Depression (Usual curriculum) CBT – + + – – – – – –
Aune and Stiles 119

Anxiety (No intervention) CBT + + + – – – – – –
2009
Baker and Butler120 Anxiety CBT CBT – + + – – + – – –

1984
– + + – – + – – –
Barrett et al. 121

Anxiety (No intervention) CBT + + + – – + – – –
2005
Bonhauser et al.122 Anxiety + Exercise Exercise – – – – – – – + –

2005 depression
Bonhauser et al.122 – – – – – – – + –
2005
Britton et al.123 Anxiety + (Attention control) Mindfulness/ – – – + – + – – –

2014 depression relaxation
Burckhardt et al.124 Anxiety + (Attention control) Mindfulness/ – – – – – + – – –

Calear et al.125 Anxiety + (Waiting list) CBT – + + – – + – – –

2009 depression
Calear et al.126 Anxiety (Waiting list) CBT CBT + + + + – + – – –

2016
+ + + + – + – – –
Calear et al. 127

Anxiety (Waiting list) CBT + + + + – + – – –
2016
Gillham et al.128 Anxiety + (No intervention) CBT + + + – – – – – –

2006 depression
Gucht et al.129 Anxiety + (Usual curriculum) Third wave + – – – + – – – –

2017 depression
DOI: 10.3310/phr09080
Classification
Third
Hiebert et al. 130

1989 Anxiety (Attention control) Mindfulness/ + – – – – + + – –
relaxation
Hodas131 2016 Anxiety + (Waiting list) CBT + + + – – – – – –

depression
Johnson et al.132 Anxiety + (Usual curriculum) Third wave – – – + + + – – –

2016 depression
Johnson et al.133 Anxiety + (Usual curriculum) Third wave Third wave – – – + + + – – –

2017 depression
Johnson et al.133 – – – + + + – – –
2017
Lock and Barrett134 Anxiety (No intervention) CBT + + + – – + – – –

2003
Lowry-Webster Anxiety + (Waiting list) CBT + + + – – + – – –

et al.135 2001 depression
Perry et al.136 Depression (Attention control) CBT + + + – – + – – –
Public Health Research 2021 Vol. 9 No. 8

2017
Potek137 2012 Anxiety (Waiting list) Mindfulness/ + – – + – + – – –

relaxation
Roberts et al.138 Depression (Usual curriculum) CBT – + + – – – – – –

2003
Roberts et al.139 Anxiety + (Usual curriculum) CBT – + + – – – – – –

2010 depression
Rodgers and Anxiety (Waiting list) CBT + + + – – + – – –

Dunsmuir140
2015
continued
29
30

TABLE 2 Intervention-level classifications and component classifications by population and setting for anxiety outcome (continued )
Classification
Third
Sheffield et al. 141

Depression (No intervention) CBT + + + – – – – – –
2006
Stallard et al.142 Depression (Usual curriculum) (Attention CBT + IPT + + + – – + – – –

2013 control)
Tomba et al.143 2010 Anxiety + CBT CBT + + + – – + – – –

depression
Tomba et al.143 2010 + + + – – + – – –
Wong et al. 144

2014 Anxiety + (Usual curriculum) CBT CBT + + + – – – – – –
depression
Wong et al.144 2014 + + + – – – – – –
Universal primary setting
Ahlen et al.145 2018 Anxiety + (Usual curriculum) CBT + + + – – + – – –

depression
Attwood et al.146 Anxiety (Attention control) CBT + + + – – – – – –

2012
Barrett and Turner147 Anxiety (Usual curriculum) CBT CBT + + + – – + – – –

2001
Barrett and Turner147 + + + – – + – – –

2001
Bouchard et al.148 Anxiety (Waiting list) CBT + + + – – – – – –

2013
Collins et al.149 Anxiety (Usual curriculum) CBT CBT + + + – – + – – –

2014
Collins et al.149 + + + – – + – – –
2014
DOI: 10.3310/phr09080
Classification
Third
Essau et al. 150

Anxiety (Waiting list) CBT + + + – – + – – –
2012
Gallegos151 Anxiety + (Usual curriculum) CBT + + + – – + – – –

2008 depression
Johnstone et al.152 Anxiety + (Usual curriculum) CBT – + + – – + – – –

2014 depression
Miller et al.153 Anxiety (Waiting list) CBT + + + – – – – – –

2010
Miller et al.154 Anxiety (Waiting list) CBT + + + – – + – – –

2011
Miller et al.154 Anxiety (Attention control) CBT + + + – – + – – –

2011
Pattison and Depression (No intervention) (Attention CBT CBT – + + – – – – – –

Lynd-Stevenson155 control)
2001
Pattison and – + + – – – – – –
Lynd-Stevenson155

2001
Pophillat et al.156 Anxiety + (Usual curriculum) CBT + + – – – – – – –

2016 depression
Rooney et al.157 Depression (No intervention) CBT – + + – – + – – –

2006
Ruttledge et al.158 Anxiety (Waiting list) CBT + + + – – + – – –

2016
Stallard et al.159 Anxiety (Usual curriculum) CBT CBT + + + – – + – – –

2014
Stallard et al.159 + + + – – + – – –
2014
continued
31
32

Classification
Third
Targeted secondary setting
Balle and Tortella- Anxiety (Waiting list) CBT + + + – – + – – –

Feliu160 2010
Berry and Hunt161 Anxiety (Waiting list) CBT + + + – – – – – –

2009
Cova et al.162 2011 Depression (No intervention) CBT + + + – – – – – –
Dobson et al. 163

2010 Anxiety + (Attention control) CBT – + + – – – – – –
depression
Fitzgerald et al.114 Anxiety (Attention control) CBM – – – – – – – – +

2016
Gaete et al.164 2016 Depression (Usual curriculum) CBT – + + – – – – – –
Gillham et al.165 Depression (No intervention) CBT CBT + + + – – + – – –

2012
Gillham et al.165 + + + – – + – – –
2012
Hiebert et al.130 1989 Anxiety (Waiting list) Mindfulness/ Biofeedback + – – – – + + – –

relaxation
Hiebert et al.130 1989 – – – – – – + – –
Hunt et al. 166

2009 Anxiety (No intervention) CBT + + + – – + – – –
Jordans et al. 167

Anxiety + (Waiting list) CBT + + + – – – – – –
2010 depression
Kiselica et al.168 Anxiety Psychosupport CBT + + + – – + – – –

1994
Owen and Lanning169 Anxiety (Waiting list) Mindfulness/ CBT CBT – – – – – + – – –

1982 relaxation
DOI: 10.3310/phr09080
Classification
Third
Owen and Lanning 169

+ + – – – – – – –
1982
Owen and Lanning169 + + – – – + – – –

1982
Peng et al.170 Anxiety + (No intervention) Exercise – – – – – + – + –

2015 depression
Rice171 2009 Anxiety (Attention control) CBT Mindfulness/ + + + – – + – – –

relaxation
Rice171 2009 – – – – – + – + –
Scholten et al.172 Anxiety (Attention control) Biofeedback – – – – – + + – –

2016
Sheffield et al.141 Depression (No intervention) CBT CBT CBT + + + – – – – – –

2006

Sheffield et al.141 + + + – – – – – –
2006
Sheffield et al.141 + + + – – – – – –
2006
Sportel et al.117 2013 Anxiety (No intervention) CBM CBT – + – – – – – – +
Sportel et al. 117

2013 – + + – – – – – –
Topper et al. 173

2017 Anxiety + (Waiting list) CBT + + + – – – – – –
depression
continued
33
34

Classification
Third
Targeted primary setting
Cooley-Strickland Anxiety (Waiting list) CBT + + + – – + – – –

et al.174 2011
Manassis et al.175 Anxiety + (Attention control) CBT + + – – – – – – –

2010 depression
McLoone et al.176 Anxiety (Waiting list) CBT CBT + + + – – – – – –

2012
McLoone et al.176 + + + – – – – – –
2012
Mifsud and Rapee177 Anxiety (Waiting list) CBT + + + – – – – – –

2005
Miller et al.178 Anxiety (Attention control) CBT + + + – – + – – –

2011
Schoneveld et al.115 Anxiety (Attention control) Biofeedback – – + – – + + – +

2016
Schoneveld et al.116 Anxiety CBT Biofeedback – + + – – + – – –

2018
Schoneveld et al.116 – – + – – – + – +
2018
Simpson179 Anxiety + (Attention control) CBT + + + – – – – – –

2008 depression
Siu180 2007 Anxiety + (Waiting list) CBT + + + – – + – – –

depression
Tokolahi et al.181 Anxiety + (Waiting list) Occupational – – – – – – – – –

2018 depression therapy
van Starrenburg Anxiety (Waiting list) CBT + + + – – + – – –

et al.182 2017
DOI: 10.3310/phr09080
Classification
Third
Targeted tertiary/university setting
Cui et al.183 Depression (Waiting list) Psychosupport CBT + + + – – + – – –

2016
Ellis et al.184 Depression (No intervention) Psychosupport CBT + + + – – + – – –

2011
Higgins185 Anxiety (No intervention) CBT + + + – – + – – –

2007
Seligman et al.186 Anxiety + (No intervention) CBT + + + – – + – – –

1999 depression

2007 depression
Multiple/mixed settings

Liddle and Anxiety (Waiting list) CBT + + + – – + – – –
Macmillan188
2010
Velásquez et al.189 Anxiety + (Waiting list) Mindfulness/ – – – – – + – – –

a Focus of intervention describes the CMD that the intervention aimed to prevent.
b Arm = number of arms included in the study. Studies listed multiple times denote multiple active arms. Components are listed for active interventions only.
Note
Parentheses indicate control interventions (usual curriculum, attention control, waiting list and no intervention).
35
CBT
CBT + IPT
Biofeedback
Exercise
Cognitive bias modification
Mindfulness/relaxation
Attention control
No intervention
Waiting list
OT
Usual curriculum
Psychosupport
Third wave
FIGURE 3 Network plot of all eligible studies reporting an anxiety outcome. OT, occupational therapy; third wave,
third-wave CBT-based therapies. The plot edges (lines) connecting each pair of interventions represent a direct comparison
and are proportional to the number of trials making that direct comparison. Intervention ‘nodes’ are proportional to the
number of participants randomised to each intervention.
TABLE 3 Results from the NMA and pairwise meta-analyses for the primary end point of post intervention for self-reported
anxiety
NMA Direct meta-analysis

Reference Number of
Setting Intervention intervention SMD 95% CrI SMD 95% CrI direct trials
Universal secondary CBT Usual curriculum –0.15 –0.34 to 0.04 –0.15 –0.33 to 0.02 3
Third wave Usual curriculum 0.03 –0.14 to 0.20 0.04 –0.10 to 0.19 3
Mindfulness/ Usual curriculum –0.65 –1.14 to –0.19 NA NA 0
relaxation
Universal primary CBT Usual curriculum –0.07 –0.23 to 0.05 –0.08 –0.24 to 0.04 6
Targeted secondary CBT No intervention 0.03 –0.11 to 0.16 0.03 –0.10 to 0.16 4
CBM No intervention –0.17 –0.45 to 0.11 –0.21 –0.54 to 0.15 1
Exercise No intervention –0.47 –0.86 to –0.09 –0.47 –0.86 to –0.08 1
Biofeedback No intervention –0.18 –0.55 to 0.21 NA NA 0
Mindfulness/ No intervention 0.03 –0.42 to 0.48 NA NA 0
relaxation
Targeted primary CBT Waiting list –0.38 –0.84 to 0.07 –0.35 –0.79 to 0.09 5
Occupational Waiting list 0.11 –0.91 to 1.14 0.11 –0.93 to 1.16 1
therapy
Biofeedback Waiting list –0.38 –1.50 to 0.72 NA NA 0
NA, not available.
Notes
Network meta-analysis results from a random-effects model assuming consistency and pairwise results from a random-
effects unrelated treatment effect model. Intervention effects are reported relative to a reference intervention per
network. In universal networks, the reference intervention was usual curriculum. In the targeted secondary network,
the reference intervention was no intervention, and for targeted primary, it was waiting list. Full NMA results for all
available comparisons are reported in Appendix 4.
36

Universal population, secondary setting
Post intervention
The analysis-specific network diagram is reported in Figure 4. Twenty-one studies (n = 10,208 participants)
contributed to the analysis for the main time point of immediately post intervention.119,120,125–141,143,144 Most
studies in this network were judged to be at unclear risk of bias. The risk of bias was judged to be
unclear for 13 studies and low for three studies in both the randomised sequence generation and
allocation concealment domains. In four studies, the risk of bias was judged to be low for randomisation
but unclear for allocation concealment. In one study, the risk of bias was judged to be unclear for
randomisation but low for allocation concealment. Sixteen studies included an intervention based on
CBT, three were based on third-wave interventions, and two were mindfulness/relaxation-based
interventions; the reference intervention was usual curriculum (see Appendix 2 for details). All reported
results are from a random-effects NMA model unless otherwise stated. Model fit and selection statistics
suggested that a consistency model was appropriate. Of the three models fitted (intervention, additive and
full interaction), the additive model was preferred, suggesting evidence for effect modification by
components. All model fit statistics are reported in Appendix 3. Results reported in the following
sections are SMDs and 95% CrIs.
Intervention-level model
Between-study posterior median SDs (τ) were indicative of moderate heterogeneity (τ 0.11, 95% CrI
0.02 to 0.22). Table 3 reports SMDs (and 95% CrIs) for each active intervention relative to usual
curriculum. There was weak evidence of a modest effect of CBT in preventing symptoms of anxiety
post intervention (SMD –0.15, 95% CrI –0.34 to 0.04). Mindfulness/relaxation interventions (SMD
–0.65, 95% CrI –1.14 to –0.19) reduced symptoms relative to usual curriculum. However, this finding
must be interpreted in the context of the possible small-study effects observed in the funnel plot
reported in Appendix 6, Figure 17, and the ratings of unclear risk of bias. Only two small mindfulness/
relaxation studies (n = 30,130 and n = 79137 participants) contributed to the network, and both were
rated as having an unclear risk of bias for random sequence generation and allocation concealment.
There was a lack of evidence for the effect of third-wave interventions (SMD 0.03, 95% CrI –0.14 to 0.20).
CBT
No intervention
Attention control
Third wave
Waiting list
Usual curriculum
FIGURE 4 Network plot for universal population, secondary setting: post-intervention anxiety outcome.
37
Additive model: components nested within intervention

Component-level models were fitted to evaluate whether or not the observed between-study
heterogeneity in the intervention model could be explained by differences in intervention components.
We fitted an additive model with components nested within interventions, such that a main intervention
effect was estimated, plus an additional effect for the inclusion of a specific component. Results are
reported as regression coefficients (β-values and 95% CrIs) describing the increase or decrease in
SMD via the addition of each component to each intervention. The coefficients can be interpreted as the
additional effect of each specific component over and above the ‘common’ intervention-level effect.
All CBT interventions in the universal secondary network included a cognitive and a behavioural component.
We estimated the additional effect of including a psychoeducational, mindfulness or relaxation component
to cognitive and behavioural components. The between-study heterogeneity was reduced compared
with that of the intervention-level analysis (τ 0.06, 95% CrI 0.00 to 0.21) (see Appendix 3). The effect of
any CBT intervention including a psychoeducation component was to reduce the SMD (β –0.39, 95% CrI
–0.78 to 0.01). The effect of including a mindfulness component in a CBT intervention was to increase
the SMD (β 0.57, 95% CrI 0.08 to 1.03) (i.e. less effective at reducing anxiety). There was no evidence to
suggest an effect of adding a relaxation component to CBT (β 0.07, 95% CrI –0.21 to 0.38).
Table 4 reports the SMDs for all specific additive combinations of intervention components. Under the
additive component model, it is possible to estimate an effect for all combinations, even in the absence
of directly observable trials. Relative to a usual curriculum control, there is some evidence that the
combination of cognitive + behavioural + psychoeducation components is effective at reducing anxiety
post intervention in universal secondary settings (SMD –0.30, 95% CrI –0.59 to –0.01). There is a lack
of evidence for all other combinations.
TABLE 4 Results from additive and full interaction component models: universal secondary settings, self-reported anxiety
Model, SMD (95% CrI)

Population/ Main Components (within main Study
setting intervention intervention) arms (n) Additive Full interaction
Universal CBT (Cognitive + behavioural) 2 0.09 (–0.17 to 0.36) 0.09 (–0.22 to 0.40)
secondary,
anxiety (Cognitive + behavioural) + 6 –0.30 (–0.59 to –0.01) –0.30 (–0.62 to 0.02)
psychoeducation
(Cognitive + behavioural) + 2 0.16 (–0.22 to 0.57) –31.49 (–144.2 to 90.84)

relaxation
(Cognitive + behavioural) + 6 –0.23 (–0.62 to 0.19) –0.21 (–0.66 to 0.26)

psychoeducation + relaxation
(Cognitive + behavioural) + 3 0.34 (–0.12 to 0.82) –31.32 (–144 to 91.01)

psychoeducation +
mindfulness + relaxation
(Cognitive + behavioural) + 0 0.66 (–0.02 to 1.31) –

mindfulness
(Cognitive + behavioural) + 0 0.73 (0.03 to 1.45) –

(Cognitive + behavioural) + 0 0.27 (–0.10 to 0.64) –
psychoeducation + mindfulness
Notes
Intervention components are nested within the main intervention (CBT). All CBT interventions in the universal secondary
analysis contained a cognitive and a behavioural component. The ‘Study arms’ column reports the number of trial arms
that include the specific combination of components listed. As there are several multiarm trials, this is not equivalent to
the number of studies. For example, there are two study arms that include a CBT intervention, which is defined only by
cognitive and behavioural components. The reference intervention is usual curriculum. SMD and 95% CrIs are reported
for the additive and full interaction models. For full details of the models, see Chapter 2 and Appendix 1.
38

Full interaction model: components nested within intervention

Under a full interaction model, each different combination of intervention and components is considered as
a separate intervention. For example, a CBT intervention with cognitive + behavioural + psychoeducation
components is considered to be distinct from CBT with cognitive + behavioural + psychoeducation +
relaxation components. However, the power to estimate and detect evidence of interactions is limited by
the data available for each distinct combination. For the universal secondary anxiety analysis, there were
sufficient data to estimate the effects for CBT-based interventions only, although we note that power
was low and convergence was problematic. Model fit statistics suggested that the full interaction model
was slightly preferred over the intervention-level model, but that the additive effect model is preferred
overall (see Appendix 3). However, for completeness, we also report the full interaction results in Table 4.
There was weak evidence that CBT with cognitive + behavioural + psychoeducation components is
effective relative to usual curriculum (SMD –0.30, 95% CrI –0.62 to 0.02). The between-study posterior
median SD was suggestive of low to moderate heterogeneity (τ 0.09, 95% CrI 0.01 to 0.24). Regression
coefficients are reported in Appendix 3, but yielded very imprecise estimates of change in SMD.
Universal, secondary, further time points: intervention-level effects

Full results for the following time points are reported in Appendix 6. Details for studies contributing to
each time point are reported in Appendix 2.
Six to 12 months post intervention Fifteen studies (n = 13,150 participants), comparing seven
interventions, were included in the analysis for 6–12 months post intervention.118,125,126,128,129,131,133–136,138,139,141–143
Twelve studies included an intervention based on CBT, one study included a CBT + IPT intervention and two
studies included a third-wave intervention. There was no evidence to suggest that any intervention reduced
symptoms of anxiety between 6 and 12 months, relative to usual curriculum (CBT: SMD –0.11, 95% CrI
–0.34 to 0.11; third wave: SMD –0.05, 95% CrI –0.32 to 0.22; and CBT + IPT: SMD –0.02, 95% CrI –0.42
to 0.36). Between-study heterogeneity was moderate (τ 0.15, 95% CrI 0.06 to 0.37).
Thirteen to 24 months post intervention Three studies (n = 1077 participants) contributed to the
analysis for 13–24 months post intervention, all of which included an intervention based on CBT.136,138,139
There was no evidence to suggest that CBT-based interventions prevented symptoms of anxiety
between 13 and 24 months, relative to usual curriculum (SMD –0.01, 95% CrI –2.84 to 2.81).
Twenty-five or more months post intervention One study (n = 92 participants) reported a follow-up
time point of 30 months.139 The SMD for the effect of CBT relative to usual curriculum was –0.23
(95% CrI –0.55 to 0.08). The study was rated as having an unclear risk of bias for random sequence
generation and allocation concealment.
Universal population, primary setting
Post intervention
The analysis-specific network diagram for universal primary settings is reported in Figure 5. Fifteen
studies from 14 publications (n = 5605 participants) contributed to the analysis for the main time point
of immediately post intervention.145–158 Thirteen studies were deemed to have an unclear risk of bias
and one study was deemed to have a low risk of bias for both randomised sequence generation and
allocation concealment domains. One study was judged to be at unclear risk of bias for randomisation
but at low risk of bias for allocation concealment. All studies included an intervention based on CBT.
Model fit and selection statistics suggested that a random-effects consistency model was appropriate.
Fit was similar across all three models (intervention, additive and full interaction) but indicated that the
intervention-level model was preferred (see Appendix 3). Therefore, we report effect estimates from
the intervention-level analysis only. Regression coefficients from the additive and full interaction
models are reported in Appendix 3.
39
CBT
No intervention
Attention control
Usual curriculum
Waiting list
FIGURE 5 Network plot for universal population, primary setting: post-intervention anxiety outcome.
Between-study posterior median SDs were indicative of moderate heterogeneity (τ 0.10, 95% CrI
0.01 to 0.26). There was weak evidence of a very small effect of CBT relative to usual curriculum
(SMD –0.07, 95% CrI –0.23 to 0.05) (see Table 3).
Universal, primary, further time points: intervention-level effects
Six to 12 months post intervention Ten studies (n = 4794 participants) contributed to the analysis for
6–12 months post intervention, all of which evaluated a CBT-based intervention.145,149–152,154,155,157,159
Between-study posterior median SDs were indicative of substantial heterogeneity (τ 0.22, 95% CrI 0.08
to 0.45). There was no evidence that CBT reduced symptoms of anxiety at between 6 and 12 months,
relative to usual curriculum (SMD –0.11, 95% CrI –0.35 to 0.11) (see Appendix 5).
Thirteen to 24 months post intervention Three studies (n = 1603 participants) contributed to the
analysis for 13–24 months post intervention, all of which included an intervention based on CBT.152,157,159
There was no evidence to suggest that CBT-based interventions prevented symptoms of anxiety at
between 13 and 24 months, relative to usual curriculum (SMD 0.00, 95% CrI –0.68 to 0.71; τ 0.13).
Twenty-five or more months post intervention One study (n = 910 participants) reported a follow-up
time point of 30 months.152 This study provided weak evidence of a small effect of CBT relative to
usual curriculum (SMD –0.12, 95% CrI –0.26 to 0.02). The study was deemed to be at unclear risk of
bias for random sequence generation and allocation concealment.
Targeted population, secondary setting
Post intervention
The analysis-specific network diagram for targeted secondary settings is reported in Figure 6. Fifteen
studies (n = 2383 participants) contributed to the analysis for the main time point of immediately post
intervention.114,117,130,141,160–163,165,167,168,170–173 Three studies were deemed to be at low risk of bias and
seven were deemed to be at unclear risk of bias for randomised sequence generation and allocation
concealment. Four studies were deemed to be at low risk of bias for randomised sequence generation
and at unclear risk for allocation concealment. Five studies were multiarm and compared multiple
active interventions. Twelve studies included an intervention based on CBT, two studies examined
40

CBT
Biofeedback
Cognitive bias modif ication
Exercise
Attention control
Waiting list
No intervention Psychosupport
FIGURE 6 Network plot for targeted population, secondary setting: post-intervention anxiety outcome.
biofeedback interventions, two studies included a CBM intervention, two studies included a mindfulness/
relaxation intervention and one study evaluated study an exercise intervention. Model fit and selection
statistics suggested that a random-effects consistency model was appropriate. Model fit was similar
across all three intervention models (main intervention, additive and full interaction) (see Appendix 3).
There was no evidence of effect modification by intervention components in targeted secondary settings.
The intervention-level model is preferred, and regression coefficients from the additive and full interaction
models are reported in Appendix 3.
Intervention-level effects
There was mild to moderate between-study heterogeneity (τ 0.06, 95% CrI 0.00 to 0.21). Table 3
reports SMDs (and 95% CrIs) for each active intervention, relative to no intervention. There was no
evidence of an effect for CBT (SMD 0.03, 95% CrI –0.11 to 0.16), biofeedback (SMD –0.18, 95% CrI
–0.55 to 0.21), CBM (SMD –0.17, 95% CrI –0.45 to 0.11) or mindfulness/relaxation (SMD 0.03,
95% CrI –0.42 to 0.48). There was evidence that exercise reduced post-intervention anxiety symptoms,
relative to no intervention (SMD –0.47, 95% CrI –0.86 to –0.09). However, exercise was evaluated in
only one study, which was judged to be at unclear risk of bias for random sequence generation and
Targeted, secondary, further time points: intervention-level effects only
Six to 12 months post intervention Six studies (n = 1284 participants) contributed to the analysis for
6–12 months post intervention, of which all included a CBT-based intervention and one included a
CBM intervention (three-arm study).117,141,160,163,165,173 There was evidence of mild to moderate between-
study heterogeneity (τ 0.06, 95% CrI 0.00 to 0.25). There was no evidence that either CBT (SMD 0.05,
95% CrI –0.12 to 0.20) or CBM (SMD –0.14, 95% CrI –0.53 to 0.24) reduced anxiety at between 6 and
12 months, relative to no intervention.
Thirteen to 24 months, and ≥ 25 months, post intervention One study (n = 260 participants),166
deemed to be at unclear risk of bias, provided evidence for a small effect of CBT, relative to no
intervention, for the prevention of anxiety between 13 and 24 months’ follow-up (SMD –0.26,
95% CrI –0.52 to –0.01) and at 48 months’ follow-up (SMD –0.39, 95% CrI –0.65 to –0.14).
41
Targeted population, primary setting
Post intervention
The analysis-specific network diagram for targeted primary settings is reported in Figure 7. Eleven
studies (n = 1314) contributed to the analysis for the post-intervention time point.115,116,174–182 Three
studies were deemed to be at low risk of bias and six studies were deemed to be at unclear risk of bias
for both the randomisation and allocation concealment domains. A further two studies were rated as
having an unclear risk of bias for allocation concealment, but a low risk of bias for random sequence
generation. One study compared two active interventions. Ten studies included an intervention based
on CBT, one examined a biofeedback intervention and one included an occupational therapy intervention.
Model fit and selection statistics indicated that a random-effects consistency model was appropriate.
Model fit was similar across all three intervention models (main intervention, additive and full interaction),
but suggested that the intervention-level model was preferred (see Appendix 3). Regression coefficients
from the additive and full interaction models are reported in Appendix 3.
There was evidence of substantial between-study heterogeneity (τ 0.42, 95% CrI 0.21 to 0.89). Table 3
reports SMDs (95% CrIs) for each intervention relative to a waiting list. There was weak evidence of an
effect for CBT (SMD –0.38, 95% CrI –0.84 to 0.07), but a lack of evidence for biofeedback (SMD –0.38,
95% CrI –1.50 to 0.72) or occupational therapy (SMD 0.11, 95% CrI –0.91 to 1.14).
Targeted, primary, further time points: intervention-level effects only
Six to 12 months post intervention Five studies (n = 713 participants) contributed to the analysis for
6–12 months post intervention, of which five included a CBT-based intervention and one included a
biofeedback intervention (one study compared two active interventions).116,175–178 The between-study
posterior median SD was indicative of substantial heterogeneity (τ 0.52, 95% CrI 0.15 to 2.51).
There was no evidence that either CBT (SMD –0.17, 95% CrI –1.37 to 1.06) or biofeedback (SMD –0.28,
95% CrI –2.49 to 1.93) reduced anxiety symptoms at between 6 and 12 months, relative to a waiting list.
No studies reported a follow-up of > 12 months post intervention.
Biofeedback
CBT
Attention control
OT
Waiting list
FIGURE 7 Network plot for targeted population, primary setting: post-intervention anxiety outcome. OT, occupational
therapy.
42

Targeted population, tertiary/university setting

The analysis-specific network diagram is reported in Figure 8. Four studies (n = 743 participants) contributed
to the analysis for the main post-intervention time point, of which all included an intervention based on
CBT.183,184,186,187 Owing to insufficient data in this network, the component models were not fitted.
Post intervention, and 6–12 and 13–24 months post intervention

Model fit and selection statistics suggested that a random-effects consistency model was reasonable
(see Appendix 3). However, the between-study posterior median SDs were indicative of substantial
heterogeneity (τ 0.43, 95% CrI 0.05 to 2.24). This was considerably reduced in the unrelated intervention
effects model (τ 0.21, 95% CrI 0.01 to 2.68), and may indicate the presence of inconsistency. For this
reason, results are not reported. However, this potential inconsistency should be interpreted in the light
of the inclusion criteria that interventions needed to be delivered in the educational institution, and the
unanticipated limitations this caused for the tertiary/university setting analyses. We consider the
limitations in Chapter 10, Limitations relating to inclusion criteria.
Exploring heterogeneity and small-study effects

Subgroup analyses, metaregression and sensitivity analyses were conducted for the intervention-level
NMA, for the main outcome and for the primary end point of post intervention only. The comparison-
adjusted funnel plots suggest that small study effects are possible in the universal primary and secondary
settings analyses. That is, smaller studies may be reporting more beneficial results than larger studies
among non-active controlled trials reporting an anxiety outcome (see Appendix 6). This is a potentially
important finding. Of all the populations and settings considered in this chapter, the universal analyses
provided the strongest evidence for a reduction in anxiety post intervention. There was no evidence to
suggest the presence of small-study effects for the analyses of targeted populations in either setting.
A metaregression was conducted for intervention mode of delivery (face to face or via computer),
and for intervention facilitator (teacher or a MHP). There was no evidence of effect modification by
facilitator or mode of delivery for any population or setting combination (see Appendix 6). However,
for the universal primary analysis, there was weak evidence that teacher-delivered CBT interventions
(SMD –0.05, 95% CrI –0.21 to 0.08) may be slightly less effective than MHP-delivered CBT interventions
(SMD –0.18, 95% CrI –0.42 to 0.00).
No intervention
Psychosupport CBT
Waiting list
FIGURE 8 Network plot for targeted population, tertiary/university setting: post-intervention anxiety outcome.
43
Subgroup analyses were conducted to evaluate if intervention effects differed by intended focus of
the intervention. For each population and setting combination, intervention estimates were compared
across three subgroups: (1) interventions that aimed to prevent anxiety (2) interventions that aimed
to prevent only depressive symptoms and (3) interventions that aimed to prevent both anxiety
and depression.
For the universal secondary and universal primary anxiety networks, there was very weak evidence
that intervention focus was important. Interventions focused on preventing anxiety appeared to have
a larger effect on anxiety symptoms than those focusing on depression or combined depression and
anxiety. However, CrIs overlapped, and we did not conduct a statistical test to examine subgroup
differences. For targeted populations, there was some evidence to suggest that interventions focusing
on both anxiety and depression were slightly more effective than interventions focused on anxiety
alone. However, we emphasise that these results are to be considered descriptive only. Full results
are reported in Appendix 6.
Sensitivity analyses: risk of bias

Sensitivity analyses were conducted for the intervention-level NMA, for the main outcome and
primary end point of post intervention only. We explored the robustness of the findings to excluding
studies judged to be at high/unclear risk of bias for the domains of random sequence generation and
Having removed studies judged to be at high/unclear risk of bias, few studies were eligible for
inclusion. In the universal secondary network, only three studies125,126,141 of three interventions (waiting
list, no intervention and CBT) remained after excluding studies judged to be at high risk of bias, and
there was no evidence of an effect for CBT (SMD –0.07, 95% CrI –0.77 to 0.58), relative to a waiting list
control (Table 5). For targeted secondary interventions, there were three studies judged to be at low risk
of bias comparing four interventions (waiting list, no intervention, CBT and CBM).117,141,167 There was no
evidence of a beneficial effect for either CBT (SMD 0.07, 95% CrI –0.25 to 0.41) or CBM (SMD –0.20,
95% CrI –0.69 to 0.30), relative to no intervention. One study was judged to be at low risk of bias in the
universal primary network.145 A sensitivity analysis was not possible for the targeted primary network.
Sensitivity analyses: intracluster correlation coefficient and change from

baseline scores
When cluster randomised trials did not explicitly account for clustering in their analyses, we followed
the advice in the Cochrane handbook (section 16.3.4)81 for calculating an approximate sample size,
using an ICC of 0.03. We explored the robustness of this decision in a best-case/worst-case sensitivity
analysis using ICCs of 0.01 and 0.06, respectively. All results were robust to alternative ICC values.
TABLE 5 Risk-of-bias sensitivity analyses for self-reported anxiety
SMD (95% CrI)

Reference
Population/setting Intervention intervention Trials (n) Low risk of bias All
Universal secondary CBT Waiting list 3 –0.07 (–0.77 to 0.58) –0.09 (–0.24 to 0.03)
Universal primary CBT Usual curriculum 1 –0.01 (–0.18 to 0.17)a –0.07 (–0.23 to 0.05)
Targeted secondary CBT No intervention 3 0.07 (–0.25 to 0.41) 0.03 (–0.11 to 0.16)
CBM No intervention –0.20 (–0.69 to 0.30) –0.17 (–0.45 to 0.11)

a From fixed-effect analysis.
Notes
Results are listed by population, setting and outcome. Results are compared for the immediate post-intervention time
point. Comparisons listed are those remaining once studies deemed to be at high/unclear risk of bias for random
sequence generation and allocation concealment had been removed from the network. Results are SMDs and
95% CrIs, for the intervention relative to the reference intervention listed.
44

To calculate the standardised mean change from baseline, we assumed a correlation of 0.7, which was
based on previous analyses (see Chapter 2, Data preparation). Sensitivity analyses were robust to using
correlation values of 0.6 and 0.8 (see Appendix 6).
Summary of main results
Seventy-nine studies met the inclusion criteria for the anxiety prevention review, most of which
(n = 66) were deemed to be at high or unclear risk of bias for random sequence generation and/or
allocation concealment. In addition, there was evidence of possible small-study effects in the universal
primary and universal secondary networks. Moderate levels of heterogeneity were observed in
all analyses.
A more detailed interpretation of the results, applying the criteria outlined in Chapter 3, is considered
in Chapter 9. Seventy-one studies contributed data to the NMA. In the universal secondary network,
there was evidence that mindfulness/relaxation interventions (SMD –0.65, 95% CrI –1.14 to –0.19)
reduced symptoms of anxiety, relative to usual curriculum. There was weak evidence for a small effect
of CBT in reducing self-reported anxiety symptoms (SMD –0.15, 95% CrI –0.34 to 0.04). However, the
two mindfulness/relaxation studies were connected to the network only via single small studies.130,137
Both studies were rated as having an unclear risk of bias for random sequence generation and allocation
concealment. The CBT estimate is based on 16 studies (n = 8851 participants),119,120,125–128,131,134–136,138–141,143,144
of which three (n = 4001 participants) were judged to be at low risk of bias for random sequence generation
and allocation concealment.125,126,141 This could, therefore, be considered a more robust finding (because of
the lower risk of bias).
There was evidence of effect modification by intervention components for the CBT interventions
in the universal secondary network. The additive components analysis suggests that a CBT
intervention with a psychoeducation component was more effective than other CBT combinations.
There was a reduction in the SMD of –0.39 (95% CrI –0.78 to 0.01) for CBT interventions with a
psychoeducation component.
Studies included in the universal primary network were mostly judged to be at unclear risk of bias.
There was weak evidence of a very small effect that CBT prevented symptoms of anxiety, relative to
usual curriculum, at post intervention.
For the targeted secondary analysis there was evidence that exercise was effective, relative to no
intervention (SMD –0.47, 95% CrI –0.86 to –0.09). However, this was based on a single study,
connected to the network via no intervention (n = 121 participants) and judged to be at unclear
risk of selection bias.170 There was no evidence of an effect for any other type of intervention in
this network.
There was weak evidence to suggest that CBT was effective, relative to waiting list, in the targeted
primary analysis at post intervention.
There was evidence of inconsistency in the targeted tertiary/university network. We consider this, and
the limitations imposed by the inclusion criteria on the validity of the university network, in Chapter 10,
Limitations relating to inclusion criteria.
45

depression
T he main findings for the intervention-level NMA reported in this chapter are reproduced or adapted
from Caldwell et al.1 © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article
distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license,
which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided
the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The text below
includes substantial additions and formatting changes to the original text, as well as changes to the
reporting approach.
In this chapter, we report the systematic review and NMA results for studies reporting a depression
outcome only.
Systematic review

The overall PRISMA flow diagram for the project can be seen in Figure 2. There were 105 studies
reporting a self-reported depression outcome. The full list of included studies can be found in Appendix 2.
Of these 105 studies, the primary focus of 62 studies was the prevention of depression, 29 focused on
the prevention of anxiety and depression, and 14 focused on the prevention of anxiety alone. A subgroup
analysis to explore whether or not intervention effects varied depending on intended intervention focus is
reported subsequently in Exploring heterogeneity and small-study effects.
Study characteristics are reported in Appendix 2. Included studies were published between 1993 and
2018, and randomised between 16 and 8873 participants (median 198). Fifty-three studies were
cluster randomised, of which seven reported cluster-adjusted means (SEs) and 29 reported results
from appropriate models. The median number of clusters was 13 [interquartile range (IQR) 8–22 clusters].
Fifty-two were individually randomised trials. Ninety-seven studies reported a post-intervention end
point, 64 reported a follow-up of between 6 and 12 months, and 18 reported a follow-up of between
13 and 24 months. Six reported a follow-up of ≥ 25 months.
Fifty-seven studies were classified as universal and 48 as targeted (38 indicated, 10 selective).
Twenty studies were implemented in a primary school setting, 72 in secondary school, eight in tertiary
education and five across multiple settings. A total of 94 studies were conducted in HICs, with
10 conducted in MICs and one in a LIC. Of the studies conducted in HICs, seven were conducted in
lower-income settings, as specified by the trial authors.
Risk-of-bias assessment
Study-level risk-of-bias assessments are reported in Appendix 2. Seventeen of the 105 studies reporting
a depression outcome were assessed as being at low risk of bias for both random sequence generation
and allocation concealment. A further 21 studies reported a suitable randomisation approach, but did
not report sufficient details of allocation concealment to allow assessment. Seven studies were judged
as being at low risk of bias for participant blinding; all were active, or attention controlled. Study
protocols and/or trial registrations were available for 27 studies, of which 25 were judged to be at low
risk of bias for selective outcome reporting. Two studies were judged as being at unclear risk of bias.
One reported a trial registration number that we could not locate, and the primary outcome was not
clear for the other. For cluster randomised trials, we also considered how recruitment, randomisation
47
EFFECTIVENESS OF EDUCATIONAL SETTING-BASED INTERVENTIONS FOR PREVENTING DEPRESSION
and analysis were conducted under the Cochrane Risk of Bias tool heading of ‘other bias’. Of 53 cluster
RCTs, 18 were judged to be at high risk and 16 at unclear risk of ‘other bias’.
Interventions and components identified in the review

Table 6 reports the interventions and components identified for studies reporting a self-reported
depression outcome. Twenty-three studies were multiarm, comparing three or more interventions.
Seventy-six studies included an intervention based on CBT, five studies included an intervention based
on a combination of CBT + IPT and four were based on IPT alone. Four studies included a relaxation/
mindfulness-based intervention, six included a third-wave intervention, four included a behavioural
intervention, two included an exercise intervention and one used a CBM approach. One study used an
occupational therapy-based intervention. With regard to non-active comparators, 26 studies were
waiting list controlled, 33 were usual curriculum controlled, 27 had a no-intervention control and nine
used an attention control. Two studies were classified as having a psychoeducation control group and
six were classified as having a psychosupport control.
Table 6 also reports the combinations of components identified across all studies reporting a depression
outcome (at any time point) by population and setting. Components identified were psychoeducation,
cognitive, behavioural, mindful, third wave, relaxation, physiological, exercise and CBM. There were
123 active intervention arms from the 105 studies reporting a self-reported depression outcome. Of
these active intervention arms, 72 had a psychoeducation component, 96 had a cognitive component,
100 had a behavioural component, 11 had mindful components, seven had third-wave components, 61
had a relaxation component, two had an exercise component and one had a CBM component. The most
frequently identified combinations were psychoeducation + cognitive + behavioural (26 study arms),
psychoeducation + cognitive + behavioural + relaxation (28 arms) and cognitive + behavioural +
relaxation (17 arms).
Further intervention process and delivery characteristics are reported in Appendix 2. The number
of intervention sessions implemented ranged from 2 to 120 [median 10 (IQR 8–12) sessions]. As a
proxy for intervention dose, we calculated the intervention intensity as total session time (number of
sessions × duration in minutes); this ranged from 135 to 10,800 minutes [median 600 (IQR 450–900)
minutes]. Ninety per cent of interventions were delivered to whole classrooms or small groups.
In 52 studies, interventions were delivered by a MHP, school counsellor or student psychologist.
In 10 studies, interventions were delivered by miscellaneous external professionals. Twenty studies
used interventions delivered solely by teachers. Fifteen studies involved a combination of teaching,
psychology and other professionals. Three studies implemented interventions via computer. Five
studies could not be classified.
Network meta-analysis results
Of the 105 studies in the depression review, 86 studies (50,159 participants) contributed to the NMA
for depression. Studies not contributing to the NMA are listed in Appendix 2. The network plot for
all studies reporting a depression outcome across all populations and settings is reported in Figure 9.
The plot edges (lines) connecting each pair of interventions represent a direct comparison and are
proportional to the number of trials making that direct comparison. Intervention ‘nodes’ are proportional
to the number of participants randomised to each intervention.
Model details are described in Chapter 2 and Appendix 1. Three models were compared for each
analysis. We report the results from an intervention-level main effect, a nested additive component
and a full interaction component model. Results are reported by population, setting and follow-up
time point. The longer-term follow-ups of 6–12, 13–24 and ≥ 25 months are reported for the main
intervention-level model only. When data were available from head-to-head trials, we conducted
pairwise meta-analyses. The results are reported alongside NMA results in Table 7. Full NMA and
pairwise results are reported in Appendix 4.
48

DOI: 10.3310/phr09080
TABLE 6 Intervention-level classifications and component classifications by population and setting for depression outcome
Classification
Intervention level Component level for active intervention only
Third Bias
a b b b b
Study Focus Arm 1 Arm 2 Arm 3 Arm 4 Psychoeducation Cognitive Behavioural Mindfulness wave Relaxation Physiological Exercise modification
Universal secondary
Araya et al.118 2013 Depression (Usual curriculum) CBT – + + – – – – – –
Aune and Stiles 119

Anxiety (No intervention) CBT + + + – – – – – –
2009
Barrett et al.121 Anxiety (No intervention) CBT + + + – – + – – –

2005
Barry et al.190 Depression (Usual curriculum) CBT + + – – – – – – –

2017
Bonhauser et al.122 Anxiety + Exercise Exercise – – – – – – – + –

2005 depression
Bonhauser et al.122 – – – – – – – + –
2005
Burckhardt et al.124 Anxiety + (Attention control) Mindfulness/ – – – + – + – – –

Burckhardt et al.191 Anxiety + (Usual curriculum) Third wave + – + + + + – – –

2016 depression

Calear et al.125 Anxiety + (Waiting list) CBT – + + – – + – – –
2009 depression
Calear et al.126 Anxiety (Waiting list) CBT CBT + + + + – + – – –

2016
Calear et al.126 Anxiety + + + + – + – – –

2016
Calear et al.127 Anxiety (Waiting list) CBT + + + + – + – – –

2016
Chaplin et al.192 Depression (No intervention) CBT CBT – + + – – + – – –

2006
Chaplin et al.192 Depression – + + – – + – – –

2006
continued
49
50

TABLE 6 Intervention-level classifications and component classifications by population and setting for depression outcome (continued )
Classification
Third Bias
a b b b b
Clarke et al.193 Depression (Usual curriculum) Psychoeducation + – – – – – – – –

1993
Clarke et al.193 Depression (Usual curriculum) Behavioural + – + – – – – – –

1993 therapy
Gillham et al.128 Anxiety + (No intervention) CBT + + + – – – – – –

2006 depression
Gillham et al.194 Depression (No intervention) (Attention CBT – + + – – + – – –

2007 control)
Gucht et al.129 Anxiety + (Usual curriculum) Third wave + – – – + – – – –

2017 depression
Hodas131 Anxiety + (Waiting list) CBT + + + – – – – – –

2016 depression
Horowitz et al.195 Depression (Usual curriculum) CBT IPT + + + – – – – – –

2007
Horowitz et al.195 Depression + – + – – – – – –

2007
Johnson et al.132 Anxiety + (Usual curriculum) Third wave – – – + + + – – –

2016 depression
Johnson et al.133 Anxiety + (Usual curriculum) Third wave Third wave – – – + + + – – –

2017 depression
Johnson et al.133 Anxiety + – – – + + + – – –

2017 depression
Kindt et al.196 Depression (Usual curriculum) CBT + + + – – + – – –

2014
Lock and Barrett134 Anxiety (No intervention) CBT + + + – – + – – –

2003
Lowry-Webster Anxiety + (Waiting list) CBT + + + – – + – – –

et al.135 2001 depression
Merry et al.197 Depression (Attention control) CBT + IPT – + + – – + – – –

2004
Perry et al.136 Depression (Attention control) CBT + + + – – + – – –

2017
DOI: 10.3310/phr09080
Classification
Third Bias
a b b b b
Pössel et al.198 Depression (Usual curriculum) CBT + + + – – – – – –

2004
Pössel et al.199 Depression (Usual curriculum) CBT + + + – – – – – –

2011
Pössel et al.200 Depression (Usual curriculum) (Attention CBT + + + – – – – – –

2013 control)
Raes et al.201 Depression (Usual curriculum) Third wave + – – + + + – – –

2014
Rivet-Duval et al.202 Depression (Waiting list) CBT + IPT – + + – – + – – –

2011
Roberts et al.138 Depression (Usual curriculum) CBT – + + – – – – – –

2003
Roberts et al.139 Anxiety + (Usual curriculum) CBT – + + – – – – – –

2010 depression
Rose et al.203 Depression (Attention control) CBT + IPT CBT + IPT – + + – – + – – –

2014
Rose et al.203 Depression – + + – – + – – –

2014

Sawyer et al.204 Depression (Usual curriculum) CBT + + + – – + – – –
2010
Shatté205 1997 Depression (No intervention) (Attention CBT – + + – – – – – –

control)
Sheffield et al.141 Depression (No intervention) CBT + + + – – – – – –

2006
Spence et al.206 Depression (Usual curriculum) CBT – + + – – – – – –

2003

2013 control)
Tak et al.207 2016 Depression (Usual curriculum) CBT + + + – – – – – –
Tomba et al.143 Anxiety + CBT CBT + + + – – + – – –

2010 depression
continued
51
52

Classification
Third Bias
a b b b b
Tomba et al.143 + + + – – + – – –
2010
Wong et al.144 2014 Anxiety + (Usual curriculum) CBT CBT + + + – – – – – –

depression
Wong et al.144 2014 Anxiety + + + + – – – – – –

depression
Universal primary
Ahlen et al.145 2018 Anxiety + (Usual curriculum) CBT + + + – – + – – –

depression
Barrett and Anxiety (Usual curriculum) CBT CBT + + + – – + – – –

Turner147 2001
Barrett and Anxiety + + + – – + – – –

Turner147 2001
Cardemil et al.208 Depression (Usual curriculum) CBT + + + – – – – – –

2007
Essau et al.150 2012 Anxiety (Waiting list) CBT + + + – – + – – –
Gallegos 151
2008 Anxiety + (Usual curriculum) CBT + + + – – + – – –
depression
Gillham209 1994 Depression (No intervention) CBT CBT – + + – – + – – –
Gillham209 1994 – + + – – + – – –
Johnstone et al. 152

Anxiety + (Usual curriculum) CBT – + + – – + – – –
2014 depression
Mendelson et al.210 Depression (Waiting list) Mindfulness/ – – – + – + – – –

2010 relaxation
Pattison and Depression (No intervention) (Attention CBT CBT – + + – – – – – –

Lynd-Stevenson155 control)
2001
Pattison and Depression – + + – – – – – –

Lynd-Stevenson155
2001
DOI: 10.3310/phr09080
Classification
Third Bias
a b b b b
Pophillat et al.156 Anxiety + (Usual curriculum) CBT + + + – – + – – –

2016 depression
Quayle et al.211 Depression (Waiting list) CBT + + + – – – – – –

2001
Rooney et al.157 Depression (No intervention) CBT – + + – – + – – –

2006
Soffer212 2003 Depression (No intervention) (Attention Behavioural – – + – – – – – –

control) therapy
Stallard et al.159 Anxiety (Usual curriculum) CBT CBT + + + – – + – – –

2014
Stallard et al.159 Anxiety + + + – – + – – –

2014
Targeted secondary
Arnarson and Depression (Waiting list) CBT + IPT – + + – – + – – –

Craighead213
2009
+ + + – – + – – –

Balle and Tortella- Anxiety (Waiting list) CBT
Feliu160 2010
Berry and Hunt161 Anxiety (Waiting list) CBT + + + – – – – – –

2009
Clarke et al.214 Depression (No intervention) CBT – + – – – – – – –

1995
Congleton215 Depression (Waiting list) CBT + + – – – – – – –

1995
Cova et al.162 Depression (No intervention) CBT + + + – – – – – –

2011
Dobson et al.163 Anxiety + (Attention control) CBT – + + – – – – – –

2010 depression
continued
53
54

Classification
Third Bias
a b b b b
Fitzgerald et al.114 Anxiety (Attention control) CBM – – – – – – – – +

2016
Fung et al.216 Anxiety + (Waiting list) Mindfulness/ – – – + – + – – –

Gaete et al.164 2016 Depression (Usual curriculum) CBT – + + – – – – – –
Gillham et al. 165

Depression (No intervention) CBT CBT + + + – – + – – –
2012
Gillham et al.165 Depression + + + – – + – – –

2012
Hunt et al.166 2009 Anxiety (No intervention) CBT + + + – – + – – –
Jordans et al. 167

Anxiety + (Waiting list) CBT + + + – – – – – –
2010 depression
Livheim et al.217 Depression Psychosupport Third wave – – – – + – – – –

2015
McCarty et al.218 Depression (Usual curriculum) CBT – + + – – + – – –

2011
McCarty et al.219 Depression Psychosupport CBT – + + – – + – – –

2013
Noël et al.220 2013 Depression (Waiting list) CBT + + + – – – – – –
Peng et al. 170

2015 Anxiety + (No intervention) Exercise – – – – – + – + –
depression
Poppelaars et al.221 Depression (Waiting list) CBT CBT CBT + + – – – – – – –

2016
Poppelaars et al.221 Depression – + + – – – – – –

2016
Poppelaars et al.221 Depression + + + – – – – – –

2016
Puskar et al.222 Depression (No intervention) CBT – + + – – + – – –

2003
DOI: 10.3310/phr09080
Classification
Third Bias
a b b b b
Rohde et al.223 Depression Psychoeducation CBT CBT – + + – – – – – –

2014
Rohde et al.223 Depression – + + – – – – – –

2014
Sheffield et al.141 Depression (No intervention) CBT CBT CBT + + + – – – – – –

2006
Sheffield et al.141 Depression + + + – – – – – –

2006
Sheffield et al.141 Depression + + + – – – – – –

2006

2013 control)
Stice et al.224 2008 Depression Psychoeducation Psychosupport CBT CBT – + + – – – – – –
Stice et al. 224

2008 Depression + – + – – – – – –
Stoppelbein225 Depression (Attention control) CBT + + + – – + – – –

2003

Topper et al.173 Anxiety + (Waiting list) CBT + + + – – – – – –
2017 depression
Wijnhoven et al.226 Depression (Waiting list) CBT – + – – – – – – –

2014
Woods and Jose227 Depression (Usual curriculum) CBT + + + – – – – – –

2011
Young et al.228 Depression Psychosupport IPT + – + – – – – – –

2006

2010

2016
continued
55
56

Classification
Third Bias
a b b b b
Targeted primary
Cowell et al.231 Depression (No intervention) Psychosupport – – – – – – – – –

2009
Jaycox et al.232 Depression (Waiting list) CBT – + + – – + – – –

1994
Manassis et al.175 Anxiety + (Attention control) CBT + + – – – – – – –

2010 depression
Simpson179 2008 Anxiety + (Attention control) CBT + + + – – – – – –

depression
Siu180 2007 Anxiety + (Waiting list) CBT + + + – – + – – –

depression
Tokolahi et al.181 Anxiety + (Waiting list) Occupational – – – – – – – – –

2018 depression therapy
Universal tertiary/university setting
Reynolds et al.233 Depression (Usual curriculum) Behavioural – – + – – – – – –

2011 therapy
Targeted tertiary/university setting
Cui et al.183 2016 Depression (Waiting list) Psychosupport CBT + + + – – + – – –
Ellis et al.184 2011 Depression (No intervention) Psychosupport CBT + + + – – + – – –
Higgins185 2007 Anxiety (No intervention) CBT + + + – – + – – –
Peden et al. 234

Depression (No intervention) CBT – + – – – – – – –
2000

1999 depression

2007 depression
Takagaki et al.235 Depression (No intervention) Behavioural + – + – – – – – –

2016 therapy
DOI: 10.3310/phr09080
Classification
Third Bias
a b b b b
Multiple/mixed settings
Liddle and Anxiety (Waiting list) CBT + + + – – + – – –

Macmillan188 2010
McLaughlin236 Depression Psychosupport CBT – + + – – + – – –

2011
Stice et al.237 2007 Depression (Waiting list) CBT + + + – – – – – –
Velásquez et al.189
Anxiety + (Waiting list) Mindfulness/ – – – – – + – – –

Yu238 2002 Depression (No intervention) CBT + + + – – – – – –
a Focus of intervention describes whether the intervention aimed to prevent anxiety, depression or anxiety + depression.
b Arm = number of arms included in the study. Studies listed multiple times denote multiple active arms. Components are described for active arms only.
Note
Parentheses indicate control interventions (usual curriculum, attention control, waiting list and no intervention).
57
CBT SH CBT
CBT + IPT
Exercise Cognitive bias modif ication
IPT Behavioural therapy
Mindfulness/relaxation Attention control
No intervention
Waiting list
OT
Usual curriculum
Psychoeducation Third wave
Psychosupport
FIGURE 9 Network plot for all eligible studies reporting a depression outcome. OT, occupational therapy; SH, self-help;
third wave, third-wave CBT-based therapies.
TABLE 7 Results from the NMA and pairwise meta-analyses for the primary end point of post intervention for
self-reported depression
NMA Direct meta-analysis

Reference Number
Setting Intervention intervention SMD 95% CrI SMD 95% CrI of trials
Universal secondary CBT Usual curriculum –0.04 –0.16 to 0.07 –0.05 –0.17 to 0.06 11
CBT + IPT Usual curriculum –0.18 –0.46 to 0.08 NA NA 0

Behavioural Usual curriculum –0.02 –0.40 to 0.37 –0.02 –0.40 to 0.37 1
therapy
IPT Usual curriculum –0.03 –0.36 to 0.29 –0.10 –0.47 to 0.26 1

Third wave Usual curriculum –0.03 –0.21 to 0.14 –0.02 –0.19 to 0.14 4
Universal primary CBT Usual curriculum –0.13 –0.44 to 0.17 –0.11 –0.37 to 0.16 6
Behavioural Usual curriculum –0.10 –1.04 to 0.80 NA NA 0

therapy
Targeted secondary CBT No intervention –0.22 –0.58 to 0.13 –0.16 –0.47 to 0.15 5
IPT No intervention –0.65 –1.50 to 0.16 NA NA 0
Third wave No intervention –0.68 –1.83 to 0.47 NA NA 0
CBM No intervention –0.90 –2.20 to 0.40 NA NA 0
Exercise No intervention –0.28 –1.13 to 0.58 –0.28 –1.12 to 0.57 1
Targeted primary CBT Waiting list –0.48 –2.49 to 1.50 –0.48 –2.48 to 1.47 2
Occupational Waiting list –0.10 –2.94 to 2.71 –0.10 –2.87 to 2.69 1

therapy
NA, not available.
Notes
NMA results from random-effects model assuming consistency and pairwise results from a random-effects, unrelated
treatment effect model. Intervention effects are reported relative to a reference intervention per network. In universal
networks, the reference intervention was usual curriculum. In the targeted secondary network, the reference
intervention was no intervention, and for targeted primary it was a waiting list. Full NMA results for all available
comparisons are reported in Appendix 4.
58

Universal population, secondary setting
Post intervention
The analysis-specific network diagram is reported in Figure 10. Thirty-four studies (18,094 participants)
contributed to the analysis for the main time point of immediately post intervention, of which nine
were multiarm trials.119,125–129,131–136,138,139,141,143,144,190,192–203,205–207 Six studies were deemed to be at low
risk of bias, and 18 studies were deemed to be at unclear risk of bias, for both random sequence
generation and allocation concealment. Five studies were rated as having an unclear risk of bias for
randomisation and a low risk of bias for allocation concealment. Three studies were rated as having a
low risk of bias for randomisation and an unclear risk of bias for allocation concealment. Two studies
were rated as having an unclear risk of bias for randomised sequence generation and a high risk of bias
for allocation concealment. Twenty-five studies included an intervention based on CBT, one included an
intervention based on IPT and three included an intervention based on a combination of CBT and IPT. Four
interventions were based on third wave and one was based on behavioural therapy. All reported results are
from a random-effects NMA model unless otherwise stated. Model fit and selection statistics suggested
that a consistency model was appropriate. Of the three component models fitted (intervention, additive
and full interaction), the additive model was preferred, suggesting evidence for effect modification by
components. All model fit statistics are reported in Appendix 3. Results are reported as SMDs and
95% CrIs.
The between-study posterior median SD (τ) was indicative of moderate heterogeneity (τ 0.15, 95% CrI
0.10 to 0.22). Table 7 reports SMDs (95% CrIs) for each intervention relative to usual curriculum. There
was weak evidence of a very small effect of CBT (SMD –0.04, 95% CrI –0.16 to 0.07) in preventing
symptoms of depression post intervention. There was weak evidence of a small effect of CBT + IPT
(SMD –0.18, 95% CrI –0.46 to 0.08) in preventing symptoms at the post-intervention time point. There
was no evidence to suggest that IPT (SMD –0.03, 95% CrI –0.36 to 0.29), third-wave therapies (SMD
–0.03, 95% CrI –0.21 to 0.14) or behavioural therapy (SMD –0.02, 95% CrI –0.40 to 0.37) are effective.

Component-level models were fitted to evaluate whether or not the observed between-study heterogeneity
in the intervention model could be explained by differences in intervention components. It was possible to
estimate additive component effects in CBT and third-wave interventions.
CBT
CBT + IPT
IPT Behavioural therapy
No intervention
Attention control
Psychoeducation
Waiting list
Third wave
Usual curriculum
FIGURE 10 Network plot for universal population, secondary setting: post-intervention depression outcome.
59
The between-study posterior median SD was indicative of moderate heterogeneity (τ 0.14, 95% CrI
0.08 to 0.22). All CBT interventions included a cognitive component, and additive effects were
estimated for psychoeducation, behavioural, mindful and relaxation components. The regression
coefficients are reported in Appendix 3 and suggest that there was no evidence of effect modification
by components for CBT interventions. Table 8 reports the SMDs for all specific additive combinations
of intervention components. Relative to a usual curriculum control, there was weak evidence that a
cognitive plus a behavioural component may be effective at reducing symptoms of depression post
intervention in universal secondary settings (SMD –0.11, 95% CrI –0.28 to 0.05). There was a lack of
evidence for all other combinations.
TABLE 8 Results from additive and full interaction component models: universal secondary settings, self-reported depression
SMD (95% CrI)

Population/
setting/ Main Components (within main Study Full interaction
outcome intervention intervention) arms (n) Additive model model
Universal/ CBT Cognitive + psychoeducational + 11 0.01 (–0.12 to 0.13) –0.03 (–0.15 to 0.09)
secondary/ behavioural
depression
Cognitive + psychoeducational 1 –0.55 (–1.33 to 0.20) –0.57 (–1.33 to 0.21)
Cognitive + behavioural + 4 –0.10 (–0.31 to 0.11) –0.11 (–0.4 to 0.17)
relaxation
Cognitive + behavioural 4 –0.11 (–0.28 to 0.05) –0.03 (–0.15 to 0.09)
Cognitive + psychoeducational + 6 0.02 (–0.18 to 0.22) 0.02 (–0.20 to 0.24)
behavioural + relaxation
Cognitive + psychoeducational + 3 –0.01 (–0.4 to 0.38) –0.02 (–0.46 to 0.41)
behavioural + mindfulness +
relaxation
Cognitive + mindfulness 0 –0.70 (–1.6 to 0.18) –
Cognitive + relaxation 0 –0.66 (–1.47 to 0.13) –
Cognitive + psychoeducational + 0 –0.59 (–1.44 to 0.26) –
mindfulness
Cognitive + behavioural + 0 –0.54 (–1.33 to 0.24) –
relaxation
mindfulness +relaxation
behavioural + mindfulness
mindfulness
Cognitive + mindfulness + 0 –0.69 (–1.6 to 0.21) –
relaxation
Third wave Third wave + psychoeducational 1 –0.05 (–0.38 to 0.27) –0.05 (–0.40 to 0.30)
Third wave + mindfulness + 3 0.10 (–0.12 to 0.33) 0.11 (–0.13 to 0.35)
relaxation
Third wave + psychoeducational + 1 –0.35 (–0.70 to 0.00) –0.35 (–0.72 to 0.02)
Notes
Intervention components are nested within the main intervention (CBT and third wave). All CBT interventions in the
universal secondary analysis contained a cognitive component. All third-wave interventions contained a third-wave
component. Study arms reports the number of trial arms that included the specific combination of components listed.
As there were several multiarm trials, this is not equivalent to the number of studies/trials. For example, one study arm
includes a CBT intervention, which is defined by cognitive and psychoeducational components only. The reference
intervention is usual curriculum. For full details of model, see Chapter 2 and Appendix 1.
60

All third-wave interventions contained a third-wave component, and additive effects were estimated
for psychoeducation and a combined mindfulness + relaxation component. Owing to the data structure,
it was not possible to estimate the effects for mindfulness and relaxation components separately.
The impact of including a psychoeducation component in third-wave interventions was to reduce the
SMD by –0.45 (β –0.45, 95% CrI –0.87 to –0.04). Although this regression coefficient indicates the
presence of effect modification, Table 8 shows that there was still only weak evidence that a third-
wave intervention (when made up of third wave + mindfulness + relaxation components) is effective at
reducing symptoms of depression relative to a usual curriculum (SMD –0.35, 95% CrI –0.70 to 0.00).
We note that this is based on evidence from a single study.

Table 8 also reports the number of studies comparing each unique combination of components for
CBT and third-wave interventions for the full interaction component model. Model fit and regression
coefficients are reported in Appendix 3. The between-study posterior median SD for the full interaction
model was suggestive of moderate heterogeneity (τ 0.15, 95% CrI 0.10 to 0.23). There was no evidence
of a differential effect of CBT or third wave by intervention components in universal secondary settings.
Universal, secondary, further time points: intervention-level effects
Six to 12 months post intervention Twenty-eight studies (19,817 participants) contributed to the
analysis for 6–12 months post intervention, eight of which were multiarm trials.118,125,126,128,129,131,133–136,138,139,
Twenty-one studies included an intervention based on CBT, four studies included a
141–143,194–203,205–207
CBT + IPT intervention and one study evaluated an IPT-based intervention. Three studies included a
third-wave-based intervention. The between-study posterior median SD was indicative of low heterogeneity
(τ 0.08, 95% CrI 0.02 to 0.15). There was weak evidence, of small effects, to suggest that CBT (SMD –0.02,
95% CrI –0.10 to 0.06), CBT + IPT (SMD –0.10, 95% CrI –0.26 to 0.05) and third-wave interventions
(SMD –0.13, 95% CrI –0.27 to 0.01) could prevent symptoms of depression, compared with a usual
curriculum comparator. The third-wave studies were judged to be at low risk of bias. The CBT and CBT +
IPT studies were judged to be at mostly unclear risk of selection bias (see Appendix 2). There was no
evidence to support IPT (SMD 0.11, 95% CrI –0.13 to 0.35) reducing symptoms at 6–12 months, relative
to usual curriculum.
Thirteen to 24 months post intervention Eight studies (7584 participants) contributed to the analysis
for 13–24 months post intervention, seven of which included an intervention based on CBT and one that
included an intervention based on CBT + IPT.136,138,139,194,197,204,206,207 There was no evidence to suggest that
CBT-based (SMD –0.04, 95% CrI –0.20 to 0.14) or CBT + IPT (SMD –0.10, 95% CrI –0.57 to 0.39)
interventions prevented symptoms of depression at 13–24 months, relative to usual curriculum. The
between-study posterior median SD was indicative of low heterogeneity (τ 0.07, 95% CrI 0.00 to 0.35).
Twenty-five or more months post intervention We combined studies reporting time points closest to
36 months post intervention. Three studies (1303 participants) reported time points between 30 and
36 months post intervention.138,194,206 All evaluated a CBT intervention. There was no evidence of an
effect for preventing symptoms (SMD –0.14, 95% CrI –2.89 to 2.63), compared with usual curriculum.
Universal population, primary setting
Post intervention
The analysis-specific network diagram is reported in Figure 11. Twelve studies (4116 participants)
contributed to the analysis for the main time point of immediately post intervention.145,147,150–152,155–157,208,209,211,212
Eleven included an intervention based on CBT and one study evaluated a behavioural intervention. Model fit
and selection statistics were suggestive of slight lack of fit, but a consistency model was preferred. Model fit
was similar across all three component models fitted (intervention, additive and full interaction), but
61
CBT
Behavioural therapy
No intervention
Attention control
Usual curriculum Waiting list
FIGURE 11 Network plot for universal population, primary setting: post-intervention depression outcome.
suggests that the intervention-level model was appropriate (see Appendix 3). Therefore, we report effect
estimates from the random-effects intervention-level NMA only. Regression coefficients from the additive
and full interaction models are reported in Appendix 3.
The between-study posterior median SD was indicative of moderate to substantial heterogeneity (τ 0.32,
95% CrI 0.18 to 0.59). Table 7 reports SMDs (95% CrIs) for each intervention, relative to usual curriculum.
There was a lack of evidence that CBT (SMD –0.13, 95% CrI –0.44 to 0.17) or behavioural therapy
(SMD –0.10, 95% CrI –1.04 to 0.80) reduced self-reported symptoms of depression post intervention.

The between-study posterior median SD was indicative of high heterogeneity (τ 0.37, 95% CrI 0.20
to 0.70). All CBT interventions included a cognitive and a behavioural component, and additive effects
could be estimated for psychoeducation and relaxation components only. However, there was no evidence
for effect modification; regression coefficients are reported in Appendix 3, Table 40.

The between-study posterior median SD was suggestive of high heterogeneity (τ 0.39, 95% CrI
0.21 to 0.78). There was no evidence of effect modification by intervention components for CBT in
universal primary settings; regression coefficients are reported in Appendix 3, Table 40.
Universal, primary, further time points: intervention-level effects
Six to 12 months post intervention Nine studies (4134 participants) contributed to the analysis for
6–12 months post intervention, all of which evaluated a CBT-based intervention.145,150–152,155,157,159,208,211
The between-study posterior median SDs were indicative of moderate to substantial heterogeneity
(τ 0.21, 95% CrI 0.06 to 0.56). There was weak evidence, of a small effect, that CBT prevents symptoms
of depression at 6–12 months, relative to usual curriculum (SMD –0.15, 95% CrI –0.43 to 0.09).
Thirteen to 24 months post intervention Three studies (1602 participants) contributed to the analysis
for 13–24 months post intervention, all of which included an intervention based on CBT.152,157,159
There was no evidence to suggest that CBT-based interventions prevented symptoms of depression at
13–24 months, relative to usual curriculum (SMD –0.03, 95% CrI –0.62 to 0.55).
62

Twenty-five or more months post intervention One study (910 participants) reported a follow-up
time point of 30 months post intervention.152 There was evidence that CBT prevented symptoms of
depression at 30 months’ follow-up (SMD –0.27, 95% CrI –0.42 to –0.13).
Targeted population, secondary setting
Post intervention
The analysis-specific network diagram for targeted secondary settings is reported in Figure 12. Twenty-four
studies (3669 participants) contributed to the analysis for the main time point of immediately post
intervention.114,141,160–163,165,167,170,173,214,215,217–219,221–224,226–230 Four studies were deemed to be at low risk of
bias and seven studies were deemed to be at unclear risk of bias for both random sequence generation
and allocation concealment. Eleven studies were judged to be at low risk of bias for random sequence
generation but at unclear risk of bias for allocation concealment, and two studies were judged to be at
unclear risk of bias for random sequence generation but at low risk of bias for allocation concealment.
Eighteen studies included an intervention based on CBT, three studies included IPT-based interventions,
one study evaluated a third-wave intervention, one included a CBM intervention and one evaluated
an exercise intervention. Model fit and selection statistics were suggestive of slight lack of fit, but a
consistency model was considered reasonable. Model fit was similar across all three component models
(intervention, additive and full interaction). Reported results are from a random-effects, consistency
intervention-level NMA. Full model fit details are provided in Appendix 3.
There was evidence of moderate to substantial between-study heterogeneity (τ 0.38, 95% CrI 0.25 to
0.58). Table 7 reports SMDs (95% CrIs) for each intervention relative to no intervention. There was no
evidence of an effect for any intervention: CBT (SMD –0.22, 95% CrI –0.58 to 0.13); CBM (SMD –0.90,
95% CrI –2.20 to 0.40); IPT (SMD –0.65, 95% CrI –1.50 to 0.16); exercise (SMD –0.28, 95% CrI
–1.13. to 0.58); and third wave (SMD –0.68, 95% CrI –1.83 to 0.47).
Component models: additive and full interaction

Regression coefficients are reported for both the additive and full interaction models in Appendix 3,
Table 42. There was no evidence of effect modification according to components for CBT interventions
in a targeted secondary setting.
Exercise CBT
IPT
Cognitive bias modif ication

No intervention
Attention control
Psychoeducation
Waiting list
Psychosupport
Usual curriculum
Third wave
FIGURE 12 Network plot for targeted population, secondary setting: post-intervention depression outcome.
63
Targeted, secondary, further time points: intervention-level effects only
Six to 12 months post intervention Seventeen studies (2728 participants) contributed to the analysis
for 6–12 months post intervention, of which 14 included a CBT-based intervention and three included
an IPT intervention.141,160,163,165,173,214,218,219,221–224,226–230 There was evidence of high levels of between-study
heterogeneity (τ 0.44, 95% CrI 0.27 to 0.71). There was no evidence that either CBT (SMD –0.04,
95% CrI –0.51 to 0.41) or IPT (SMD –0.49, 95% CrI –1.49 to 0.48) prevented symptoms of depression
at 6–12 months, relative to no intervention.
Thirteen to 24 months post intervention Five studies (1089 participants) provided data for the NMA
of 13–24 months’ follow-up.166,218,223,224,229 Four evaluated a CBT intervention and one evaluated an
IPT-based intervention. Between-study heterogeneity was high (τ 0.58, 95% CrI 0.12 to 3.08). There
was no evidence that CBT (SMD –0.18, 95% CrI –2.56 to 2.16) or IPT (SMD 0.09, 95% CrI 3.81 to 3.93)
reduced symptoms of depression at 13–24 months post intervention.
Twenty-five or more months post intervention One study (260 participants), judged to be at unclear
risk of bias, provided no evidence to suggest that CBT prevented symptoms at 48 months’ follow-up
(SMD –0.27, 95% CrI –1.05 to 0.50).166
Targeted population, primary setting
Post intervention
The analysis-specific network diagram for targeted primary settings is reported in Figure 13. Five studies
(497 participants) contributed to the analysis for the post-intervention time point, of which four included
an intervention based on CBT, and one examined an occupational therapy-based intervention.175,179–181,232
One study was deemed to be at low risk of bias for both random sequence generation and allocation
concealment, and three studies were deemed to be at unclear risk of bias. One study was deemed to be
at low risk of bias for random sequence generation but at unclear risk of bias for allocation concealment.
CBT
OT
Attention control
Waiting list
FIGURE 13 Network plot for targeted population, primary setting: post-intervention depression outcome.
OT, occupational therapy.
64

Model fit statistics are reported in Appendix 3. There were limited data available for the component-level
models; however, model fit was similar across the three models. The between-study posterior median
SD was lowest for the intervention-level model; it is on this basis that the intervention-level model is
preferred here (see Appendix 3). All reported results are from a consistency random-effects NMA model
unless otherwise stated.
There was evidence of substantial between-study heterogeneity (τ 0.60, 95% CrI 0.08 to 3.80). Table 7
reports SMDs (95% CrIs) for each intervention relative to a waiting list. There was no evidence of an
effect for CBT (SMD –0.48, 95% CrI –2.49 to 1.50) or occupational therapy (SMD –0.10, 95% CrI
–2.94 to 2.71) at the immediate post-intervention time point.
Component models: additive and full interaction

For the additive component model, the between-study posterior median SD tended to the prior
(τ 2.48, 95% CrI 0.12 to 4.87), as did the regression coefficient for occupational therapy (β –8.97,
95% CrI –144.7 to 144.5). As a result, we conclude that data were insufficient to estimate additive
or full interaction effects for targeted primary settings.
Targeted, primary, further time points: intervention-level effects only

Two studies (230 participants) reported follow-up at 6–12 months, both of which included a CBT-based
intervention.175,232 A fixed-effects NMA was conducted. There was weak evidence that CBT (SMD –0.34,
95% CrI –0.72 to 0.05) prevented symptoms of depression at 6–12 months, relative to a waiting list.
There was weak evidence from one study (83 participants), judged to be at unclear risk of bias, that CBT
prevented symptoms of depression at 24 months’ follow-up, compared with a waiting list (SMD –0.50,
95% CrI –0.96 to 0.05).232
Targeted population, tertiary/university setting

The analysis-specific network diagram is reported in Figure 14. Five studies (789 participants) contributed
to the analysis for the main time point of post intervention, four of which included an intervention
based on CBT and one of which included an intervention based on behavioural therapy.183,184,186,187,235
CBT
No intervention
Behavioural therapy
Psychosupport
Waiting list
FIGURE 14 Network plot for targeted population, tertiary/university setting: post-intervention depression outcome.
65
Model fit and selection statistics suggested that a random-effects consistency model was reasonable
(see Appendix 3); however, the between-study posterior median SD was indicative of substantial
heterogeneity (τ 0.51, 95% CrI 0.12 to 2.50). This was considerably reduced in the unrelated intervention
effects model (τ 0.26, 95% CrI 0.02 to 2.48), and may indicate the presence of inconsistency. Therefore,
results for the tertiary setting are not reported. This possible inconsistency should also be interpreted in
the light of the inclusion criteria adopted in this review, that interventions needed to be delivered in the
educational institution itself, and the unanticipated limitations it caused for the tertiary/university setting
analyses. We consider the limitations in Chapter 10.
Exploring heterogeneity and small-study effects

Subgroup analyses, metaregression and sensitivity analyses were conducted for the intervention-level
NMA, for the main outcome and primary end point of post intervention only. Comparison-adjusted
funnel plots did not provide evidence of small-study effects (see Appendix 6). However, the small number
of studies available for the primary settings makes interpretation difficult.
Metaregression was conducted for intervention mode of delivery (face to face or via computer) and for
intervention facilitator (teacher or a MHP). There was no evidence of effect modification by facilitator
or mode of delivery for any population or setting combination (see Appendix 6).
Subgroup analyses were conducted to assess whether or not intervention effects differed by intended
focus of the intervention, for example whether or not interventions addressing depression had a larger
effect on anxiety outcomes than interventions intended to focus on anxiety but which also recorded
depression outcomes. For each population and setting combination, intervention estimates were compared
across three subgroups: (1) interventions that aimed to prevent anxiety (2) interventions that aimed to
prevent depression only and (3) interventions that aimed to prevent both anxiety and depression. The
results are reported in Appendix 6 but should be considered descriptive only. For the universal secondary
network, there was some evidence that intervention focus was important. Interventions focused on
preventing depression appear to have a larger effect on self-reported symptoms of depression than
those focusing on anxiety or combined depression and anxiety. However, CrIs overlap, and we did not
conduct a statistical test to examine subgroup differences.
Sensitivity analyses: risk of bias

Sensitivity analyses were conducted for the intervention-level NMA, for the main outcome and primary
end point of post intervention only. We explored the robustness of the findings to excluding studies
judged to be at high/unclear risk of bias for the randomised sequence generation and allocation
concealment domains.
Having removed studies judged to be at high/unclear risk of bias for randomisation and allocation
concealment, only six studies of six interventions remained in the universal secondary depression
network.125,126,141,196,197,201 However, only five studies formed a connected network.125,126,141,196,201 Restricting
to studies judged to have a low risk of bias, there was no evidence that CBT (SMD 0.02, 95% CrI –0.77 to
0.80) or third-wave (SMD –0.35, 95% CrI –1.15 to 0.45) interventions are effective to prevent symptoms of
depression in universal secondary settings (Table 9). For targeted secondary interventions, only four studies
of four interventions could be included in the analysis of studies judged to have a low risk of bias, and there
was no evidence that CBT was effective.141,167,219,226 One study was judged to be at low risk of bias in the
universal primary network.145 A sensitivity analysis was not possible for the targeted primary network.
Sensitivity analyses: intracluster correlation coefficient and change from baseline scores
When cluster-randomised trials did not explicitly account for clustering in their analyses, we followed
the advice in the Cochrane handbook (section 16.3.4)81 for calculating an approximate sample size,
using an ICC of 0.03. We explored the robustness of this decision in a best-case/worst-case sensitivity
analysis using ICCs of 0.01 and 0.06, respectively. Results were robust to alternative ICC values.
66

TABLE 9 Risk-of-bias sensitivity analyses for self-reported depression
SMD (95% CrI)
Reference Number Low risk of bias

Population/setting intervention Intervention of studies studies All studies
Universal secondary Usual curriculum CBT 5 0.02 (–0.77 to 0.80) –0.04 (–0.16 to 0.07)
Usual curriculum Third wave –0.35 (–1.15 to 0.45) –0.03 (–0.21 to 0.14)
Universal primary Usual curriculum CBT 1 –0.10 (–0.29 to 0.09) a

–0.13 (–0.44 to 0.17)
Targeted secondary No intervention CBT 4 0.07 (–1.33 to 1.49) –0.22 (–0.58 to 0.13)
a From fixed-effects analysis.
Notes
Results are compared for the immediate post-intervention time point. Comparisons listed are those remaining once
studies deemed to be at high/unclear risk of bias for random sequence generation and allocation concealment had
been removed from the network. Results are SMDs and 95% CrIs, for the intervention relative to the reference
intervention listed.
When necessary, we derived mean change from baseline from reported baseline and follow-up means
and SDs. To do so, we assumed a correlation coefficient of 0.7, which was based on previous analyses.82
We conducted sensitivity analyses using correlation values of 0.6 and 0.8. Results were robust to
alternative correlation values (see Appendix 6).
Summary of main results
A total of 105 studies met the inclusion criteria for the depression prevention review, of which 88
were judged to be at high or unclear risk of bias for random sequence generation and/or allocation
concealment. Eighty-six studies contributed data to the NMA across all settings and time points.
Moderate levels of heterogeneity were observed in all analyses, and high levels of heterogeneity were
observed in some analyses. There was no suggestion of small-study effects in the depression networks.
At the primary time point of post intervention, there was weak evidence from 34 studies to suggest that
CBT (SMD –0.04, 95% CrI –0.16 to 0.07) and CBT + IPT (SMD –0.18, 95% CrI –0.46 to 0.08) may be
effective in universal secondary settings. In all other populations and settings, there was no evidence to
suggest that any type of intervention was effective for preventing depression at the post-intervention time
point. The interpretation of these results and the implications for conclusions are presented in Chapter 9.
At 6–12 months’ follow-up, there was weak evidence to suggest that CBT (SMD –0.02, 95% CrI –0.10
to 0.06), CBT + IPT (SMD –0.10, 95% CrI –0.26 to 0.05) and third-wave interventions (SMD –0.13,
95% CrI –0.27 to 0.01) may reduce depression, compared with usual curriculum, in universal secondary
settings. There was also weak evidence that CBT reduced self-reported depression at 6–12 months,
relative to usual curriculum, in universal primary settings (SMD –0.15, 95% CrI –0.43 to 0.09), and
relative to a waiting list in targeted primary settings (SMD –0.34, 95% CrI –0.72 to 0.05). In targeted
primary settings, there was weak evidence, from a single study judged to be at unclear risk of bias, for
the beneficial effect of CBT-based interventions (relative to a waiting list) at 13–24 months’ follow-up
(SMD –0.50, 95% CrI –0.96 to 0.05).
In all other populations and settings, at all remaining time points, there was an absence of evidence
that any type of intervention was effective.
Owing to possible statistical inconsistency, we do not report the results for tertiary education settings.
As noted in Chapter 4, we consider this, and the limitations imposed by the inclusion criteria on the
validity of the tertiary/university network, in Chapter 10.
67
Chapter 6 Additional primary outcomes

and secondary outcomes from studies
focusing on prevention of depression
and/or anxiety
I n the preceding chapters, we reported the effectiveness results for the main outcomes of
self-reported anxiety and depression. In this chapter, we report the additional outcomes from
all studies focusing on anxiety, depression or anxiety and depression.
Additional primary outcomes
Self-reported psychological well-being

Of the 137 studies focused on preventing anxiety, depression, or both depression and anxiety, 15 reported
an outcome of self-reported psychological well-being, life satisfaction or quality of life. Five studies
reported measuring well-being using the Warwick–Edinburgh Mental Wellbeing Scale,124,126,127,132,133
seven studies reported a measure of life satisfaction124,131,159,181,187,203,239 and two studies reported a
quality-of-life measure.129,235 One study reported a measure of social functioning206 and one used the
Ryff Scales of Psychological Well-being.143 Planned NMAs by population and setting were not possible;
data are reported by outcome measure and study in Table 10. From their model-based analysis,
Calear et al.16 reported that there were no differences between interventions for school-led CBT and
a waiting list (Cohen’s d –0.08, 95% CI –0.29 to 0.13) or between health service-led CBT and a waiting
list (Cohen’s d –0.06, 95% CI –0.21 to 0.09). Using the data reported in the paper, we calculated the
difference in mean change from baseline at post intervention, which suggested a small drop in well-being
at post intervention. For each of the remaining 12 studies, summary intervention effects were compatible
with both an increase and a decrease in well-being/life satisfaction.
TABLE 10 Well-being and life satisfaction: population, setting and intervention comparison reported by study for the
post-intervention time point
Study Population Setting Comparisona Results, mean difference (95% CI)
Warwick–Edinburgh Mental Wellbeing Scale
Calear et al.126 Universal Secondary CBT vs. CBT vs. waiting list Post intervention: –2.07 (–3.56 to –0.58)
2016
Post intervention: –1.09 (–2.32 to –0.14)
Calear et al.127 Universal Secondary CBT vs. waiting list Post intervention: 1.85 (–0.35 to 4.05)
2016
Johnson et al.132 Universal Secondary Third wave vs. usual Post intervention: 0.01 (–0.12 to 0.14)
2016 curriculum
Johnson et al.133 Universal Secondary Third wave vs. third wave Post intervention: 0.02 (–0.10 to 0.14)
2017 vs. usual curriculum
Post intervention: –0.06 (–0.18 to 0.06)
Burckhardt Universal Secondary Mindfulness/relaxation vs. Post intervention data not reported
et al.124 2015 attention control
continued
69
ADDITIONAL PRIMARY AND SECONDARY OUTCOMES
TABLE 10 Well-being and life satisfaction: population, setting and intervention comparison reported by study for the
post-intervention time point (continued )
Study Population Setting Comparisona Results, mean difference (95% CI)
Life satisfaction scales

Hodas131 2016 Universal Secondary CBT vs. waiting list Post intervention: 1.74 (–1.28 to 4.76)
239
Khalsa et al. Universal Secondary Mindfulness/relaxation Post intervention: 0.03 (–0.29 to 0.35)
2012 vs. usual curriculum
Rose et al.203 Universal Secondary CBT + IPT vs. CBT + IPT Post intervention: 0.13 (–0.12 to 0.38)
2014 vs. waiting list
Post intervention –0.13 (–0.37 to 0.11)
Burckhardt Universal Secondary Mindfulness/relaxation Post intervention data not reported
et al.124 2015 vs. attention control
Stallard et al.159 Universal Primary CBT vs. CBT vs. usual 12-month follow-up: –0.58 (–1.26 to 0.10)
2014 curriculum
12-month follow-up: 0.03 (–0.66 to 0.72)
Tokolahi Targeted Primary Occupational therapy Post intervention: –0.45 (–3.39 to 2.49)
et al.181 2018 vs. waiting list
Seligman Targeted Tertiary CBT vs. no intervention Post intervention: 0.10 (–1.06 to 1.26)
et al.187 2007
Quality of life, social functioning and Ryff Scales of Psychological Well-being
Quality of life
Gucht et al.129 Universal Secondary Third wave vs. usual Post intervention: 0.09 (–0.26 to 0.44)
2017 curriculum
Takagaki Targeted University Behavioural therapy vs. no Post intervention: 0.05 (0.02 to 0.08)
et al.235 2016 intervention
Social functioning
Spence et al.206 Universal Secondary CBT vs. usual curriculum Post intervention: 0.22 (–0.70 to 1.14)
2003
Ryff Scales of Psychological Well-being
Tomba et al.143 Universal Secondary CBT vs. CBT Multiple subscales reported: autonomy,
2010 environmental mastery, personal growth,
positive relations, purpose in life and
self-acceptance
a Where there are three arms, effect estimates have been calculated for the active intervention versus the
control intervention.
Self-reported suicidal ideation, behaviour and self-harm

Author-defined suicidal ideation, behaviour or self-harm was referenced in 34 studies narratively
or quantitatively. However, of these, the majority (n = 21) excluded participants reporting suicidal thoughts
or behaviours and/or removed questions asking about suicide and self-harm from the baseline questionnaires.
Some studies reported that the removal of questions was requested by participating schools or education
authorities. Eleven studies reported that suicidal thoughts and behaviours were measured at baseline and that
participants were referred to further services when necessary. However, nine did not then provide details on
whether or not these students continued in the study, nor did they provide follow-up measures. The full
details of these studies are reported in Appendix 7.
Seven studies reported participants experiencing suicidal thoughts or self-harm at post intervention.123,136,142,162,221,235,240
Details are reported in Table 11. Three studies were conducted in a universal secondary setting and formed
a connected network via attention control. However, NMA model fit was suggestive of inconsistency, and
combined results are not reported. Two studies were conducted in a targeted secondary setting, one in an
indicated tertiary setting and one in a universal primary setting. There was no evidence to suggest that
educational setting-based interventions to prevent anxiety and/or depression had an impact on suicidal
ideation or thoughts of self-harm for CYP.
70

TABLE 11 Study-level summary for suicidal ideation and self-harm outcomes at post-intervention time point
Analysis
(population,
Study setting) Comparison Outcome Results
Perry et al.136 Universal, Attention control Suicidal OR 0.83 (95% CrI 0.28 to 2.40)
2017 secondary vs. CBT ideation
a
Stallard et al.142 Universal, Attention control Self-harm OR 0.87 (95% CrI 0.72 to 1.04)
2013 secondary vs. usual thoughts
curriculum
Attention control OR 0.83 (95% CrI 0.70 to 1.00)

vs. CBT + IPT
Britton et al.123 Universal, Attention control Suicidal Not estimable

2014 secondary vs. mindfulness/ ideation or
relaxation self-harm
Poppelaars Indicated, Waiting list vs. Suicidal OR 2.20 (95% CrI 0.29 to 65.56)
et al.221 2016 secondary CBT ideation
Cova et al.162 Indicated, No intervention Self-harm Results not presented because of missing SDs
2011 secondary vs. CBT
Roberts et al.240 Universal, Usual curriculum Suicidal For suicidal ideation, there was no significant
2018 primary vs. CBT vs. CBT ideation group time interaction [F(2,198) = 2.84,
p = 0.061]. There were, however, significant
main effects for group [F(2,198) = 3.41,
p = 0.035] and time [F(1,198) = 6.14,
p = 0.014]
Takagaki Indicated, No intervention Suicidal OR 0.39 (95% CrI 0.05 to 2.28)

et al.235 2016 tertiary/ vs. behavioural ideation
university activation
a Six months’ follow-up.
Notes
Population, setting and intervention comparison as reported by study. ORs were calculated when sufficient information
was reported by author.
Inequalities in health
None of the included studies reported the impact of the intervention on inequalities in health;241
therefore, we conducted post hoc subgroup analyses on the basis of available data. Data had been
extracted on participant characteristics, including SES, sex and ethnicity (see Chapter 2). Descriptions
of SES, sex and ethnicity, as defined by study authors, are reported in Appendix 7. Owing to insufficient
data, subgroup analyses could not be conducted by sex or ethnicity for any population or setting.
Subgroup analyses for studies conducted in lower socioeconomic settings (as described by the author)
are reported.
Eleven studies reported being conducted in lower SES settings, of which three were conducted in
MICs118,122,189 and eight in HICs.139,140,152,156,157,196,208,210 Interventions evaluated in lower SES settings were
CBT relative to usual curriculum, no intervention or a waiting list. Unfortunately, for the primary time
point of post intervention, data were available for only seven studies conducted in HICs.139,140,152,156,157,196,208
The results suggest that, in the case of interventions in secondary school settings, those delivered in lower
SES settings may be less effective than those delivered in higher/mixed SES settings in reducing self-reported
symptoms of anxiety. However, owing to the number of studies available, it was necessary to conduct
fixed-effects analyses for the lower SES subgroup. This was not observed for self-reported depression,
although it is of interest that the SMD for CBT compared with usual curriculum in higher/mixed SES settings
was –0.07 (95% CrI –0.20 to 0.06); in lower SES settings, the SMD was 0.04 (95% CrI –0.06 to 0.15).
71
Table 12 reports the subgroup analysis findings. There was no evidence of a difference by SES for
either self-reported depression or anxiety in primary educational settings. However, for self-reported
anxiety, the SMD of CBT compared with usual curriculum in higher/mixed SES settings was 0.15
(95% CrI –0.37 to 0.02); in lower SES settings, the SMD was 0.05 (95% CrI –0.08 to 0.18).
Combined depression and anxiety scores and other ‘internalising’ outcomes

As described in Chapter 1, Changes to protocol, clarifications and additional analyses, and Table 1, a post
hoc decision was made to assess composite ‘internalising’ outcomes, for example outcome scales that
reported combined anxiety and depression scores (such as total Depression, Anxiety and Stress Scale
or RCADS scores) or ‘internalising’ subscales of broader psychological functioning measures such as
the SDQ. Six studies reported an internalising outcome, with useable data at post intervention, and
are reported in Table 13 by population and setting.119,123,163,171,216,219 Four studies in targeted secondary
settings provided sufficient data for inclusion in a random-effects NMA.163,171,216,219 Model fit statistics
suggested that a consistency model was reasonable; however, the posterior median between-study SD
was indicative of substantial heterogeneity (τ 0.97, 95% CrI 0.03 to 9.03) and tended to the prior
distribution [uniform(0,10)]. Consequently, we report only study-specific SMDs in Table 13.
TABLE 12 Results from subgroup analysis by socioeconomic status
SES, SMD (95% CrI)
Population/setting Outcome Comparison Low High/mixed
Universal secondary Depression CBT vs. usual curriculum 0.04 (–0.06 to 0.15)a –0.07 (–0.20 to 0.06)
Anxiety CBT vs. usual curriculum 0.09 (–0.11 to 0.29) a

–0.29 (–0.50 to –0.07)
Universal primary Depression CBT vs. usual curriculum –0.23 (–0.60 to 1.13) –0.05 (–0.55 to 0.45)
Anxiety CBT vs. usual curriculum 0.05 (–0.08 to 0.18) a

–0.15 (–0.37 to 0.02)
a Results from a fixed-effects analysis.
Notes
SMDs and 95% CrIs are reported by subgroup (lower vs. higher/mixed SES). Only CBT vs. usual curriculum could be
compared in each subgroup.
TABLE 13 Composite internalising outcomes at post intervention time point
Study Population Setting Time Comparison Results, SMD (95% CrI)
Britton et al.123 Universal Secondary Post Attention control vs. 0.12 (–0.32 to 0.54)
2014 intervention mindfulness/relaxation
Aune and Stiles119 Universal Secondary Post No intervention vs. CBT –0.02 (–0.10 to 0.06)
2009 intervention
Fung et al.216 2016 Targeted Secondary Post Waiting list vs. –0.19 (–0.83 to 0.44)
intervention mindfulness/relaxation
McCarty et al.219 Targeted Secondary Post Psychosupport vs. CBT –0.33 (–0.62 to –0.05)
2013 intervention
Rice171 2009 Targeted Secondary Post Attention control vs. CBT 0.08 (–0.89 to 1.04)
intervention
Rice171 2009 Targeted Secondary Post Attention control vs. 0.41 (–0.31 to 1.13)
intervention mindfulness/relaxation
Dobson et al.163 Targeted Secondary Post Attention control vs. CBT 0.19 (–0.26 to 0.64)
2010 intervention
Note
All results reported as SMDs (95% CrIs) for comparability with NMA.
72

A fixed-effects NMA was possible for a further two studies142,206 reporting a 12-month follow-up in a
universal secondary setting, as they formed a connected network via usual curriculum.. However, there
was no evidence that interventions based on CBT (SMD 0.03, 95% CrI –0.14 to 0.20) or CBT + IPT
(SMD 0.01, 95% CrI –0.16 to 0.17) were more effective than usual curriculum for improving composite
internalising outcomes at a 12-month follow-up.
Secondary outcomes
Acceptability and attendance

Intervention acceptability was defined by study authors. We anticipated considerable variability in the
reporting of acceptability outcomes, but have combined them here under loose categories relating to
(1) attitudes towards and satisfaction with intervention, (2) enjoyment and utility, and (3) attendance.
Thirty-three studies reported a summary of acceptability of the intervention to study participants in
terms of satisfaction or enjoyment and are summarised in Tables 14 and 15 by population and setting.
Attendance data, as reported by authors, are reported in Appendix 7, Table 72.
Attitudes and satisfaction with intervention

Eight studies reported satisfaction with the intervention (see Table 14). Two studies120,137 reported
an overall satisfaction outcome in a universal secondary setting. Both used Likert-type scales and
suggested that students were highly satisfied with the interventions. In targeted secondary settings,
five studies reported a satisfaction or attitude to ‘treatment’ measure.168,216,218,219,224 However, results
were reported for the experimental/active intervention arms only, and not for controls. All reported
that participants were satisfied with their intervention assignment. One study185 in a targeted tertiary
setting reported satisfaction with intervention assignment, with a mean score of 4.0 (SD 0.47) on a
five-point scale, suggesting that the majority of participants were satisfied with the intervention.
Intervention enjoyment and utility

Twenty-five studies reported enjoyment or utility of intervention. In universal secondary settings,
11 studies reported an acceptability outcome assessing enjoyment or usefulness of the intervention.123,127,132,
133,135,139,142,197,202,206,207 However, only two studies reported comparative data for all arms of the study. Stallard
et al.142 note that the control group intervention: ‘Usual PSHE [personal, social and health education]
was rated more positively than both classroom-based CBT and attention control PSHE for liking [F 7.11,
df (degrees of freedom) 2970; p < 0.01], usefulness (F 6.46, df 2966; p < 0.01) and relevance for their
age (F 8.84, df 2963; p < 0.01).’ Merry et al.197 compared intervention arms on a five-point Likert scale,
where five was the most positive score and one the most negative. The programmes were rated by the
students as reasonably enjoyable. The control group intervention received slightly higher ratings than the
experimental intervention for both enjoyment and utility (see Table 15). The majority of studies reported
that participants enjoyed the intervention and found it useful. Only one study reported negative enjoyment
and utility feedback from students207 (see Table 15).
In universal primary settings, eight studies reported some detail for enjoyment or usefulness of the
intervention.145,146,150,156,158,159,210,212 Two studies evaluating the FRIENDS anxiety programme reported an
acceptability outcome assessing enjoyment or usefulness.158,159 In Ruttledge et al.,158 68% of the children
found the FRIENDS for Life programme ‘very useful’ or ‘somewhat useful’. Stallard et al.159 reported
that 74% of participants enjoyed the intervention, 59% thought that it had been helpful and 62%
would recommend it to a friend. Across all studies, results suggest that participants generally found the
interventions enjoyable and useful (see Table 15).
Four studies reported enjoyment/utility in targeted secondary settings.162,217,221,227 Poppelaars et al.221

provided comparative data for two CBT-based interventions and concluded that acceptability was
similar across the programmes. Woods and Jose227 conducted semistructured focus groups at the end
73
TABLE 14 Author-reported satisfaction with the intervention
Study Satisfaction
Baker and Butler120 1984 This was measured using the Attitudes Toward Treatment Scale, a 14-item Likert-
type scale, with possible scores ranging from 14 to 98. Higher scores indicate a
higher degree of satisfaction. Treatment group: mean score 75.47 (SD 12.93);
control group: mean score 63.69 (SD 10.02)
Potek137 2012 On a 10-point Likert scale, the intervention group gave an average rating of 8.05
(SD 0.99, minimum 5.93, maximum 9.57). Higher scores indicate a higher degree
of satisfaction
Fung et al.216 2016 On a scale of 1–10, the author reports ‘moderate levels of satisfaction’ among
participants (mean score 7.21, SD 0.67)
Kiselica et al.168 1994 . . . female participants had a more favourable attitude toward training experience than
did male participants, regardless of the treatment condition they were assigned to
McCarty et al.218 2011 Participants were asked how satisfied they were with group membership: ‘very
much’, 48%; ‘pretty much’, 36%; and ‘all right’, 13%. One student disliked the group
‘a little’ and felt ‘embarrassed’ (3%)
McCarty et al.219 2013 Satisfaction: 83% liked their intervention group ‘very much’ or ‘pretty much’.
Comfort: 84% of students were comfortable in their intervention group
Stice et al.224 2008 In the two group-based interventions, 76% and 71% of respondents were ‘pleased’
or ‘very pleased’ with their assigned group. In the bibliotherapy group, 29% reported
being ‘pleased’ or ‘very pleased’
Higgins185 2007 On a scale of 1–5, the mean satisfaction score was 4.0 (SD 0.47). The author describes
this as showing that most participants were ‘somewhat satisfied’ with the workshop
Note
Details reported by study and as reported in original publication.
TABLE 15 Author-reported enjoyment and usefulness of the intervention
Study Enjoyment and usefulness of intervention

142
Stallard et al. 2013 Usual PSHE was preferred over both classroom-based CBT and attention control
PSHE: liking (F 7.11, df 2970; p < 0.01), usefulness (F 6.46, df 2966; p < 0.01),
relevance (F 8.84, df 2963; p < 0.01)
Merry et al.197 2004 Enjoyment and usefulness were assessed using five-point Likert scales. Enjoyment:
both the RAP-Kiwi intervention (mean score 3.0, SD 1.1) and attention control
(mean score 3.7, SD 1.0) were rated ‘reasonably enjoyable’. Usefulness: RAP-Kiwi
mean score 2.9 (SD 1.1); attention control mean score 3.1 (SD 1.1). Higher values
indicate greater enjoyment and usefulness
Johnson et al.133 2017 On a 10-point Likert scale, enjoyment and interest were rated as follows: mean
score 6.92 (median 7.0, range 0–10). Higher values indicate greater enjoyment
Tak et al.207 2016 Rated on a four-point Likert-scale. Authors report that participants did not like the
intervention (mean score 1.58, SD 0.69) and did not find it useful (mean score 1.96,
SD 0.85). Higher values indicate greater enjoyment and usefulness
Roberts et al.139 2010 SLS: the ‘Learning to negotiate’ lessons were rated most enjoyable by students and
‘Networks’ the least enjoyable. Role plays were the most popular activities. A total
of 68.7% to 79.0% rated the utility of SLS as average or higher
OTS: the most enjoyable activities were games and quizzes. A total of 67.3% rated
the utility of OTS as average or higher
Lowry-Webster et al.135 2001 Participants were asked ‘How much did you enjoy the FRIENDS program?’; 31.1%
enjoyed it ‘a lot’, 53.7% enjoyed it ‘some’, 14.2% ‘a little’ and 1% ‘not at all’
Johnson et al.132 2016 On a 10-point Likert scale, student enjoyment and interest was rated as follows:
mean score 6.67 (median 7.0, range 0–10). Higher values indicate greater enjoyment
and interest
74

TABLE 15 Author-reported enjoyment and usefulness of the intervention (continued )
Study Enjoyment and usefulness of intervention
Spence et al.206 2003 A total of 42% would recommend the course to other students, 31% would maybe
recommend it and 27% would not recommend the course. A total of 34% expected
to use the skills learnt, 49% thought that they would maybe use the skills, and 17%
did not think that they would use the skills in their everyday life
Rivet-Duval et al.202 2011 Intervention participants rated the usefulness and acceptability of the programme as
high (mean score 4.57, SD 0.78). (No detail provided on scale)
Britton et al.123 2014 A total of 82% of students felt more focused, more able to concentrate or less
distracted, and 88% reported feeling more relaxed and calmer
Calear et al.127 2016 Over 60% of participants found the website to be useful or very useful . . . over 50% . . .
reported they would use the website again and a further 10% had already
recommended the website to a friend
Poppelaars et al.221 2016 On a five-point scale, the mean response for liking OVK was 3.13 (SD 1.09); for
SPARX, it was 3.16 (SD 1.35). The mean response for programme usefulness in daily
life was 3.07 (SD 1.19) for OVK and 2.72 (SD 1.26) for SPARX
Cova et al.162 2011 A total of 71.6% strongly agreed or agreed that participation was enjoyable, and
8.7% strongly disagreed or disagreed. A total of 79.0% strongly agreed or agreed
that the intervention was useful, and 13.5% strongly disagreed or disagreed
Livheim et al.217 2015 A total of 91% of participants ‘gave exclusively positive feedback’ about the
intervention. Half stated that it was ‘very valuable’ and the remainder that it was
‘quite valuable’. All would recommend the course to a friend
Woods and Jose227 2011 Participants reported the following positive aspects of the intervention:
confectionery rewards, missing lessons and playing games. Negative aspects: amount
of reading and writing required and ‘out-of-date’ scenarios
Ahlen et al.145 2018 A total of 80% of participants in the high level of supervision group, compared with
68% in the low level of supervision group, enjoyed Friends for Life ‘much or some’
Mendelson et al.210 2010 The authors conducted focus groups:
. . . students generally had a positive experience in the program and felt they learned
skills that helped them in their day-to-day lives
Pophillat et al.156 2016 The proportion of children who enjoyed the intervention was 92%
212
Soffer 2003 A total of 100% of participants in the behavioural intervention and 79% in the attention
control group responded that they ‘would like to be in a program like this again’
Attwood et al.146 2012 Participants were generally positive about ‘Think, Feel, Do’ and no sessions were
identified as unhelpful
Most reported applying the skills learnt in their daily life. However, the authors note
that content was challenging for some younger participants
Stallard et al.159 2014 A total of 934 participants in the active arm responded that the intervention was
fun, 742 thought that it had helped them and 787 would recommend the
intervention to a friend
Essau et al.150 2012 The authors state that children were asked whether or not they enjoyed the
programme and if they used the skills taught. However, no results are reported
Ruttledge et al.158 2016 A total of 68% of respondents found FRIENDS for Life ‘very useful’ or ‘somewhat useful’
Schoneveld et al. 116
2018 On a five-point scale, participants were asked to rate (1) ‘I found it fun to participate
in the intervention’ [CBT: mean score 2.35 (SD 1.39); biofeedback: mean score 2.77
(SD 1.18)] and (2) ‘I can use what I learned in my daily life well’ [CBT: mean score
2.96 (SD 0.95); biofeedback: mean score 2.13 (SD 1.38)]
Schoneveld et al.115 2016 On a five-point scale, participants were asked to rate (1) ‘I liked to play the game’
[control: mean score 2.74 (SD 1.24); biofeedback: mean score 1.90 (SD 1.38);
p ≤ 0.001) and (2) ‘I can use what I learned in my daily life well’ [control: mean score
1.72 (SD 1.28); biofeedback: mean score 1.68 (SD 1.29)]
M, mean; OTS, optimistic thinking skills; OVK, Op Volle Kracht; PSHE, personal, social and health education;
RAP, Resourceful Adolescent Program; SLS, social life skills; SPARX, smart, positive, active, realistic, X-factor thoughts.
Note
Details reported by study, and as reported in original publications.
75
of a CBT intervention, Adolescents Coping with Emotions. The focus groups were conducted in New
Zealand, with the majority of participants being Maori and Pacific Islander students and identifying trust
in the group as an important benefit of the intervention. In addition, some participants noted that the
insight gained about thinking processes was useful. Participants liked the use of confectionery as a
reward, and identified the games played and missing class as good aspects of the programme. However,
they also felt that the intervention used out-of-date scenarios and that there was too much reading and
writing involved in the sessions. Livheim et al.217 reported that most participants (91%) gave exclusively
positive feedback on the evaluation of the acceptance and commitment therapy-based intervention and
all reported that they would recommend it to a friend. The majority of students included in Cova et al.’s162
study enjoyed (71.6%) and found the CBT intervention useful (79%).
Two studies provided information on enjoyment in a targeted primary setting.115,116 Schoneveld et al.116
noted that children enjoyed both the experimental and control interventions equally (CBT vs. biofeedback).
However, in an earlier trial, in which the control intervention was a commercially available computer game,
children clearly preferred the control intervention.115
Attendance and dropouts from intervention

Only one study explicitly mentioned attendance as a proxy for acceptability of the intervention to
participants. Congleton215 noted that attendance was excellent and that this reflected how much the
students enjoyed the course and the importance of convenient timetabling.
Across all other studies, attendance was reported descriptively. Study-specific attendance details,
as reported by trial author, are reported in Appendix 7.
Parent-reported child anxiety, depression or internalising outcomes

A post hoc decision was made to analyse parent-reported child anxiety, depression or internalising
symptoms. For some of the studies, participants were considered too young for self-reported measures
and parents were the primary respondents. In universal primary settings, five studies145,146,156,158,242
provided baseline and follow-up data on parent-reported child anxiety outcomes. From a random-effects
NMA, there was no evidence that CBT-based interventions reduced parent-reported child anxiety
symptoms relative to usual curriculum (SMD –0.10, 95% CrI –2.13 to 1.83).
Six studies115,116,176,177,181,182 provided both baseline and follow-up data to enable a NMA for targeted primary
settings. There was no evidence that CBT-based interventions (SMD –0.43, 95% CrI –1.08 to 0.14),
biofeedback (SMD –0.48, 95% CrI –1.76 to 0.72) or occupational therapy (SMD 0.05, 95% CrI –1.07 to
1.19) reduced parent-reported child anxiety symptoms relative to a waiting list.
Academic attainment
Seven studies reported academic attainment data.131,136,137,145,159,168,174 Various measures of attainment
were used; we report study-specific results in Table 16. Across all studies, there was no evidence of an
effect of intervention on academic outcomes.
Problem behaviours
Few studies reported problem behaviours, and those that did reported substance use. The following results
are reported as per the original publications. In a universal secondary setting, Stallard et al.142 reported
that there was evidence of a beneficial effect of CBT + IPT on cannabis use at 6 months (OR 0.56, 95% CI
0.38 to 0.82) and at 12 months (OR 0.70, 95% CI 0.48 to 0.93), but not on alcohol or ‘street drug’ use.
In targeted secondary settings, Stice et al.224 reported that CBT reduced ‘substance use’ (F[6,674] 3.60;
p = 0.002) relative to control and Topper et al.173 reported that there was ‘no significant difference’
between the intervention and control groups for binge drinking (Cohen’s d 0.22). In a tertiary/university
setting, Reynolds et al.233 reported results from the Alcohol Use Disorders Identification Test (AUDIT)
76

TABLE 16 Author-reported academic achievement and attainment
Study Measure Results, mean difference (95% CI)
Ahlen et al.145 2018 Teacher-rated five-point scale 0.01 (–0.10 to 0.12)

174
Cooley-Strickland et al. 2011 WIAT-reading (age equivalent) 0.30 (–0.24 to 0.83)
174
Cooley-Strickland et al. 2011 WIAT-mathematics (age equivalent) 0.30 (–0.20 to 0.80)
131
Hodas 2016 Mathematics computation Results reflect an older age of students in a
(age equivalent) waiting list group
Hodas131 2016 Reading comprehension Results reflect an older age of students in a
waiting list group
Kiselica et al.168 1994 Quarterly GPA Univariate F tests revealed [no] significant
differences between the treatment and
control participants for GPA
Perry et al.136 2017 Final exam results (standardised) Notably, academic outcomes did not differ
between the 2 groups p = 0.41
Potek137 2012 SAT language assessment –0.10 (–1.60 to 1.40)
a
Stallard et al.159 2014 SAT reading 0.10b (–0.56 to 0.76)
a
Stallard et al.159 2014 SAT mathematics 1.83b (1.13 to 2.53)
a
Stallard et al.159 2014 SAT writing 0.68b (0.02 to 1.34)
a
Stallard et al.159 2014 SAT reading 0.93b (0.30 to 1.57)
a
Stallard et al.159 2014 SAT mathematics 1.15b (0.45 to 1.85)
a
Stallard et al.159 2014 SAT writing 1.48b (0.84 to 2.12)
GPA, grade point average; SAT, Scholastic Aptitude Test; WIAT, Wechsler Individual Achievement Test®.
a Stallard et al.159 is a three-arm trial and results are for each of the two ‘active’ CBT interventions relative to
the control.
b Final values used to calculate mean difference.
Note
When feasible, the mean difference was calculated as a change from baseline.
and concluded that there was ‘no significant difference’ observed between the intervention and control
groups for alcohol consumption or alcohol problems, although they also report that:
. . . a significant interaction of the orientation group effect with the linear effect of time was found,
suggesting differential change for the [intervention] and [control] groups across the three time points.
The overall percentage of youth above the clinical cut off for the BATD [behavioural activation treatment
for depression] group generally decreased over time.
Mental health-related stigma

During our initial PPI work, reducing the stigma associated with mental health problems was identified
as an important outcome for young people. Only one study reported a mental health-related stigma
outcome. In Perry et al.,136 stigma was measured using a nine-item subscale of the Depression Stigma
Scale, an 18-item scale that assesses personal and perceived stigma towards depression, on which
higher scores indicate greater stigma. At the immediate post-intervention time point, there was no
evidence of a reduction in personal or perceived stigma in the SPARX (smart, positive, active, realistic,
X-factor thoughts) computerised CBT group, compared with the attention control intervention
(mean difference –0.50, 95% CI –2.90 to 1.90).
77

conduct disorder
Systematic review results

The overall PRISMA flow diagram for the project is reported in Figure 2. Twenty-seven papers relating
to five studies met our eligibility criteria for inclusion in the conduct disorder review. Included studies
were published between 1999 and 2018, and randomised between 225 and 891 participants (median
245 participants). All studies were cluster randomised, of which four reported results from appropriate
models incorporating the multilevel nature of the data.
One study was classified as universal243 and four were classified as targeted244–247 (all indicated). All
studies were conducted in primary school settings, with age at baseline ranging from 4.2 to 7.91 years.
The majority of study participants were boys. In the four indicated studies, the proportion of boys
ranged from 69% to 74% of participants. Four studies were conducted in HICs,243,244,246,247 and one was
conducted in a MIC.245 Of the studies conducted in HICs, all were conducted in lower-income settings,
as specified by the trial authors.
Owing to intervention complexity and the flexible nature of the intervention implementation, we were
not able to calculate an average ‘dose’, as was done for anxiety and depression outcomes.
Risk-of-bias assessments are reported in Figure 15 by individual study. Three studies were judged as
having unclear risk of bias for random sequence generation and allocation concealment.243,244,247 All
studies were judged to be at high risk of bias for participant and outcome assessor blinding. Prospective
trial registrations were available for one study.245 For cluster randomised trials we also considered how
recruitment, randomisation and analysis were conducted under the Cochrane Risk of Bias tool heading
of ‘other bias’. Four studies were judged to be at high or unclear risk for ‘other bias’.
Owing to the diversity of interventions, outcome measures and time points reported by the studies,
results are reported narratively by trial, and by date of publication. Owing to this diversity, intervention
components are also described narratively, by study, where these could be identified from trial reports.
Unless otherwise stated, statistical summaries are reported as described in the original publications.
Fast Track: the Conduct Problems Prevention Research Group247

The Fast Track trial247 was a cluster randomised trial of 54 primary schools in the USA. Beginning
in 1991, the trial followed participants for > 20 years. The indicated prevention intervention was
delivered over 10 years, targeting children in primary school settings with early-starting disruptive
behaviour. The aim of the intervention was to prevent long-term severe and chronic conduct problems,
including psychological disorder. The study compared a multicomponent intervention (n = 445) with a
no-intervention control (n = 446). Children who were within the top 10% of a combined parent–teacher
screen for externalising behaviour problems were invited to take part. The mean age of child participants
was 6.5 years (SD 0.48 years); 69% were boys, 51% were African American and 47% were European
American. The schools were in areas of high crime and poverty.
79
EFFECTIVENESS OF EDUCATIONAL SETTING-BASED INTERVENTIONS
Blinding of participants and personnel (performance bias)
Blinding of outcome assessment (detection bias)

Random sequence generation (selection bias)
Incomplete outcome data (attrition bias)

Allocation concealment (selection bias)
Selective reporting (reporting bias)
Other bias
August et al.244 2002 ? ? – – + + ?
Baker-Henningham et al.245 2012 + + – – + + +

Study
Conduct Problems Prevention Research Group247 1999 ? ? – – + ? –
Havighurst et al.246 2015 + ? – – + + ?
Kyranides et al.243 2018 ? ? – – + ? –
FIGURE 15 Conduct disorder risk-of-bias assessments by domain and study. +, Low risk of bias; –, high risk of bias; ?, unclear
risk of bias.
Seven intervention components were implemented, the content of which changed each year to be
developmentally appropriate for the children and based on the families’ needs. There was insufficient
detail provided in the reports to describe the exact nature of these changes. The intervention described
subsequently is from the primary school phase of the project (i.e. grades 1–3, ages 6–9 years).
The school-based component was delivered to whole classrooms, and not just to the students enrolled
in the Fast Track trial. The PATHS® (Promoting Alternative THinking Strategies) intervention was delivered
by classroom teachers across two or three lessons per week across the whole school year. PATHS is a social
and emotional learning intervention that focuses on children managing and understanding their behaviour
and emotions and includes social and problem-solving skills training. Fidelity was checked by Fast Track
educational co-ordinators via weekly classroom and teacher visits. Educational co-ordinators were
usually ex-teachers.
There were five parent and/or child components: parent groups, child social skills training groups,
parent–child sharing time, child–peer pairing and academic tutoring. Parent groups, child social skills
training groups and parent–child sharing time ran during a weekly 2-hour enrichment programme held at
school but outside school hours. A total of 22 sessions was offered. Average attendance was 78% for the
child group and 71% for the parent group. The child groups focused on reviewing and practising skills in
emotional understanding and communication, friendship-building, self-control and social problem-solving.
The parent groups focused on parenting skills, self-control and building positive family–school relationships.
Individual support was provided to children and parents by family co-ordinators; this formed the home
visiting component. Visits focused on problem-solving and encouraging parental empowerment and
self-efficacy. Family co-ordinators typically had advanced degrees in counselling or social work. Home
visits were typically every other week across the first year of the intervention. Children were also
provided with academic tutoring three times each week for 30-minute sessions during school hours,
delivered by ‘paraprofessional tutors’.
80

Seventy-two per cent of participants received > 50% of each of the following intervention components:
parent group, child social skills group, peer pairing and tutoring. Overall, 81% of participants received
at least 50% of the recommended number of home visits (i.e. at least six visits). All programme staff
attended a 3-day cross-site workshop. Fidelity was monitored using intervention manuals, weekly
supervisory telephone calls and weekly staff meetings.
Multiple assessment scales were administered; primary outcomes were not specified. Appropriate
multilevel models were conducted for the end of year 1 analyses, but not for later time points. At the
end of grade 1 (i.e. 1 year into the intervention), the following effect sizes (Cohen’s d) were reported
by the Conduct Problems Prevention Research Group,247 as computed from the F-value and degrees of
freedom. Parent ratings of child behaviour change (Cohen’s d 0.50, 95% CI 0.25 to 0.76) and teacher
ratings of child behaviour change (Cohen’s d 0.53, 95% CI 0.28 to 0.79) suggested a beneficial effect
of the intervention, compared with the control. However for externalising behaviours, parent ratings
on the Child Behaviour Checklist (CBCL) (Cohen’s d 0.04, 95% CI –0.15 to 0.26) and teacher ratings on
the Teacher Report Form (Cohen’s d 0.02, 95% CI –0.19 to 0.24) suggested no evidence of a difference
between intervention and control groups at the end of grade 1. At the end of grade 3, parent ratings
of child behaviour change (β 0.18, 95% CI 0.04 to 0.32) and teacher ratings of child behaviour change
(β 0.24, 95% CI 0.12 to 0.35) also suggested a beneficial effect for the intervention, compared with the
control. However, the parent-rated CBCL was not reported and the teacher-rated Teacher Report
Form (β –0.05, 95% CI –1.42 to 1.32) externalising problems scales suggested no evidence of a difference
between the intervention and control groups at the end of grade 3.
Three further measures were reported at the end of grade 3. Academic progress in reading (β 0.06,
95% CI –0.06 to 0.17) and mathematics (β 0.08, 95% CI –1.42 to 1.32), and clinical diagnosis of
oppositional defiant disorder (ODD) or conduct disorder (β 0.02, 95% CI –0.04 to 0.08). There was no
evidence to suggest an intervention effect on these outcomes. Note that the 95% CIs for these effect
sizes and regression coefficients are an approximation248 based on data reported by the Conduct
Problems Prevention Research Group across two papers.247,249
In grades 7 and 8, there was no evidence of a difference between intervention and control groups
for the parent-rated CBCL (β 1.50, 95% CI –0.15 to 3.15) or the teacher-rated Teacher Report Form
(β –0.33, 95% CI –2.45 to 1.79) externalising problems scales. Hyperactivity was also reported and was
reduced in the intervention group, compared with the control group.
An independent analysis of the data suggests that there was also little evidence of an effect on mental
health outcomes during ‘the high school years’ (i.e. between 9 and 13 years of follow-up).250 However,
the Fast Track trial team conducted a further follow-up, 20 years from baseline (when participants
were aged 25 years). On the basis of self-reported outcomes, there was strong evidence for a beneficial
effect of the intervention for a composite outcome of any externalising, internalising or substance use
problem (OR 0.59, 95% CI 0.43 to 0.81). The authors of the paper state that this is equivalent to a
number needed to treat of 8. For diagnosis of antisocial personality disorder, there was a benefit of
the intervention, relative to the control (OR 0.60, 95% CI 0.39 to 0.93), but not for attention deficit
hyperactivity disorder (OR 0.65, 95% CI 0.39 to 1.08). There was no evidence to suggest that the
intervention prevented diagnoses of anxiety (OR 0.79, 95% CI 0.47 to 1.33) or depression (OR 0.68,
95% CI 0.42 to 1.08). Analyses were based on the intention-to-treat principle and appropriately
accounted for clustering.
Substance use outcomes included alcohol abuse (OR 0.69, 95% CI 0.48 to 0.99), binge drinking (OR 0.75,
95% CI 0.55 to 1.01), heavy marijuana use (OR 0.76, 95% CI 0.45 to 1.30) and serious substance use
(OR 0.58, 95% CI 0.36 to 0.92). There was no evidence of a difference between intervention and control
groups for having graduated from high school (OR 0.93, 95% CI 0.68 to 1.27) or currently being in full-time
education or employment (OR 0.84, 95% CI 0.60 to 1.18).
81
Early Risers Skills for Success: August et al.244

The Early Risers ‘Skills for Success’ study244 was a cluster randomised trial for the prevention of serious
behaviour problems, as indicated by aggressive–disruptive behaviour. Ten schools were randomised
to a multicomponent intervention and 10 were randomised to no intervention. Participants were
screened prior to trial entry, to ensure that they were at high risk of a serious conduct problem, as
assessed by a T-score of ≥ 58 on the CBCL aggression subscale (which was teacher rated). A total of
245 children were included in the trial: 124 in intervention schools and 121 in control schools. The
mean age of participants at baseline was 6.6 years (SD 0.6 years) and 69% were male. Schools were
in semirural midwestern USA, in low to low–middle socioeconomic areas. There have been multiple
follow-ups of the participants, the latest being 10 years from the start of intervention (i.e. 5 years
post intervention).
The intervention was multicomponent and multiphase. Beginning in the summer preceding grade 1
(i.e. year 1 of the intervention) and continuing over the next 2 years (i.e. 3 years in total), students
attended a 6-week summer school, equivalent to 432 hours of programme content. Participants
received academic content, enrichment activities and small-group social skills training. Peer mentoring
was also used. It is not clear who delivered the summer school component of the intervention. In years
4 and 5, ‘booster’ summer camps were offered, each of 6 days’ duration.
The second intervention component was a monitoring and mentoring programme overseen by ‘family
advocates’, who provided weekly support to the participants and teachers in their regular school
setting. Support provided was flexible, depending on student needs. The third component was a
biweekly family programme, based on the Incredible Years intervention, delivered concurrently, but
separately, to parents and children. The Incredible Years programme is described elsewhere as being
based on CBT principles, but was not described as such here.251 Twenty-nine sessions, over 3 years,
were offered, and were equivalent to 58 hours in total. However, attendance was low [mean 39%
(SD 29%)]. In years 4 and 5, six family sessions were offered. In addition to the previously mentioned
core intervention components, a personalised home visitation component was available on the basis of
individual need.
Approximately 60% participated across all three intervention components in the first 3 years, and
67% participated in three or more components offered during the booster phase. The intervention was
manualised, and training was provided to all staff. Intervention fidelity was measured via log books and
checked during unannounced visits by ‘fidelity technicians’.
At the end of the main intervention (year 3), externalising outcomes were reported as a composite
across a maximum of four measurement scales for outcomes of (1) aggression, (2) hyperactivity and
(3) impulsivity. The scales were the Teacher Observation of Classroom Adaptation, the Parent
Observation of Classroom Adaptation, the Behavior Assessment System for Children (BASC) – Teacher
Rating Scale (BASC-TRS) and the BASC – Parent Rating Scale (BASC-PRS). Teacher-reported academic
achievement was also a composite outcome combined across four separate scales (the broad reading
and applied problems composite scores from the Woodcock–Johnson Tests of Achievement-Revised,
the Learning Problems scale of the BASC-TRS, and the Cognitive Competence scale of the Teacher’s
Scale of Child’s Actual Competence and Social Acceptance). An intention-to-treat, three-level model
was appropriately conducted, given the clustered nature of the data; however, the school level was
retained for the aggression analysis only.
At the end of year 3, intervention participants (n = 199) showed a greater improvement in academic
achievement than control participants. However, there was no evidence of an effect for aggression,
hyperactivity or impulsivity, and quantitative results were not reported. At the end of year 6 (n = 151),
outcomes included self-reported conduct disorder symptoms and diagnosis, ODD symptoms and
diagnosis, and self-reported drug use. Based on the means and SDs reported by the authors, we calculated
that there was no evidence that the intervention prevented self-reported conduct disorder symptoms
82

(mean difference –0.20, 95% CI –0.91 to 0.51). However, there was evidence to suggest that, for ODD
symptoms, the intervention was beneficial (mean difference –1.53, 95% CI –2.58 to –0.48). The authors
reported that the ODD effect size was 0.47 (p ≤ 0.01). The effect size for conduct disorder symptoms
was not reported. There was no evidence that conduct disorder or ODD diagnoses differed across the
intervention and control groups. There was no evidence of an effect for tobacco or alcohol use.
At 10 years from baseline (n = 129), self-reported conduct disorder and ODD were reported. The
authors report that the Early Risers intervention was associated with fewer conduct disorder and
ODD symptoms in late high school. The estimated mean number of conduct disorder symptoms per
participant was 1.81 lower (95% CI 0.34 to 3.30) in the programme group than in the control group
and the mean number of ODD symptoms was 1.56 lower (95% CI 0.47 to 2.63).
Incredible Years teacher programme: Baker-Henningham et al.245

Baker-Henningham et al.245 reported a cluster randomised trial for the indicated prevention of disruptive
and aggressive/destructive behaviours. Twenty-four preschools were included and were randomised
to either the Incredible Years intervention group (n = 12) or a control group (n = 12). It was not clear
from the paper what intervention the control group received, although the trial registration (ISRCTN
35476268) suggests that it was information only. Children were selected for inclusion by a teacher-rated
scale based on the ICD-10 criteria for conduct disorder. Three children with the highest scores in each
class were enrolled in the study. A total of 225 children aged 3–6 years were included (113 in the
intervention group and 112 in the control group). The mean age of participants was 4.2 years (SD 0.9 years),
and 69% of participants were boys. Schools were in Kingston, Jamaica, and in ‘disadvantaged’ inner-city
areas with high levels of community violence.
The intervention evaluated was the Incredible Years Teacher Training programme, tailored to a Jamaican
context. Few details on the intervention were provided in the paper, but it included collaborative and
experiential learning; individual goal-setting and self-monitoring; building teachers’ self-efficacy; a focus
on teachers’ cognitions, behaviour and emotions; and emphasis on teachers’ ability to generalise the skills
learnt. The Incredible Years programme has been described elsewhere as being based on CBT principles,
but we note that it was not described as such here.251 The intervention lasted for 6 months. To ensure
fidelity, intervention teachers attended eight full-day training workshops over the period of the intervention
and received in-class support from a psychology graduate with previous experience in Incredible Years.
The authors reported that teachers attended a median of eight workshops (range 2–8 workshops), with
95% attending at least six workshops; 89% of teachers received all four in-class consultations.
The primary outcome was directly observed in-class child behaviour and reported as frequency of
aggressive/destructive behaviours (as defined by a study manual). Secondary outcomes of interest
were teacher and parent reports of child behaviour. Teacher-reported child conduct problems were
measured using the Sutter–Eyberg Student Behavior Inventory™ (SESBI), and the SDQ was used to
measure behaviour difficulties and prosocial skills. Parent-reported child conduct problems were
measured using the Eyberg Child Behavior Inventory™ (ECBI), and the SDQ was used to measure
behaviour difficulties and prosocial skills. Hyperactivity and attention difficulties were also measured
using Conners Global Index. These scales formed a composite outcome of ‘behavioural difficulties’.
Child school attendance was taken from school records.
Statistical analyses appropriately accounted for the clustered nature of the data. For the author-reported
primary outcome, the intervention reduced the number of directly observed conduct problems (effect
size 0.42, 95% CI 0.12 to 0.71). For author-reported secondary outcomes, the intervention reduced the
number of teacher-reported behavioural difficulties (effect size 0.47, 95% CI 0.18 to 0.76) and parent-
reported behavioural difficulties (effect size 0.22, 95% CI 0.03 to 0.42), relative to the control group.
School attendance was also higher in the intervention group than in the control group (effect size 0.30,
95% CI 0.05 to 0.55). Children in the intervention group were less likely to be rated in the clinical
range for conduct disorder by teachers (OR 0.31, 95% CI 0.11 to 0.92) than by parents (OR 0.56,
95% CI 0.27 to 1.16).
83
Multisystemic early intervention: Havighurst et al.246

Havighurst et al.246 reported a cluster RCT of a multisystemic indicated intervention for primary school-
aged children at risk of presenting with conduct disorder. Thirty-three schools in lower socioeconomic
areas of Victoria, Australia, were included and were randomised to either the intervention (n = 14) or to
a waiting list group (n = 19). Children between the ages of 5 and 9 years were eligible, and those scoring
in the top 8% on a joint parent–teacher screen for behaviour problems (using the Conduct Problems
Risk Screen) were invited to participate in the study. A total of 113 child participants were randomised
to the intervention, and 118 were randomised to the waiting list control group. The mean age was
7.05 years (SD 1.06 years) and 74% of participants were boys.
The intervention contained separate parent, child and school components. The parent component was
delivered across eight 2-hour sessions and focused on emotion socialisation coaching, whereby parents
learn to respond positively to their children’s emotions. Average parent attendance was six sessions,
with 78% of parents attending five or more. The intervention was delivered by clinical or educational
psychologists, social workers, speech and language therapists, or occupational therapists. To ensure
fidelity, intervention facilitators attended 2-day training, followed an intervention manual and
completed weekly checklists. Intervention fidelity was rated as consistently high, with 100% of the
foundation skills delivered and 78% of the optional skills delivered.
The child component focused on skills in emotional competence, de-escalation of anger and social
problem-solving. Eight sessions were delivered to small groups during school time. Groups were
facilitated by two professionals: an intervention clinician and a member of school staff (often a school
psychologist or teacher). Average attendance was 7.3 sessions, with 84 children (92.3%) attending at
least six sessions. To ensure fidelity, intervention facilitators attended a half-day training, followed a
structured intervention manual and completed weekly checklists. One hundred per cent of the child
programme content was covered in all groups.
In addition to the parent and child components, schools were also offered the choice between two
universal interventions. Seven schools (32 children) received the PATHS intervention, and an additional
seven schools received a Professional Learning Package (59 children). Fidelity was not measured.
Follow-up assessments were conducted 10 months post baseline. The following effect estimates are
based on adjusted means as reported by the authors. Primary outcomes of interest included parent-
reported child behaviour, as measured by the Eyberg Child Behavior Inventory (ODD, conduct disorder
and hyperactivity subscales), and teacher-reported child behaviour, as measured by the total SDQ
score. Statistical analyses appropriately accounted for the clustered nature of the data and were based
on the intention-to-treat principle. For parent-reported child behaviour, there was a beneficial effect of
the intervention for conduct disorder (mean difference –2.94, 95% CI –3.43 to –2.45), ODD (mean
difference –4.75, 95% CI –5.51 to –3.99) and hyperactivity (mean difference –3.47, 95% CI –3.89 to
–3.05), relative to a waiting list control. For teacher-reported child behaviour, the intervention reduced
the total SDQ score, relative to the control group (mean difference –1.56, 95% CI –1.80 to –1.32).
Kyranides et al.243
Kyranides et al.243 reported a small (three schools) cluster RCT of a universal intervention for preventing
conduct disorder and callous unemotional traits among children between the ages of 7 and 9 years.
Three schools in areas of low SES were randomised to either a skills-building intervention (n = 1) or
usual curriculum control (n = 2). Ninety-four children were allocated to the intervention and 210 to the
control. The mean age was 7.9 years (SD 0.74 years) and 51% of participants were female.
The (unnamed) intervention was 8 weeks long, with one 45-minute session delivered each week during
school hours. The intervention was based on CBT with an added emotional component and aimed to
increase children’s awareness of their own and others’ emotions, teach self-control and emotion
regulation, promote a positive self-concept, improve social skills and peer relations, and develop
84

problem-solving and communication skills. The intervention was delivered to whole classes by PhD
(Doctor of Philosophy) students with master’s degrees in school psychology. An intervention manual
was provided, and fidelity was monitored by the research supervisor.
Primary outcomes of interest to this review are the parent-reported Checkmate Child Symptom
Inventory-4 to assess symptoms of conduct disorder and the Antisocial Process Screening Device to
assess impulsivity. Analyses did not consider clustering. Immediately post intervention (mean difference
–0.67, 95% CI –1.30 to –0.04) and at 9 months post intervention (mean difference –0.93, 95% CI
–1.32 to –0.55), there was evidence to suggest that conduct disorder symptoms were reduced in the
intervention group, relative to the control group. Impulsivity was reported for the post-intervention
time point only: the result suggested that there was a beneficial effect of the intervention, relative to
the usual curriculum control (mean difference –1.03, 95% CI –1.72 to –0.34).
Summary
Only two studies clearly specified a post-intervention time point.243,245 Results for all studies at the time
point most closely approximating post intervention are summarised in Table 17. All studies reported
parent- or teacher-reported outcomes. Only one study reported the primary review outcome of conduct
disorder symptoms;243 the remainder reported externalising behaviours or behaviour difficulties.
TABLE 17 Summary of post-intervention results from conduct disorder prevention studies
Study Time point Outcome Scale Results

a
Conduct Problems 3 years from Child behaviour Not clear l Parent: β 0.18 (95% CI 0.04 to 0.32)
Prevention baselinea change l Teacher: β 0.24 (95% CI 0.12 to 0.35)
Research Group247
3 years from Externalising CBCL l Parent: NR
baseline behaviours l Teacher: β 0.05 (95% CI –1.42 to 1.32)
August et al.244 3 years from Externalising Multiscale . . . no overall Intervention X Time
2002 baselinea behaviours composite interaction for aggression, hyperactivity
or impulsivity
Baker-Henningham Post Observations of DPICS and Effect size 0.42 (95% CI 0.12 to 0.71)
et al.245 2012 intervention child behaviour MOOSES
Post Behaviour Multiscale l Parent: effect size 0.22
intervention difficulties composite (95% CI 0.03 to 0.42)
l Teacher: effect size 0.47
(95% CI 0.18 to 0.76)
Havighurst et al.246 10 months Child behaviour Eyberg Child Parent:
2015 from baselineb Behavior
Inventory l Conduct disorder, MD –2.94
(subscales) (95% CI –3.43 to –2.45)
l ODD, MD –4.75 (95% CI –5.51
to –3.99)
l Hyperactivity, MD –3.47
(95% CI –3.89 to –3.05)
10 months Child behaviour SDQ Teacher: MD –1.56 (95% CI
from baseline –1.80 to –1.32)
Kyranides et al.243 Post Conduct disorder Checkmate Parent: MD –0.67 (95% CI
2018 intervention symptoms Child Symptom –1.30 to –0.04)
Inventory-4
DPICS, Dyadic Parent–Child Interaction Coding System; MD, mean difference; MOOSES, MultiOption Observation
System for Experimental Studies; NR, not reported.
a The 95% CIs for the Fast Track study have been calculated from published data247,249 and should be regarded as
an approximation.
b When not clearly stated in the trial reports, we have included a time point most closely approximating
post intervention.
85
Two studies243,245 implemented school-only interventions, one of which described the intervention as
based on CBT principles.243 For the primary time point of post intervention, both studies reported
evidence of a beneficial effect of intervention. One study245 was judged to be at low risk of bias for
allocation concealment and randomised sequence generation; the other243 was judged to be at unclear
risk of bias for both domains.
Three studies implemented multisystemic, multicomponent and multiphase ‘packages’ of interventions.244,246,247

Based on the components reported, it is possible that the child-focused school-based components of these
interventions were informed by cognitive–behavioural principles. However, none of the authors identified
them as CBT-based interventions and their results were reported at the combined ‘package’ level. The
studies also reported different follow-up time points. At the (presumed) post-intervention time point,
Havighurst et al.246 reported strong evidence of a beneficial effect of the intervention for parent-reported
child behaviour, relative to a waiting list control. This study was rated as having a low risk of bias for
randomised sequence generation, but an unclear risk of bias for allocation concealment. No further
follow-up time points were reported.
Two studies244,247 reported interventions that, in addition to being multisystemic, were implemented in
stages over several years, so it is difficult to discern a ‘post-intervention’ time point. The Fast Track247
study did not clearly specify a primary outcome, and the outcome measures reported vary at each time
point. At 1 year and 3 years from baseline, the authors reported a beneficial effect of intervention for
child behaviour change, but not for externalising behaviours. At 7 years’ follow-up, the authors reported
no evidence of an effect of the intervention for reducing externalising behaviours. Finally, at 20 years’
follow-up, the authors reported a composite internalising, externalising and substance use self-reported
outcome and concluded that there was strong evidence of an effect of the intervention. The Fast
Track247 study rated as having an unclear risk of bias for both randomised sequence generation and
At 3 years from baseline, August et al.244 reported that there was no evidence that the Early Risers
intervention reduced teacher-/parent-reported externalising behaviours. At 6 years from baseline,
there was no evidence that the intervention prevented self-reported conduct disorder symptoms,
although there was a beneficial effect for self-reported ODD symptoms. At 10 years from baseline, the
authors reported that there was evidence that the intervention was associated with fewer self-reported
conduct disorder symptoms, relative to no intervention. The study was rated as having an unclear risk of
bias for both randomised sequence generation and allocation concealment.
86

Chapter 8 Economic evaluation

A s described in Chapter 1, the aim of the economic study was to assess the costs and consequences
for intervention components, or combinations of components, that were found to be effective,
compared with usual curriculum, in the NMA. Costs and consequences were considered separately for:
l targeted interventions to prevent anxiety, depression or conduct disorders among (1) primary school-
aged children, (2) secondary school-aged children/young people and (3) university-aged young people
l universal interventions for (1) primary school-aged children, (2) secondary school-aged children and
(3) university-aged young people.
For the economic evaluation, we included interventions for which there was robust evidence of an
intervention effect in one of the populations considered in the NMA. The intervention-level NMA
results (see Chapters 4 and 5) found that CBT interventions (including those combined with IPT) were
effective, compared with usual curriculum, at the post-intervention follow-up time point for universal
secondary populations. There was also evidence that mindfulness/relaxation interventions reduced
symptoms of anxiety. However, the findings were not considered robust because of small study size
and unclear risk of bias for the key domains of randomisation and allocation concealment. Similarly,
there was evidence that exercise reduced symptoms of anxiety in the targeted secondary analysis.
However, this was based on a single study on a network ‘spur’, which was judged to be at unclear risk
of bias. There was potential inconsistency in the tertiary/university setting analyses and NMA findings
were not reported. We therefore analysed costs and consequences for CBT and CBT + IPT in a
universal secondary population. For completeness, we extrapolate the costs for CBT interventions to
primary and targeted secondary settings (as CBT was included in the NMA for these settings).
Results from the component NMA suggested that the only intervention component for which there
was robust evidence of effectiveness, compared with usual curriculum, was the inclusion of a psychoeducation
component in CBT interventions in a universal secondary school setting. We therefore only present
costs and consequences for the inclusion of a psychoeducation component in a CBT intervention in the
universal secondary population.
If sufficient evidence was available, we planned to conduct full model-based cost-effectiveness analyses
for all identified groups. However, there was no robust evidence that any of the interventions were
effective at ≥ 6 months post intervention, based on the NMAs. We therefore did not consider that a
full model-based cost-effectiveness analysis would be of value, as it was unlikely to demonstrate cost-
effectiveness of any of the interventions, compared with usual curriculum, in any of the populations,
based on the evidence identified in our review.
The economic study also aimed to review previous economic evaluations of school-based interventions
to provide up-to-date and rigorously collated information on costs and cost-effectiveness to inform
both future intervention development and implementation decisions. We aimed to complement the
effectiveness results by reviewing current literature describing the costs and cost-effectiveness of educational
setting-based interventions for preventing anxiety, depression or conduct disorder among CYP. We also
aimed to undertake a microcosting study for effective interventions, assigning appropriate costs to the
constituent components of the interventions when feasible, for use in the cost–consequence analysis.
Methods
We first describe the methods for the narrative review of previous economic evaluations of educational
setting-based interventions that aimed to prevent anxiety, depression or conduct disorder among CYP.
We then describe the methods for the microcosting study of the inclusion of a psychoeducation component
in universal secondary CBT interventions described in a cost–consequence analysis.
87
ECONOMIC EVALUATION
Narrative review
Search strategy
We searched for relevant studies describing economic evaluations of educational setting-based
preventative interventions in several ways:
l The body of abstracts identified in the detailed systematic review described in Chapter 2 was
restricted by terms to identify costing studies (e.g. ‘economic evaluation’, ‘cost’).
l The search strategy used for the systematic review (described in Chapter 2 and Appendix 1, and carried
out on 4 April 2018) was reproduced and applied to the full extent of the NHS Economic Evaluation
Database (NHS EED; date range searched: 1968 to 2014) on 22 May 2019 (see Appendix 8).
l Potentially relevant articles were sought by searching for economic evaluations of interventions
described in the clinical effectiveness studies included in the NMA (see Chapters 4 and 5). The 142
included articles were inspected for details of trial registration and, when present, the registration
record was searched for ‘cost’ or ‘economic’, which might have indicated an intention to conduct an
economic analysis. References to the words ‘cost’ or ‘economic’ in the text of the included articles
themselves were followed up when appropriate. Authors were contacted to request details of
publications if we believed that an economic study may have been carried out but were unable to
locate the report.
l As a supplemental search, economic evaluations associated with the interventions tested in the
142 included effectiveness articles were sought using the Google Scholar (Google Inc., Mountain
View, CA, USA) forward citation search functionality.252,253
The original searches described in Chapter 2 were based on RCTs and may have missed relevant
decision models. Therefore, a scoping search was carried out in MEDLINE to assess the likelihood of
modelling articles having been missed (see Appendix 8), with the intention of reproducing and repeating
the initial searches without the RCT restriction if it appeared that a substantial body of modelling
articles had been missed.
Inclusion criteria
The following inclusion criteria were agreed by Joanna C Thorn, Deborah M Caldwell and Nicky J Welton
prior to screening articles:
l educational setting-based intervention

l intervention designed explicitly to prevent anxiety, depression or conduct disorder
l intervention aimed at CYP aged 4–18 years
l original study based on a RCT with an embedded economic evaluation or an economic decision model.
All population, intervention, comparator and outcome inclusion criteria for the effectiveness review
were reflected in the economic search. We did not include papers that were written in languages other
than English, conference abstracts or review papers. Titles and abstracts were screened for inclusion,
and full texts were obtained for all articles that either clearly met the inclusion criteria or for which
inclusion was unclear. Screening of both abstracts and full texts was carried out by one author (JT),
with a second opinion (DMC) sought when necessary. Reasons for exclusion were recorded for articles
rejected after full-text screening.
Data extraction and quality control

Data covering study characteristics (publication date, unit of randomisation, location, setting, study
design, type of model, model time horizon or empirical follow-up period, size of study, comparator),
intervention details (description of intervention, intervention cost, condition targeted, population,
type of intervention) and economic details (type of economic analysis, outcomes measured, sources of
outcomes, discount rate, resources included and source of resources, cost year, currency, perspective)
were extracted from included studies using a bespoke form in Microsoft Access® (Microsoft Corporation,
88

Redmond, WA, USA). Verbatim descriptions of the study conclusions were also extracted. The quality of
the included studies was qualitatively assessed against the Drummond et al.254 10-point checklist for RCTs
and the Philips et al.255 checklist for decision models. Costs were converted to Great British pounds using
purchasing power parity figures256 and inflated to 2018 equivalents257 for comparison purposes.
Data synthesis
Included interventions were categorised as targeted (indicated or selective) or universal, and the
cost-effectiveness analyses were described in a narrative review.
Intervention costing
The NMA results (see Tables 3, 4, 7 and 8) suggested that CBT-based interventions were the most
likely to produce positive outcomes, with CBT + IPT-based interventions also showing some indication
of effect for preventing depression in a universal secondary-age population. Results from the component
NMA indicated that the only component for which there was evidence of a beneficial effect in universal
secondary CBT interventions was a psychoeducation component, with CBT interventions with psychoeducational
components reducing the standardised anxiety score by –0.39 (95% CrI –0.78 to 0.01). Therefore, our
intervention costing analysis (and subsequent component breakdown) focused on CBT interventions
that incorporated identifiable psychoeducation components and CBT + IPT interventions. As there are
considerable similarities between interventions designed to prevent depression and those focusing on
anxiety (with some interventions explicitly targeting both), we included both depression and anxiety
interventions in the costing estimate without distinguishing between them.
Studies describing universal secondary CBT interventions with a psychoeducation component were
identified from the systematic review described in Chapter 2. Details of the interventions were
extracted (i.e. year of publication, number of sessions offered, average session duration, size of group,
number of group leaders, professional background of leaders, provision of a manual, training, materials,
provision of parent sessions and other costs). Further details of the interventions were sought from
intervention websites and from linked papers describing the branded interventions in more detail.
Through scrutinising the extracted data, an ‘indicative’ intervention was developed. Unit costs for the
individual elements for a universal intervention in a secondary population were identified in the UK
context, and cost estimates were calculated for the ‘indicative’ intervention. The CBT cost estimates
were extrapolated to primary populations and targeted interventions. A similar extraction process was
carried out for CBT + IPT interventions.
Component costing
When the CBT intervention was described in sufficient detail (either in the paper itself or by consulting
the intervention manual), the approximate proportion of each intervention devoted to psychoeducation
elements was estimated. Psychoeducation was defined to include the provision of information, the
explanation of symptoms, advice on managing the condition and the provision of written materials,258
while excluding practical experiences (such as role play) and activities based on the individual’s own
life experience. Intervention descriptions and manuals were scrutinised carefully, and elements of
psychoeducation were identified. The approximate time commitment to each psychoeducation element
was estimated, summed for each intervention and expressed as a proportion of the whole intervention.
An approximate estimate of the cost that could be ascribed to psychoeducation components was derived
based on the overall cost of the indicative intervention.
Cost–consequence analysis
The intervention costs and consequences (SMD relative to usual curriculum post intervention) that
could be ascribed to the ‘indicative’ interventions and psychoeducation components are presented as
a cost–consequence table (Table 19). If no effectiveness estimates are available relative to usual
curriculum, the results relative to a waiting list are reported; if these are also not available, then the
results relative to no intervention are presented.
89
ECONOMIC EVALUATION
Results
Narrative review of previous economic evaluations
Article selection
A flow diagram summarising the identification and selection of articles is given in Figure 16. A total
of 434 titles and abstracts were screened for inclusion; full texts were obtained for 36 articles.
Eight articles, reporting on six study time points, were deemed to meet the inclusion criteria.
Only 3 of the 137 depression and anxiety effectiveness articles (2.2%) included in Chapters 4 and 5
were found to have published economic evaluations. Three further authors of effectiveness papers
were contacted to request details of potential economic evaluations. All three authors confirmed that
no economic study had been published, although one is still planning to complete and publish the study
in future. Of the five included conduct disorder studies (see Chapter 7), only one (i.e. Fast Track247) had
undergone economic evaluation. The additional scoping search carried out in MEDLINE to identify
economic decision model papers returned 186 potentially relevant articles. The search identified both
of the modelling papers that had already been identified in the original review,259,260 but did not identify
any additional articles. Based on this finding, we did not conduct further searches for economic
decision model papers in the other databases searched in the systematic review. Although there is a
possibility that we may have missed some decision model papers, we think that this is unlikely.
Records identified through

database searches (MEDLINE,
EMBASE, PsycInfo, CENTRAL)
(n=11,990)
Records excluded
Records after application (n=11,589)
of economic filters
(n=401)
Records identified in NHS EED and

by seeking economic studies of
relevant effectiveness studies
(n=62)
Titles/abstracts screened after

Records excluded
deduplication
(n=398)
(n=434)
Full-text articles excluded

(n=28)
Full-text articles screened
• No economic study, n=11
(n=36)
• Not prevention, n=7
• Not anxiety, depression or
conduct disorder, n=3
• Not school based, n=5
Studies included in review • Outside age range, n=2
(n = 6)
(from eight articles; four articles

report on the same two studies)
FIGURE 16 Study selection process: flow diagram for review of economic evaluations.
90

Included studies characteristics

The six included studies were published between 2006 and 2017, with costs reported in currency
years from 2003 to 2014. The numbers of participants in the studies describing RCTs ranged from
308 to 3357. Two studies described universal interventions, three studies reported on an indicated
intervention (of which two included a universal component) and the final study considered both
universal and indicated interventions. Two analyses were based on economic decision models (both
Markov models) and four analyses were based on data from RCTs. The follow-up period ranged
from 6 months to 14 years for the trial-based analysis, and the model horizons were 5 or 10 years.
Interventions were compared with usual provision (n = 4) or no intervention (n = 2). Additional
characteristics are summarised in Table 18, and the extracted data are provided in Appendix 8.
Quality of articles
The study by Mihalopoulos et al.260 met the majority of the Philips checklist criteria.255 However, the
intervention was not described in adequate detail, half-cycle corrections were neither incorporated nor
discussed and there were weaknesses in both the assessment of uncertainty and description of data
incorporation. Lee et al.259 published a very detailed supplementary document alongside the article,
thereby meeting most of the reporting requirements, although the cycle length was not explicitly
stated and parameter distribution choices were stated but not justified. Structural uncertainty and
heterogeneity did not appear to have been explored in either article.
The analysis reported by Anderson et al.261 lacked sensitivity analyses for exploring uncertainty and did
not discuss generalisability, but was otherwise well reported. Although there was no discussion of
generalisability or comparison with other studies and no subgroups were considered, the study by
TABLE 18 Characteristics of included studies for review of economic evaluations
Characteristic n
Condition
Anxiety 1
Depression 3
Conduct disorder 2
Economic evaluation type

Cost-effectiveness analysis 3
Cost–utility analysis 4
Setting
Primary school 4
Secondary school 5
Study design
RCT 4
Decision model 2
Jurisdiction
USA 2
UK 2
Australia 2
91
ECONOMIC EVALUATION
Stallard et al.262 generally conformed to the requirements of the Drummond checklist.254 The 2006/7
articles by Foster and Jones263,264 did not adequately report the effectiveness of the intervention, and
did not include all costs that might have been relevant. Discounting was neither described fully nor
justified, and results were not compared with those of other studies. As no incremental analysis was
conducted in the 2010 study,250 the study quality was not assessed.
Costs and cost-effectiveness

A range of economic analysis perspectives was studied, including the health, social services, education
and criminal justice sectors, leading to a wide range of resources being included in the analyses.
Interventions were typically complex and ranged in cost from approximately £45 per participant to
> £60,000. The intervention for conduct disorder involved multisystemic, multicomponent and sequentially
delivered individual and group interventions over a 10-year period, whereas the interventions for
depression and anxiety were all based on CBT methods. Outcomes considered in the economic analyses
included utilities [either quality-adjusted life-years (QALYs) or DALYs averted], as well as other clinical
outcomes. The studies are described in more detail below.
Prevention of anxiety
Stallard et al.159,262 studied a universal intervention for anxiety prevention in primary schools in the UK.
The FRIENDS intervention is a CBT-based programme that teaches children to recognise anxiety and
develop strategies to address anxious feelings. The intervention was delivered by either a teacher or an
external health educator, and both were compared against usual curriculum provision in a three-arm
trial. The cost-effectiveness of the programme was assessed at 6 months in terms of the cost per unit
reduction in primary outcome (RCADS score), and a cost–utility analysis was conducted using the Child
Health Utility-9 Dimensions (CHU-9D) instrument to measure health-related quality-of-life data from
which QALYs were derived. The economic analyses were carried out from the joint health, social
services and education sectors perspective. Therefore, resources considered in the study (measured
using an adapted Client Service Receipt Inventory instrument administered by parental interview)
included hospital stays, accident and emergency visits, outpatient appointments, general practitioner
(GP) visits and visits to psychology practitioners or social workers, and medications. The scope of the
study appeared to be condition-specific resource use, except for hospital events, which encompassed
all-cause resource use. It was unclear whether use of social services was condition specific or all cause.
A very detailed breakdown of the intervention costs was provided, leading to a total of £62.96 per
child if the intervention was delivered by school staff and £59.16 per child if delivered by external
health staff (inflated to 2018 costs). Point estimates suggested that the intervention was more costly,
but less effective (by 0.004 QALYs), than the control, that is the intervention was dominated. The
economic analysis provided further evidence that the intervention was unlikely to be cost-effective,
with a probability of cost-effectiveness of < 35% at all societal willingness-to-pay values for the
intervention delivered by health staff. Furthermore, the analysis was based on complete cases for
CHU-9D measurements. This may have led to bias, as it is possible that those individuals without
complete data were less likely to have benefited from the programme. The cost of teacher time for
delivering the intervention was treated as zero. This strategy implies that there was no opportunity
cost associated with alternative learning activities from the teachers’ point of view.
Prevention of depression
Three studies (one RCT and two decision models) addressed interventions aiming to prevent
depression. The RCT evaluated the CBT-based Resourceful Adolescent Program (RAP) from the
perspective of the NHS and social care in the UK.261 We note that, in the present review, the RAP was
classified as CBT + IPT, a combined intervention type, in line with the description of the intervention in
Merry et al.197 and Hetrick et al.68 The study was described in both a report to the funder and a journal
article. The more recently published paper has been treated here as the primary account, with the
funder report consulted for further detail when necessary. The RAP is a universal intervention that was
delivered in secondary schools, recruiting young people aged 12–16 years. Cost-effectiveness was
assessed after 12 months of follow-up in relation to both QALYs (measured using the EuroQoL-5
92

Dimensions questionnaire) and clinical symptoms of low mood (measured using the Mood and Feelings
Questionnaire-Short Version). Resources considered in the study included hospital stays, accident and
emergency visits, outpatient appointments, GP visits and visits to psychology practitioners. Details of
medications were collected but not reported, as the data were considered unreliable. The cost associated
with delivering the intervention (£46.15 per child in 2018 equivalent) was relatively small, and a detailed
breakdown was reported. For both the cost-effectiveness and cost–utility analyses, the point estimates
suggested that the intervention was both more costly and less effective than the control (usual class
provision within school), albeit with considerable uncertainty around the results. The intervention was
deemed ‘highly unlikely’ to be cost-effective.
The two model-based analyses were conducted in the Australian context following the Assessing
Cost-Effectiveness in Prevention framework.259,260 The studies shared a common author, and both were
based on ‘hypothetical’ interventions developed by the project team following a literature review and
meta-analysis. In both cases, the intervention was compared with no intervention, focused on children
aged 11–17 years, considered DALYs averted as the economic outcome measure and used Markov
models. The earlier (2012) study260 involved a model time horizon of 5 years and a health sector
perspective. The more recent (2017) model259 was extended to 10 years and included both health and
education sectors in the perspective. Intervention costs were estimated by Lee et al.259 at £12.90 per
child for the universal intervention and £259.25 per child for the indicated intervention (2018 prices).
The incremental cost-effectiveness ratios (ICERs) were found to be AU$7350 per DALY averted for a
universal intervention and AU$19,550 per DALY averted for the indicated intervention in Lee et al.,259
and AU$5400 per DALY averted for an indicated intervention in Mihalopoulos et al.260 Assessed against
a standard societal willingness-to-pay threshold of $50,000 per DALY averted, both studies concluded
that school-based preventative interventions represent good value for money. However, as the studies
focused on the prevention of major depression with three health states only (healthy, diseased and
dead), the lack of granularity in terms of addressing the spectrum of disease severity limits the
usefulness of the analyses in informing implementation decisions.
Prevention of conduct disorder

Three articles, all by the same author group and relating to the same study, described the Fast Track
intervention, designed to prevent conduct disorder in the USA. The intervention was assessed at two
time points (10 years263,264 and 13 years250 post randomisation). Two articles described the same study
at the same time point, with one reporting an ICER and the other reporting the net monetary benefit
statistic. As these cost-effectiveness statistics would usually be reported together, and the articles are
identical in many aspects, the two articles have been treated as one for the purposes of this review.
The Fast Track intervention took a long-term approach to the prevention of conduct disorder. Children
were identified as ‘at risk’ at age 6–7 years and were given intensive support through multiple
activities over a 10-year period, including parent training, group meetings, friendship development
and promotion of reading skills (see Chapter 7). The multifaceted intervention was very costly, at
US$58,283 (cost year: 2014) (£60,478 in 2018 Great British pounds) per child.
The stated perspective of the economic analysis was that of a third-party payer, but the intervention
cost was the only resource included. Cost-effectiveness at 10 years was found to be US$3,481,433 per
case of conduct disorder averted, with only a 1% probability of cost-effectiveness at an assumed societal
willingness-to-pay value of US$1M. However, the authors explicitly note that the intervention was
designed for effectiveness, not cost-effectiveness. Possible future effects were addressed approximately
by estimating the costs associated with an enduring criminal lifestyle, and incorporating this estimate
into the societal willingness-to-pay value, but no other potential offsets (such as the effect on health or
social care, or directly on the education system) were included in the analysis. Only the intervention was
costed. A subgroup analysis suggested that the intervention may be cost-effective for children at the
highest risk of developing conduct disorder; however, it was unclear whether this analysis was
prespecified or conducted post hoc.
93
ECONOMIC EVALUATION
By the 13-year follow-up, evidence for cost-effectiveness had dissipated, and the study concluded that
‘[t]he most intensive psychosocial intervention ever fielded did not produce meaningful and consistent
effects on costly outcomes’.250 This study took a much broader perspective than previously, but,
citing the lack of intervention effect as a justification, the authors presented marginal effects for group
differences for a number of resources, instead of deriving any formal cost-effectiveness statistics combining
costs and outcomes. Relevant resources included health-care use, criminal justice interactions, substance
use and educational service use. Full data sets were not available for all variables. For example, medication
use was available for years 4–13 only, and health-care use was available for years 7–13 only. Costs associated
with health-care use and delinquency were investigated, although no unit costs were reported for the
resources used. Both outpatient mental health-care use and general any-cause health service use costs
were higher in the control group, these costs being, respectively, US$1344 and US$1106 lower per
participant in the intervention group. Costs associated with the criminal justice system showed no
difference between the groups. Weaknesses in the trial development and conduct were identified, and
tension arising from the differing background perspectives of the study team was apparent. For example,
the author was critical of developmental psychology as a discipline, of the lack of data-sharing in the
project and of the lack of prespecified analysis plans, leading to concerns over chance findings.
Intervention costs
Extracted elements of the interventions described in 20 papers evaluating universal CBT interventions
with a psychoeducation component identified via the ICA (see Chapters 4 and 5) are given in Appendix 8.
The number of sessions for children ranged from 3 to 30, with a median of 10 sessions. Session duration
ranged from 35 to 120 minutes (median 50 minutes). Group sizes ranged from 4 to 30 participants, with a
median of 25. Parent sessions formed part of the intervention in only five studies, with low attendance cited
as an issue in two of these studies. The group leaders included teachers (n = 8), psychologists (n = 11) and
students (n = 5) (sometimes in combination). Groups were led by either one (n = 12) or two (n = 7) individuals
(the exact leadership was unclear in one study). Of the 12 groups led by one individual, four were led by
psychologists and eight by teachers. Training for delivering the intervention (when described) took a number
of forms, including self-participation in the intervention, workshops varying from 90 minutes to 5 days (n = 9,
median 1 day) and co-leading a cohort. A facilitator manual was provided in 16 out of 20 interventions, and
workbooks or worksheets were supplied in 13 out of 20 interventions.
A ‘typical’ universal secondary CBT intervention might, therefore, comprise 10 sessions of 50 minutes,
each session each delivered to 25 children at a time by one teacher who had received 1 day of specific
intervention training. Typically a manual would be provided for facilitators, and workbooks for the
participants. Unit costs associated with these elements in the UK context are given in Appendix 8. This
leads to an estimated overall intervention cost of £43 per student from the school budget perspective.
At the school level, this would represent approximately £1825 per (small) two-form entry school, or
£7300 per larger eight-form entry school in the first year. A two-form entry school is one that has an
annual intake of two classes of approximately 30 students each, who then progress through the school
as a stable cohort. An eight-form entry school is approximately four times as large. If this universal
intervention were delivered in a primary school, the teacher costs would be slightly lower, leading to
an approximate cost of £42 per student. Assuming that a targeted (indicated or selective) intervention
would be delivered to a smaller group of students (e.g. 10), the cost per student would be £95 in a
secondary setting or £91 in a primary setting. Similarly, based on three articles describing universal
secondary CBT + IPT interventions, a typical CBT + IPT intervention might have both workbooks and a
manual, and consist of 11 sessions of 60 minutes each, delivered by one teacher to 10 students after
2 days’ training. This leads to an estimated cost of £157 per student.
Component analysis
Seven CBT interventions were described in sufficient detail to attempt to assign a very approximate
proportion of the intervention devoted to psychoeducation: e-couch (33%), ThisWayUp (40%),
94

Penn Resilience Program (30%), LARS&LISA (20%), Op Volle Kracht (50%) and two unnamed
interventions (12% and 100%). Overall, approximately one-third of the ‘typical’ intervention could be
assigned as psychoeducation. The potential cost of incorporating a psychoeducation component might,
therefore, represent approximately £14 per student (i.e. approximately £600 per two-form entry
school or £2400 per eight-form entry school).
Cost–consequence analysis
Intervention costs and consequences in SMDs that could be ascribed to the ‘indicative’ CBT interventions
for a universal secondary population are presented in Table 19, alongside extrapolated intervention costs
for similar interventions in primary and targeted populations. Adding IPT to CBT in a universal secondary
population is more costly than CBT alone, driven mainly by additional teacher training and delivery to
smaller groups of students. Although the estimated SMD shows a bigger reduction in depression score,
compared with usual curriculum, than for CBT alone, the estimate is very uncertain. There is no evidence
for the effect of CBT + IPT on anxiety in the universal secondary population. Further evidence on the
relative efficacy of CBT and CBT + IPT would be required to justify the additional intervention cost. No
studies used a usual curriculum control in either secondary or primary targeted populations. There is some
evidence that CBT is effective compared with a waiting list for reducing anxiety in a targeted primary
population, but this difference may not extend to comparisons with usual curriculum.
In Table 20, we report the intervention costs and consequences (SMD) for CBT with or without a
psychoeducation component in a universal secondary population. Because all of the CBT interventions
in the NMA for this population contained cognitive and behavioural components, the comparison is
TABLE 19 Cognitive–behavioural therapy intervention cost estimates and consequences (SMDs), compared with
usual curriculum
CBT for, SMD (95% CrI)

Intervention cost
Setting/intervention per student (£) Anxiety Depression
Secondary
Universal
CBT 43 –0.145 (–0.342 to 0.042) –0.040 (–0.156 to 0.074)

vs. usual curriculum vs. usual curriculum
CBT + IPT 157 N/A –0.184 (–0.454 to 0.085)

vs. usual curriculum
Targeted
CBT 95 0.028 (–0.108 to 0.164) –0.217 (–0.579 to 0.1307)

vs. no intervention vs. no intervention
Primary
Universal
CBT 42 –0.072 (–0.234 to 0.051) –0.131 (0.441 to 0.174)

vs. usual curriculum vs. usual curriculum
Targeted
CBT 91 –0.384 (–0.846 to 0.067) –0.477 (–2.486 to 1.50)
vs. waiting list vs. waiting list
N/A, not available.
Note
If comparisons were not available against usual curriculum, results are reported relative to a waiting list control; if that
is also not available, then the results are reported relative to no intervention.
CBT + IPT was not present in the NMA for universal, secondary, anxiety.
95
ECONOMIC EVALUATION
TABLE 20 Costs and consequences (SMD relative to usual curriculum) of a universal secondary CBT intervention that
contains cognitive and behavioural components with and without a psychoeducation component
Intervention vs. usual curriculum, SMD (95% CrI)

Intervention cost
Population/setting/intervention per student (£) Anxiety Depression
Secondary
Universal
CBT (cognitive + behavioural) 29 0.092 (–0.171 to 0.357) –0.112 (–0.278 to 0.052)
CBT (cognitive + behavioural + 43 –0.301 (–0.593 to –0.014) 0.005 (–0.118 to 0.132)

psychoeducation)
between CBT with just cognitive and behavioural components and CBT with cognitive, behavioural
and psychoeducation components. We give results for both anxiety and depression outcomes, although
the NMA results only show evidence of a difference for the anxiety outcome. We also report estimated
intervention costs, based on our microcosting of typical interventions with these components as
described in the RCTs. Adding a psychoeducation component increases intervention costs, but there
is evidence that anxiety symptom scores improve post intervention.
Discussion
Review of previous economic studies

The body of evidence described in this review is both small and heterogeneous. Conditions being
targeted, interventions and cost-effectiveness analyses were all variable. It was, therefore, not possible
to synthesise the results numerically. Multiple perspectives for the analyses were taken, leading to
the resources included in the analyses varying widely. The potential long-term costs associated with
missing school15,16 (such as lifetime earning capacity) were not estimated in any of the studies. All
included studies appropriately compared the intervention with usual provision, or with no intervention
(i.e. the model-based studies). Although an active control comparator is appropriate (and necessary)
for investigating effectiveness mechanisms, economic analyses are most informative for decision-makers
when compared with usual care/curriculum. The two model-based analyses suggested that hypothetical
interventions could be cost-effective in the Australian context. However, the trial-based analyses
suggested that the interventions were unlikely to be cost-effective in the UK or the USA. For the one
intervention that was considered potentially cost-effective in a high-risk subgroup at an interim point of
the study, the effect disappeared with longer-term follow-up. There was little empirical costing evidence
to inform decisions on the implementation of preventative interventions.
Cost–consequences analysis
The figures used to obtain intervention costs were based on a highly stylised, ‘indicative’ universal
intervention that was assumed to be delivered as specified, and there are many ways in which differences
might occur in the real world. Although it was assumed that there would be no room hire costs if the
intervention were delivered on school premises, there could be heating, lighting or security overheads
if the intervention were delivered outside school hours. It is possible that a project manager or
administrator would be required to oversee the intervention if it were rolled out across the country.
The salary of the teacher delivering the intervention could vary according to experience. Delivery by a
psychologist instead of a teacher would affect the salary costs, and psychologists additionally undergo
supervision meetings as part of their professional conduct. The intervention would be more costly if two
individuals led it instead of one. The detailed intervention cost breakdown by Stallard et al.262 illustrated
the variability in individual components that go into making up an intervention, with small changes in
delivery method (e.g. the requirement for travel) leading to big differences in costs between methods.
96

Stallard et al.’s262 work suggested that it is a fallacy to assume that delivery by schoolteachers is less costly
than delivery by health-care specialists. None of the interventions described here explicitly mentioned a
licence fee, and potential administration costs have not been considered. Deriving a value for the opportunity
cost of time diverted from other learning activities in school is currently considered problematic and has not
been taken into account here. Despite these caveats, this simplistic model serves to give an idea of the costs
that might accrue to a school budget in the first year of implementation. Subsequent years would incur lower
training outlay, assuming that the same teachers deliver the course. The limited details of interventions
described in the published reports meant that it was challenging to assign accurate proportions to
psychoeducation components.
Implementation might be more attractive if it could be demonstrated that the intervention has a positive
effect on educational outcomes or reduces the need to pay for educational psychologists in the future.
However, the systematic review found that few studies of effectiveness had considered educational
attainment outcomes (see Chapter 6). Future work should consider developing methodologies for
evaluating both effectiveness and cost-effectiveness in terms of school outcomes, as well as the
outcomes more typically encountered in health-care studies.
The cost–consequence analysis was based only on the intervention costs (i.e. the effect on health-care
use was not addressed). It is worth noting that the beneficial effects of an intervention that aims to
prevent or reduce symptoms of anxiety may also extend to reducing depression, and vice versa, which
would increase the value of such an intervention. A comparison of costs and standardised outcomes in
a cost–consequence analysis is difficult to interpret; ideally, a full cost-effectiveness analysis based on a
recognised clinical outcome would be conducted. However, we did not find sufficient evidence for the
efficacy of these interventions at 6 months’ post-intervention (and longer) follow-up for the development
of a cost-effectiveness model to be useful at the present time. An economic model needs to capture
long-term costs and benefits, which may be substantial, as issues with mental health and conduct
disorder during school years have been shown to be associated with a range of health and behavioural
problems as adults,4 which are costly to society.265 However, further research is needed to develop and
evaluate effective interventions for the prevention of mental health and conduct disorders in school-age
children before the longer-term consequences of such interventions can be fully assessed.
To ensure high-quality information for decision-makers, it is imperative that future reports of school-
based interventions to prevent anxiety, depression or conduct disorder are described in some detail
and that the cost implications of interventions are adequately measured.
97
Chapter 9 Summary and interpretation of

key findings
I n this chapter, we draw together the findings from the systematic review, NMA and economic
evaluation. Based on the criteria for interpretation described in Chapter 2, we summarise our
overall interpretation of the evidence from the NMA for the primary time point of immediately
post intervention. This summary forms the basis for the implications for practice, implications for
research and the conclusions reported in Chapter 10.
Systematic review
The full results of the systematic review are reported in Chapters 4–7 and are summarised briefly here.
The effectiveness results are based on searches conducted in April 2018. A total of 11,990 citations
were screened, and 1512 full-text articles were retrieved for screening. The review included 142 studies
of > 63,500 randomised participants. Of the 142 studies, 92 were judged to be at unclear risk of bias
for random sequence generation, 115 were judged to be at high or unclear risk of bias for allocation
concealment and 133 were judged to be at high or unclear risk of bias for blinding of participants.
We identified a protocol or trial registration for only 32 studies. This represents 23% of included studies
published post 2000.
Of the 142 eligible studies, 71 contributed data to the NMA for the prevention of anxiety, 86 were
included for the NMA for depression and five contributed to the narrative summary for the prevention of
conduct disorder. Note that there was an overlap of studies contributing to the anxiety and depression
NMA, with 47 studies reporting both an anxiety and a depression outcome.
Network meta-analyses by population and setting
This is a large and complex review, with 32 possible intervention-level NMAs conducted (condition ×
setting × population × time point), from which we reported 57 intervention effect estimates of the
primary outcomes of self-reported symptoms of anxiety or depression. This number of analyses does
not include the component NMAs or subgroup or sensitivity analyses, and does not include the
additional and secondary outcomes. Below we report the findings for our primary outcomes at the
primary time point of post intervention, for the intervention-level and component-level NMA. Note
that, to ensure conciseness in this chapter, we concentrate on interpreting findings for which the relevant
results chapter has indicated that there may be statistical evidence of an effect, as described in Chapter 2.
However, for full reporting of all results and intervention effect estimates, see Chapters 4 and 5.
Anxiety: universal population, secondary setting

This was a well-populated network of 21 studies and 10,208 participants. The between-study heterogeneity
was moderate across the network. The risk of bias for random sequence generation and allocation
concealment was deemed to be mostly unclear. At the post-intervention time point, we found weak
evidence of a small beneficial effect of CBT-based interventions (SMD –0.15, 95% CrI –0.34 to 0.04),
relative to usual curriculum. There was statistical evidence that mindfulness/relaxation interventions
(SMD –0.65, 95% CrI –1.14 to –0.19) were effective in preventing symptoms of anxiety. However, the
CrIs for the mindfulness/relaxation effect estimate were relatively imprecise, and the effect estimate is based
on two small studies, which were judged to be at unclear risk of bias for the domains of random sequence
generation and allocation concealment. We also note that there was variation between the study-level
effect estimates of the two mindfulness/relaxation studies. One study130 (with 30 participants) reports a
large effect estimate of mindfulness/relaxation relative to a waiting list (SMD –1.01, 95% CrI –1.67 to –0.35).
99
SUMMARY AND INTERPRETATION OF KEY FINDINGS
The second study137 compared mindfulness/relaxation with an attention control and reports a smaller
effect (79 participants, SMD –0.32, 95% CrI –0.72 to 0.08). Finally, the statistical findings for both CBT
and mindfulness/relaxation should be interpreted considering the possible evidence of asymmetry
from the comparison-adjusted funnel plots, which suggests the presence of small-study effects or other
non-reporting bias.
Anxiety: universal population, primary setting

This was a small network of 15 studies, but with a reasonable number of participants (n = 5605). There
was moderate between-study heterogeneity across the network. Thirteen studies were judged to be at
unclear risk of bias for random sequence generation and allocation concealment, one was judged to be
at low risk of bias for both domains and one was judged to be at low risk of bias for random sequence
generation only. There was weak evidence for a very small beneficial effect of CBT (SMD –0.07,
95% CrI –0.23 to 0.05), relative to usual curriculum. The comparison-adjusted funnel plot was suggestive
of small-study effects or other non-reporting bias.
Anxiety: targeted population, secondary setting

This was a small network of 15 studies (2383 participants). There was mild to moderate between-study
heterogeneity across the network. Three studies were judged to be at low risk of bias and seven were
judged to be at unclear risk of bias for randomised sequence generation and allocation concealment.
Four studies were judged to be at low risk of bias for randomised sequence generation and at unclear
risk of bias for allocation concealment. There was evidence that exercise was effective in reducing
self-reported anxiety in targeted secondary settings, relative to no intervention (SMD –0.47, 95% CrI
–0.86 to –0.09). However, the width of the CrI indicates a relatively imprecise estimate, and exercise
was evaluated in only one small study170 (with 121 participants) that was judged to be at unclear risk of
bias for random sequence generation and allocation concealment. We caution against overinterpreting
the finding for exercise-based interventions in this network. There was no evidence of effectiveness
for the other interventions. The comparison-adjusted funnel plot did not suggest the presence of
small-study effects or other non-reporting bias.
Anxiety: targeted population, primary setting

The targeted primary network was the smallest of all those considered for the prevention of anxiety
with only 11 studies (1314 participants). There was substantial between-study heterogeneity (τ 0.42,
95% CrI 0.21 to 0.89) across the network. Three studies were judged to be at low risk of bias and
six studies at unclear risk of bias for both the randomisation and allocation concealment domains.
A further two studies were judged to be at unclear risk of bias for allocation concealment, but at
low risk of bias for random sequence generation. Although there was weak evidence of a beneficial
effect for CBT relative to a waiting list (SMD –0.38, 95% CrI –0.84 to 0.07), the CrI for the estimate
is relatively wide. There was no evidence of small-study effects or other non-reporting biases for
this network; however, the number of studies is at the lower end required for this analysis to
be meaningful.266
Anxiety: tertiary/university setting

There was evidence of (statistical) inconsistency in the NMA for the prevention of anxiety in tertiary
settings; therefore, we do not report effectiveness findings. The inclusion criterion that interventions
needed to be implemented in the educational setting may have limited the number of eligible studies,
which, in turn, may have contributed to the lack of model fit observed. The limitations are discussed
further in Chapter 10.
Depression: universal population, secondary setting

At the post-intervention time point, this was the most connected network, including the greatest
number of studies (34 studies; 18,094 participants), of which 25 included an intervention based on
CBT. Most studies were rated as having an unclear risk of bias for at least one domain. The between-
study heterogeneity was moderate across the entire network. There was weak evidence of a very
100

small beneficial effect for CBT, compared with usual curriculum (SMD –0.04, 95% CrI –0.16 to 0.07).
There was also some evidence that CBT + IPT (SMD –0.18, 95% CrI –0.46 to 0.08) was effective at
reducing depressive symptoms. The comparison-adjusted funnel plots did not indicate small-study
effects or other non-reporting biases.
Depression: universal population, primary setting

This was a small network of 12 studies (4116 participants) of six interventions. Only one study did not
include a CBT comparator, yet the between-study heterogeneity was considered to be moderate to
substantial. One study was rated as having a low risk of bias and 11 studies were rated as having an
unclear risk of bias for both random sequence generation and allocation concealment. There was no
evidence of an effect for any intervention relative to usual curriculum. The comparison-adjusted funnel
plots did not indicate small-study effects or other non-reporting biases.
Depression: targeted population, secondary setting

Twenty-four studies contributed to this NMA. However, it was small in terms of participants (n = 3669).
There was evidence of moderate to substantial between-study heterogeneity across the network.
Most studies were rated as having a low risk of bias on at least one of the domains; however, allocation
concealment was rated as having an unclear risk of bias in 18 studies. There was no evidence of an effect
for any intervention relative to no intervention. The comparison-adjusted funnel plot did not indicate
small-study effects or other non-reporting biases.
Depression: targeted population, primary setting

There were five studies (497 participants) in this NMA. Between-study heterogeneity was substantial.
One study was judged to be at low risk of bias for both random sequence generation and allocation
concealment, and three studies were judged to be at unclear risk of bias. One study was rated as having
a low risk of bias for random sequence generation, but an unclear risk of bias for allocation concealment.
There was no evidence of an effect for either CBT or occupational therapy, relative to a waiting list.
A funnel plot was reported but not interpreted because of the small number of studies included.
Depression: tertiary/university setting

We observed evidence of inconsistency in the NMA for the prevention of anxiety in tertiary settings;
therefore, it was not appropriate to report effectiveness findings. As a consequence of the inclusion
criteria, few studies were included, which may have contributed to the lack of model fit. The limitations
of the inclusion criteria are discussed in Chapter 10.
Anxiety and depression: component network meta-analysis

The taxonomy of intervention components was reported in Chapter 3. We report the anxiety and
depression component NMA findings in Chapters 4 and 5. There was little robust evidence that specific
combinations of components were more effective than others. The exception was a psychoeducation
component: it appears that the addition of a psychoeducation component to CBT may result in a more
effective preventative intervention. The mechanism for this finding is not clear. In the psychotherapeutic
literature, Pompoli et al.72 found that the addition of a psychoeducation component to CBT decreased
the odds of remission from adult panic disorder symptoms (i.e. made remission less likely), whereas
López-López et al.82 found no evidence that adding psychoeducation to CBT changed the effectiveness
for treatment of depression in adults (SMD 0.04, 95% CrI –0.66 to 0.75). Both the Pompoli et al.72 and
López-López et al.82 studies were conducted in clinical adult populations, and the present study is in
non-clinical child and adolescent populations, and mechanisms of psychoeducation may vary. To aid
future intervention development, investigation of the potential mechanism(s) of psychoeducation should
be conducted and could also explore the possibility that the mechanism of effect is likely to vary across
adult and CYP populations.
101
Anxiety and depression: subgroup analyses

For the primary time point of post intervention, we explored whether or not effects observed in the
NMA varied by mode of delivery, facilitator and focus of the intervention. On balance, there was a
lack of evidence of effect modification by facilitator or mode of delivery for any population or setting
combination. There was weak evidence that interventions facilitated by MHPs may be more effective.
There was some evidence to suggest that interventions focused on preventing anxiety had a larger
effect on reducing self-reported symptoms of anxiety than those focused on both depression and
anxiety, or depression alone, and that interventions focused on preventing depression had a larger
effect on reducing symptoms of depression than those focused on both depression and anxiety, or
anxiety alone. However, this was not a formal statistical comparison, and, owing to the absence of
participant blinding, we cannot rule out possible Hawthorne effects. Therefore, we do not consider this
as providing evidence for, or against, the transdiagnostic hypothesis.
Anxiety and depression: additional primary and secondary outcomes

Additional primary and secondary outcomes were also analysed for the primary time point. There was
no evidence to suggest that primary or secondary educational setting-based interventions to prevent
anxiety or depression improved well-being, reduced suicidal ideation or self-harm, improved academic
attainment or improved parent reports of child mental disorder symptoms. Subgroup analyses to examine
whether or not intervention effects varied according to SES suggested that interventions delivered in
lower SES settings may be slightly less effective than those delivered in higher/mixed SES settings.
However, this is based on low SES subgroups with a maximum of four studies, and these findings may
not be considered reliable. We did not test for subgroup differences. As regards intervention acceptability,
most studies reported that participants were satisfied with their intervention assignment and interventions
were rated by the students as reasonably enjoyable. It is of note that only two studies reported the
comparative or relative enjoyment across all intervention arms. In both studies, participants preferred the
control interventions.
Conduct disorder
Owing to the diversity of interventions, outcome measures and time points reported by the conduct
disorder studies, results were reported narratively. Five studies were included, of which three were judged
as having an unclear risk of bias for random sequence generation and allocation concealment. One study
was judged as having a low risk of bias for both domains, and one was judged to be at low risk of bias for
randomisation and unclear risk for allocation concealment. No study reported the primary outcome of self-
reported conduct disorder symptoms at post intervention. Instead, results from parent and teacher reports
and secondary measures of externalising behaviours at post intervention were summarised. There was
evidence from two studies of classroom-based interventions and one study of a multisystemic intervention
that externalising behaviours were reduced post intervention. Evidence of a beneficial effect was mixed
from two studies of multisystemic, multicomponent and multiphase interventions. In the short term
(between 1 and 3 years), there was no evidence to support intervention effectiveness. However, both
studies reported evidence over the longer term (5–20 years) of a beneficial effect of the interventions
for preventing self-reported conduct disorder symptoms.
Interpretation of network meta-analysis results across all networks:

post intervention
With regard to comparative effectiveness at the primary post-intervention time point, we conclude
that there is weak statistical evidence to support the effectiveness of school-based anxiety and
depression prevention interventions, that effect sizes are modest and the evidence is not robust.
CBT-based interventions were the most commonly used across the networks analysed. Despite this,
across most networks, there was only weak statistical evidence to suggest that CBT-based interventions
may be effective. There was evidence from the universal secondary analyses that mindfulness/relaxation
interventions are effective in preventing symptoms of anxiety, and evidence from the targeted secondary
102

anxiety analyses that exercise is effective. However, we are cautious about the overinterpretation of these
results because they are based on few studies (two and one, respectively), which were judged to be at
unclear risk of bias. We note that there was also weak evidence from the universal secondary depression
NMA that CBT + IPT is effective at preventing depressive symptoms. However, the three studies including
a CBT + IPT intervention were also rated as having mostly unclear risk of bias.
The evidence base is not robust and further weakens the statistical findings. We note that the risk of
bias for random sequence generation and allocation concealment was rated as unclear across most of
the networks. Meta-epidemiological evidence suggests that, for subjective outcomes (such as self-rated
anxiety or depression), inadequate or unclear allocation concealment exaggerates intervention effect
estimates.267 In the context of this review, the observed intervention-level effects are beneficial relative
to control, but they are ‘small’.268 The potential impact of selection bias on these effect estimates
should be considered in their interpretation. Future work using bias-adjusted NMA could explore the
likely impact further.269
The possibility of non-reporting bias in the universal anxiety analyses, in particular, must be considered
in the interpretation of the statistical findings. There was some evidence that small negative studies
were absent from the anxiety analyses. Adjusting for these studies would probably further attenuate
the modest effects observed.
The between-study heterogeneity was at least moderate in 9 of the 10 primary analyses, and mild to
moderate in one. It is broadly accepted that statistical heterogeneity is inevitable in meta-analysis.270
However, steps should be taken to minimise potential sources of heterogeneity in advance of analysis,
for example by defining coherent review inclusion and exclusion criteria. This is because the extent of
between-study heterogeneity has implications for the interpretation and generalisability of results.43,103
To illustrate the difficulties heterogeneity causes for the decision-maker, we can consider a predictive
interval.271,272 A 95% prediction interval estimates where the true intervention effects are expected
to lie in a new study, or if the intervention were to be rolled out to similar populations (as those
included in the analysis). In the presence of heterogeneity, the prediction interval fully encapsulates
the uncertainty in intervention effect and will be wider than the CI or CrI. For example, in the universal
secondary anxiety analysis (see Chapter 4), the ‘best-bet’ intervention for preventing anxiety is CBT
[SMD –0.15 (95% CrI –0.34 to 0.04) vs. usual curriculum]. However, the corresponding 95% prediction
interval is–0.47 to 0.16. We can interpret this interval as the 95% range of true SMDs to be expected
if we were to implement CBT in secondary schools. That is, having considered the heterogeneity in the
existing evidence for a narrowly defined set of interventions, we cannot rule out the possibility that a
real-world implementation of CBT to school children might be harmful. We note that the observed
heterogeneity was not explained by the subgroup analyses or metaregression, adding to the uncertainty
for decision-makers seeking to implement a disorder-specific preventative intervention.
Key findings of the economic evaluation

The body of evidence described in the review of economic evidence was small (six studies) and
heterogeneous. The CMD addressed, intervention type and cost-effectiveness analyses differed across
the studies identified in the review. It was, therefore, not possible to quantitatively synthesise the
findings. Across the studies reviewed, multiple perspectives for the analyses were taken, leading to the
resources included in the analyses also varying widely. The potential long-term costs associated with
missing school (such as lifetime earning capacity) were not estimated in any of the studies. The two
model-based analyses reviewed suggested that hypothetical interventions could be cost-effective in the
Australian context. However, the trial-based analyses suggested that the interventions were unlikely to
be cost-effective in the UK or the USA. For the one intervention that was potentially cost-effective in
a high-risk subgroup at an interim point of the study, the effect had disappeared with longer-term
follow-up. There was very little empirical costing evidence to inform decisions on the implementation
of preventative interventions.
103
We developed a highly stylised, ‘indicative’ CBT intervention for a microcosting study based on a
universal secondary school setting. Taking the perspective of a single secondary school budget, an
estimated intervention cost of £43 per student was derived. Although there are several ways in which
a ‘real-world’ CBT intervention may differ, the simplistic model provides an indication of the costs that
might accrue to a school budget in the first year of implementation. We also considered the costs of
including a psychoeducation component within a CBT intervention, on the basis of the component
NMA effectiveness results. We estimated that the potential cost of incorporating a psychoeducation
component in the indicative CBT intervention might represent approximately £14 per student. Adding
a psychoeducation component increases intervention costs, but this may be offset by the slightly
greater improvement in anxiety scores post intervention. However, there was only weak evidence for
an improvement in symptoms of depression post intervention in universal secondary settings.
104

Chapter 10 Discussion
I n this chapter, we place the findings summarised in the Chapter 9 in context, with reference to the
existing literature, and we discuss the limitations of the study. The implications for practice and
research are discussed and conclusions presented.
Comparison with other studies
Depression and anxiety

In placing the findings reported here in context, it may be informative to compare the effect sizes
from the present analysis with those observed in psychotherapeutic meta-analyses for the treatment
of childhood depression and anxiety. The most robust evidence observed in our primary analyses was
in universal secondary settings, in which there was weak evidence of a small benefit for CBT-based
interventions (anxiety: SMD –0.15, 95% CrI –0.34 to 0.04; depression: SMD –0.04, 95% CrI –0.16 to
0.07). This can be contrasted with the evidence for group CBT relative to treatment as usual, observed
by Zhou et al.273,274 from a NMA of psychotherapies for treatment of anxiety274 (SMD –0.84, 95% CI
–1.47 to –0.21) and depression273 (SMD –0.32, 95% CI –0.60 to –0.08).
Our results are largely consistent with the findings from large-scale RCTs of school-based prevention
of anxiety and depression. Twelve RCTs included in our NMA had sample sizes of > 1000 at
baseline.118,119,125,126,141,142,151,159,196,204,206,207 All were passive-controlled RCTs (in two studies the control
was a waiting list, in two it was no intervention and in eight it was the usual curriculum). Eight of the
12 RCTs concluded that there was no evidence of an effect of the intervention on self-reported
symptoms of anxiety and/or depression, of which five were at low risk of bias for both random sequence
generation and allocation concealment (Table 21). We also compared our findings with those of 20
systematic reviews of RCTs published since 2005. A summary of the review characteristics is provided in
Appendix 9. Reviews were identified via a combination of non-systematic scoping searches in MEDLINE,
PsycInfo, EMBASE and Google Scholar. Nineteen concluded that there were beneficial effects of anxiety
and depression prevention programmes for CYP. Most noted that effect sizes were small; however, some
were interpreted as showing ‘significant reductions’,113 as ‘consequential’,275 of ‘practical relevance’276 or
providing ‘strong support’111 for the effect of interventions. Only one review reported that ‘Results of the
various programs . . . are not particularly positive . . . the effects (if there are any) are not sustained over
time’.277 Two reviews were more cautious in their interpretation of the small positive effects, noting that
when preventative interventions were compared with an attention control, they ‘showed a sobering lack of
effect’.68,278 We consider possible reasons for the difference in our findings and those of some systematic
reviews below.
Confirmation and developer bias

Confirmation bias may explain the differing interpretations between the present study and previously
published reviews.279 There has been debate about whether systematic reviews should be carried out
by those with no conflicts of interest or by subject experts, who are best placed to understand the
nuances of study inclusion/exclusion and interpretation of findings.280 In an empirical study in which
subject experts and methodologists were shown the same meta-analysis, Panagiotou and Ioannidis281
observed that subject experts were more likely than methodologists to over-interpret the pooled effect
from a meta-analysis. Furthermore, subject experts who had also published a ‘statistically significant’
study showing a positive intervention effect were even more likely to over-interpret findings and to
overlook the importance of the between-study heterogeneity on the overall interpretation.
105
DISCUSSION
TABLE 21 Previous large-scale RCTs of school-based prevention of anxiety and depression
Risk of bias
Author reported
Consent/ Random sequence Allocation that intervention
Study Randomiseda (n) baseline (n) generation concealment was effective
Araya et al.118 2013 2512 2508 Low Unclear ✗
Calear et al.127
2016 Not clear 1767 Low Low ✗
Kindt et al.196 2014 1440 1343 Low Low ✗
Sawyer et al.204 2010 8873 5633 Unclear Low ✗
Sheffield et al.141 2006 2479 1226 Low Low ✗

Stallard et al. 142
2013 5761 5030 Low Low ✗
Stallard et al.159 2014 1448 1362 Low Unclear ✗
Tak et al.207 2016 1390 1341 Unclear Low ✗
Aune and Stiles119 2009 2148 1748 Unclear Unclear ✓
Calear et al.125
2009 NR 1477 Low Low ✓
Gallegos126 2008 1070 1030 Unclear Unclear ✓
Spence et al.206 2003 Not clear 1500 Unclear Unclear ✓

NR, not reported.
a In some cluster randomised trials, schools are randomised to the intervention before consent is sought from
participants. Therefore, there are fewer participants assessed at baseline than originally randomised. For example, in
Stallard et al.,142 5761 participants were randomised; however, 5030 participants consented. In other trials this is not
well reported, and it was not possible to distinguish between the number randomised, the number consented and
the number providing a baseline measure.
There was some evidence to suggest that preventative RCTs involving the original intervention developer(s)
observed stronger intervention effects, although the mechanism was not clear.282,283 For example, it is
possible that implementation and fidelity to intervention are superior in developer-led trials. The impact of
so-called ‘developer bias’ on systematic reviews is unknown; however, in the case of 14 of the 20 reviews
we identified, the first or senior author was a researcher who subsequently developed/published a school-
based RCT to prevent anxiety or depression. Owing to an increased emphasis on reducing research
waste,284 it is increasingly common for intervention developers or triallists to first conduct a systematic
review. Further research could consider the role of developer bias in systematic reviews.
Inclusion criteria and meta-analytic method

Differences in inclusion criteria should also be considered. We investigate whether or not there was a
discrepancy between the studies included in the present review and the 20 reviews described above
(see Appendix 9). Reviews for which there was a > 40% discrepancy were Horowitz and Garber285 (57%),
Neil and Christensen111 (42%), Neil and Christensen112 (48%), Stice et al.113 (46%) and Teubert276 (58%).
For example, of the 30 studies included in Horowitz and Garber,285 only 13 were included in the present
review. The main inclusion differences related to the earlier reviews having broader inclusion criteria,
for example severity of symptoms;113,276 inclusion of interventions for children of divorce or alcoholics;113,285
and interventions to address situational (state) anxiety, such as test and public speaking276 or
stress reduction.111,112,276
The choice of meta-analytic method could be a further explanation for findings differing across
reviews. Of the 14 reviews conducting a meta-analysis, 10 used a random-effects model, two used a
fixed-effects model and two used an undefined model to estimate a pooled effect. Nine summarised
intervention effects using Cohen’s d and nine using Hedges’ g. In the present review, we fitted both
106

fixed- and random-effects models, but presented results from the random-effects models based on
statistical evidence of heterogeneity. We summarised effects using Hedges’ g, which is observed to be
less biased in the presence of small studies (i.e. < 20 participants). Durlak286 states that the Hedges’ g
correction typically amounts to a 4% reduction in effect when the total sample size is 20 participants,
and around 2% when the sample size is 50. In the present analysis, four studies had sample sizes of
≤ 20 participants, and 19 had sample sizes of ≤ 50. Therefore, the impact of the adjustments made by
Hedges’ g is likely to be small.
There are several ways to estimate the SMD; here we used the (standardised) difference in mean change
from baseline (also known as change score) and we standardised using the pooled baseline SD. A common
alternative is to use the final values (also known as post-intervention score, or follow-up score). It is not
clear which approach was taken in the previous meta-analyses. However, using final values may not be
appropriate when randomisation is questionable or when there is baseline imbalance in factors that
may interact with the outcome. For example, if participants randomised to the control arm have higher
depression symptom scores at baseline than those in the active arm, one cannot confidently conclude that
the final values reflect the effect of the intervention, rather than severity of initial illness. In such cases,
using final values may overestimate the effect of an intervention. In addition, our analyses were conducted
in a Bayesian framework, in contrast to all 20 previous reviews, which took a frequentist approach. In a
Bayesian analysis, the uncertainty in all parameters is fully represented. In particular, it takes full account
of uncertainty in the between-studies SD in a random-effects model. Frequentist methods typically assume
that the between-studies SD is known with certainty; as a result, Bayesian CrIs tend to be wider than
frequentist CIs for random-effects models.287
Standard pairwise meta-analysis and network meta-analysis

A further difference between the present review and those described previously is that we separated
intervention and control groups into their distinct types. We a priori identified four distinct control
conditions: attention control, waiting list, no intervention and usual curriculum. This was based on the
psychotherapeutic literature, in which it was established that control group choice contributes to
differences in effect size estimate.73,74 To explore the possible impact of this decision, we ran a simple
analysis ‘lumping’ these control conditions to form a single comparator. To emulate previous analyses
more closely, we also included psychoeducation and psychosupport conditions in the conflated ‘control’
condition. Primary and secondary settings were also combined, but we kept universal and targeted
populations separate. We also ran a second analysis combining psychological interventions, to form a
‘psychological intervention versus control’-type analysis.
When control conditions were conflated, our results were consistent with previous reviews, that is
intervention effects for CBT versus ‘control’ now indicated a beneficial effect of CBT in every network
at post intervention (see Appendix 9). This suggests that previously observed beneficial effects may
have been a consequence of differential control group effects being obscured by ‘lumping’. However,
the impact of lumping control groups in meta-analyses of public mental health interventions should be
explored further. Certainly, in the psychotherapeutic literature, the use of a waiting list has been
called a ‘nocebo’73 and a technique ‘to prove your therapy is effective, even when it is not’.74 Future
preventative and public health trials should also consider the importance of control groups at the
feasibility or pilot stages of development.
Conduct disorder
The preliminary signs of conduct problems often emerge during early childhood. As a result, school-
based interventions specifically aimed at the prevention of conduct disorder have been implemented in
primary school settings. In recent years, however, interventions for preventing conduct disorders have
largely focused on parenting skills, in community or home settings (e.g. Family Check-up, Nurse Family
Partnership, Triple P).288 The 2013 NICE guidelines on recognition of, intervention for and management
107
DISCUSSION
of conduct disorders among CYP289 included a review of classroom-based interventions for selective
and indicated prevention of conduct disorders. Noting that only 53% of the eligible studies included
sufficient data for inclusion in a meta-analysis, the NICE guidelines concluded that, for selective
interventions, the mean teacher-rated antisocial behaviour in the intervention groups was SMD –0.43
(95% CI –0.96 to –0.09). However, it is unlikely that teachers could have been blinded to intervention
allocation. Conversely, there was no evidence of an effect when rated by an external observer (SMD –0.43,
95% CI –0.96 to 0.09) or for parent-reported antisocial behaviour (SMD –0.13, 95% CI –0.39 to 0.13).
We found few reviews explicitly referring to the prevention of conduct disorder, and most were conducted
in the 1990s.290–294 Instead, authors have focused on the prevention of collections of behaviours associated
with conduct disorder, for example interventions that aim to prevent multiple risk behaviours such as
substance misuse, aggression and stealing.295 For example, in an early review of the prevention of ODD and
conduct disorder, Tremblay et al.293 state:
To our surprise, we found no preventative interventions that met our selection criteria . . . We thus
broadened the scope and selected studies with outcome measures related to CD [conduct disorder]/ODD
symptoms including court recorded or self-report delinquency, self-, parent- or teacher-rated measures
of aggressive externalising behaviour and observer measures of aversive behaviour in the classroom.
We generally refer to these outcomes using the term Disruptive Behaviour Disorders.
Tremblay et al.293
More recent reviews taking this broader approach for school settings, such as Park-Higgerson et al.,296
suggest that there is no evidence of an effect for interventions reducing aggression and violence, compared
with the control (effect size –0.09, 95% CI –0.23 to 0.05).296 de Vries et al.297 examined prevention
programmes for adolescents showing early signs of antisocial and disruptive behaviour problems.
For interventions in a school setting, there was no evidence of an effect relative to usual curriculum
[β –0.19 (SE 0.33)]. However, in a 2018 Cochrane review84 of interventions to prevent multiple risk
behaviours, a positive effect of universal school-based interventions to prevent a composite outcome of
‘anti-social behaviour and offending’ was observed (OR 0.81, 95% CI 0.66 to 0.98).84 We note that
studies contributing to such reviews may not even reference conduct or disruptive behaviour disorders
in their aims or backgrounds. We return to the issue of defining conduct disorder subsequently, in the
limitations section.
Strengths and limitations of the study
To the best of our knowledge, this is the first NMA of preventative mental health interventions and
the first to review the comparative effectiveness of distinct psychological, educational and physical
interventions in a single analysis for CYP.
Limitations relating to search strategy

There is growing interest in improving the efficiency of study identification in systematic reviews.54,298–302
However, there is no consensus on the number of databases to search or for defining appropriate ‘stopping
rules’ or abbreviated search strategies.52,53 A limitation of the present study is, therefore, that we searched
only four electronic health-related and psychology databases. The selection of databases was consistent
with the Cochrane MECIR conduct standards for searching, and included reference list searching of
published systematic reviews and scoping searches to inform the ‘stopping’ strategy. The electronic
database searches retrieved all but two eligible studies previously included in published systematic
reviews; neither of these contributed to the NMA.188,303 The scoping searches of two educational databases
(ERIC and BEI) did not identify any further eligible studies. However, the possibility that potentially eligible
studies have been missed cannot be ruled out emphatically.
108

Limitations relating to inclusion criteria

The inclusion and exclusion criteria were specified to minimise the potential for between-study heterogeneity
and to address the assumption of consistency for the NMA. This condition was satisfied in 8 of the
10 networks, with inconsistency being noted in the two tertiary/university-level analyses. Nevertheless,
we consider the implications of the narrow inclusion criteria below.
Definition of disorder
To be eligible for inclusion in the present review, the explicit aim of a study had to be the prevention
of anxiety, depression or conduct disorder. These might be considered as ‘disorder-specific’ prevention
interventions, although, in practice, some sought to prevent both anxiety and depression. The focus of
the present review was the prevention of anxiety, depression and conduct disorder, and not specific
diagnostic subtypes of disorders. Although we did not exclude studies focusing on specific disorders
(e.g. social anxiety), our preferred outcome was a total symptom score. This approach is consistent
with a population health perspective,304 the existing trial literature and previous systematic reviews.
Only one study119 focused on the prevention of a specific anxiety disorder (social anxiety), and none
addressed the prevention of subtypes of depression or conduct disorder.
To reduce the risk of selective outcome reporting, studies were not selected on the basis of reported
outcomes. That is, studies were not selected on the basis of whether or not they reported anxiety,
depression or conduct disorder outcomes. Selective outcome reporting can occur when studies measure
multiple outcomes but select only those that are ‘statistically significant’ for publication. In turn, this can
cause bias in a body of evidence and overestimate the effect of interventions. Prospective trial registration
and protocols reduce the likelihood of selective reporting; however, this was not made a mandatory
requirement in medicine until 2008. We are not aware of a current similar requirement within psychological
science. As noted in Chapter 9, only 32 of the 142 studies included in this review had protocols or trial
registrations readily available. We therefore chose a conservative approach of including studies based
on the stated intent of the trial, as written in the publication.
The decision to restrict inclusion to disorder-specific prevention interventions is likely to have had the
biggest impact for the review of conduct disorder. Fairchild et al.305 note that conduct disorder is a highly
heterogeneous disorder and they state there are > 32,000 different symptom profiles that could lead to a
diagnosis. Such clinical variation is likely to pose an even bigger problem for primary preventative studies
with regard to defining a target population. Over the preceding 25 years (since the publication of the
DSM-IV), clinical language has evolved and, in the present review, it was not easy to judge whether or not
study authors were using the terms ‘problems’ and ‘disorders’ interchangeably. Again, in the absence of
trial registrations and protocols, we chose a conservative approach and restricted to ‘disorders’. A related
concern refers to our reliance on DSM-5 criteria and the decision to exclude neurodevelopmental and
neurobiological conditions. In DSM-III, -IV and -IV Text Revision (spanning 1980–2012), conduct disorders
were categorised together with ADHD under ‘Attention-deficit and disruptive behavior disorders’.
In DSM-5,61 they were separated. Conduct disorders are now grouped under ‘Disruptive, Impulse-Control,
and Conduct Disorders’ and ADHD is separately considered under the ‘Neurodevelopmental Disorders’
heading. It is not clear whether or not older studies considered ‘conduct disorder’ as a catch-all for
‘disruptive behaviour disorders’, which historically included ADHD. In a NMA of psychosocial interventions
for the treatment of childhood disruptive behaviour disorders, Epstein et al.306 conclude that future studies
must more clearly identify the target population for intervention. We echo their conclusion here, for
preventative interventions.
Intervention focus
To minimise potential between-study heterogeneity and to address the assumption of consistency
for the NMA, we included a narrowly defined set of interventions. Unless it was clear that the aim of
the intervention was to prevent anxiety, depression or conduct disorder, we excluded interventions
focused on mental health promotion. Similarly, we excluded studies addressing the related constructs
of social and emotional well-being and positive mental health. Here we followed the NAM’s definition
109
DISCUSSION
of mental health promotion as interventions that ‘aim to enhance an individual’s ability to achieve
developmentally appropriate tasks and a positive sense of self-esteem, mastery, well-being and social
inclusion, and strengthen their ability to cope with adversity’.27 Recent evidence has suggested that
well-being is only weakly correlated (r = 0.2) with mental illness in children,64 raising doubts that
interventions targeting one will necessarily affect the other.63 However, some interventions may aim
to address both prevention and promotion, for example the Aussie Optimism Program.152 In such
instances, we referred to trial registrations and protocols to inform our inclusion decision. However,
given the absence of trial registrations or protocols, it was difficult to operationalise this distinction,
and this is a limitation of the review.
In common with previously published systematic reviews that focused on disorder-specific prevention
of anxiety, depression or conduct disorder,36–39,68 we did not include interventions that primarily
addressed the prevention of substance use, bullying or stress, although these factors have been shown
to be associated with later mental ill health. We also excluded classroom management and social and
emotional learning interventions. Classroom management interventions use conditioning and reinforcement
to encourage prosocial behaviours and reduce challenging behaviours in their classrooms (e.g. providing
clear expectations and routines, stating clear rules and consequences, and consistently using praise
and other rewards). Consequently, interventions such as the Good Behaviour Game were not included
in our review. However, there is recent evidence that these interventions do affect general conduct
outcomes for children and are cost-effective in a UK context.307 This could be considered a limitation of
the findings for conduct disorder.
Mental health is multifaceted, with biological and environmental factors contributing to the
development of a disorder. A further limitation of this review is that the interventions included are
largely ‘downstream’. That is, they are focused on changing an individual’s cognitions, emotions or
mood, without addressing the wider ‘upstream’ social determinants of mental health or the complex
adaptive systems in which interventions are implemented.308 It is, therefore, important to situate
our findings in the context that there are calls to reframe preventative mental health towards a
broader dimensional approach309,310 and incorporate other perspectives, such as a developmental
psychopathological perspective to prevention.311 In psychology and psychiatry, this has manifested in
calls for a ‘paradigm shift’ away from the categorical approach to diagnosing mental disorders (e.g. ICD
and DSM).312–314 In public health, the focus has shifted to whole-school, systemic interventions as a
wider, structural approach to tackle the increasing prevalence of CYP with mental health problems.
Whole-school interventions have shown promise for physical health outcomes83 and emotional
well-being;315 however, there is limited evidence, to date, that they are effective in the prevention
of CMDs.83,316 The present review is limited by the absence of these perspectives; future work should
be considered to evaluate the comparative effectiveness of such interventions.
Defining population
We followed the NAM’s intervention spectrum for mental disorders, which defines three populations:
universal, selective and indicated. By definition, participants in universal interventions are included
irrespective of diagnostic status; consequently, studies included in the universal analyses will have
included CYP with diagnosed mental health conditions at baseline. As noted in Chapter 1, a definitive
boundary between indicated prevention and early intervention (i.e. treatment) is difficult to draw.
Our eligibility criteria sought to minimise the inclusion of CYP with clinical conditions in the ‘targeted’
analyses, but, in the absence of clearly defined scale cut-off points or diagnostic tests for anxiety,
depression or conduct disorder, we relied on author descriptions of participants. As a result, we cannot
rule out the possibility that some of the participants in the ‘targeted’ analyses may also have had
clinically diagnosable conditions. Here we reflect that the distinction between indicated prevention and
early intervention is a qualitative one and is likely to rest with the intent of the triallist. If the intent
of a study is to decrease the likelihood of the onset of a mental disorder or decrease detectable, but
subclinical, symptoms, it can be considered prevention. If the aim of the study is to reduce existing,
clinically meaningful or diagnosed symptoms, it can be considered treatment.
110

The inclusion criteria meant that there were few studies of eligible university-based interventions.
In the original protocol, we stated that the upper age limit for eligible studies was 25 years, which was
intended to allow for follow-up time points. As described in Table 1, this was difficult to operationalise,
and was modified to be ≤ 19 years at baseline. In turn, this limited the eligible university population
and is likely to have excluded interventions specifically aimed at older undergraduate and postgraduate
students. The inclusion criterion that the intervention should be educational setting based was also
restrictive. In tertiary education institutions, many interventions were delivered in health-care settings
(e.g. primary care, psychology clinics) or remotely, without supervision (e.g. via mobile phone, internet).
As a comparison, a 2019 review with broader inclusion criteria included 62 studies of preventing
anxiety and depression in university students.317 This larger review concluded that the overall effect
size was moderate (Hedges’ g 0.65, 95% CIs 0.57 to 0.73). In combination with the potential for
inconsistency observed in the tertiary NMAs, the small number of included tertiary/university studies
is a further limitation of the present review; therefore, we do not make inferences about the effect of
interventions in that setting.
Limitations relating to outcomes

Although agreement between parent- and child-reported symptoms is typically low, multi-informant
measures of mental disorder symptoms among CYP are often considered preferable to single report.318–320
Therefore, it may be considered a limitation that our primary outcomes were only symptoms self-reported
by CYP. Parent-reported child symptoms were included as a secondary outcome; however, only 12% of
the anxiety and depression studies included a parent report. All studies included for the prevention of conduct
disorder included a parent and/or teacher report. Self-reported outcomes may be at higher risk of performance
bias than observer-rated outcomes owing to lack of blinding to intervention allocation. In trials of school-based
interventions, however, it is also questionable whether or not parents and teachers can be successfully
blinded. Furthermore, the outcome of interest for decision-makers wanting to reduce the burden of
common mental disorders is likely to be clinical diagnosis or service use, not symptoms. Clinical diagnosis
was infrequently reported for the anxiety and depression studies, but was reported for the longer-term
follow-ups in the conduct disorder studies.
Other limitations
The typology of interventions was based on previous literature, piloting and discussion among our
team. However, the use of the constant comparative method was time-consuming and, inevitably,
subjective. We sought greater objectivity by one reviewer initially drawing up a list of components,
which was refined by a second reviewer through discussion. The list was further reviewed by two
additional members of the team. Their suggested modifications were piloted and a final classification
scheme constructed. This scheme was then applied and further refined during data extraction, until no
further components were identified (saturation). Relying on published papers also generated problems
for classifying components. To ensure a consistent approach across all studies, we did not assume the
presence of a component unless it was explicitly stated in the paper or confirmed via correspondence
with the authors. Inevitably, the taxonomy reflects the narrow set of interventions on which it is based,
and it may not generalise to other preventative mental health interventions, as a result of the inclusion
and exclusion criteria adopted here. Owing to the subjectivity of classification and lack of a consistent
format for reporting of intervention details, there is potential for component misclassification.321 It is
also of note that the classification scheme that we developed for anxiety and depression did not
generalise to conduct disorder interventions. As a result, we do not claim this as a definitive taxonomy,
but a contribution to the growing literature.
Few studies reported sufficient detail to judge how randomisation or allocation concealment had been
conducted; consequently, the risk of bias for these domains are mostly judged to be unclear. Many
studies also had short follow-up periods, and it was not always clear whether reported follow-up periods
referred to post intervention or from baseline. Only 13% of studies of anxiety and depression prevention
studies reported a follow-up of > 1 year, and 5% reported a follow-up of > 2 years. For conduct disorder,
two studies reported longer-term follow-ups and both indicated strong evidence of an effect (although
they were not cost-effective; see Chapter 8).
111
DISCUSSION
Implications for practice
In this review, we conclude that there is weak evidence to support the effectiveness of school-based
anxiety, depression or conduct disorder prevention interventions, but that it is not robust evidence.
The available economic evidence for a UK context suggests that school-based anxiety and depression
prevention interventions are ‘highly unlikely’ to be cost-effective, compared with usual curriculum,
especially when the usual curriculum already contains a personal, social and health education aspect.261,322
For conduct disorder, the US-based Fast Track cost-effectiveness evaluation suggests that it is unlikely
that such a comprehensive, multisystemic approach would be implemented in practice.250,263,264
However, the policy environment in the UK has recently placed schools front and centre in the prevention,
early detection and support of students with mental health needs. Therefore, schools and local authorities
may need access to comprehensive and independent sources of information to ensure that they are not
susceptible to exaggerated claims or ‘trends’ about what works for the mental health of CYP.323,324
Examples of freely accessible, evidence-based repositories and services include Evidence for Impact325
and the Early Intervention Foundation.326 However, bespoke evidence-based services could also be
useful to support schools that have identified specific mental health needs, and could emulate those
run by AskFuse327 for Public Health and the Avon and Wiltshire Mental Health Partnership NHS Trust’s
BEST in Mental Health328 evidence service for treatment of mental disorders.
Local government, education authorities, schools and universities should be made aware that few
studies have measured potential harms or side effects of the interventions. This may include explicit
harms, social harms or equity harms.329 For example, in our study, we observed weak evidence that
depression and anxiety prevention interventions may be more beneficial in higher-income settings
than in low-income settings. The opportunity cost of implementing a potentially harmful intervention
(one that has the potential to increase symptoms) should be considered by those commissioning
interventions. Lorenc and Oliver329 describe this as ‘the potential benefits which may be forgone as a
result of committing resources to ineffective or less effective interventions’.
Implications for research
The following implications for research are described in priority order.
Although overall evidence was weak, and risk of bias was judged to be unclear, the component NMA
provided evidence that CBT interventions including a psychoeducation component may be effective for
the prevention of anxiety and depression in universal secondary settings. There was also evidence that
exercise and mindfulness/relaxation interventions were effective for symptoms of anxiety in universal
secondary settings, although this was not robust. In the light of these findings, a future RCT in a secondary
school setting might consider a multiarm design comparing CBT with mindfulness/relaxation with an
attention control. It may also be of interest to explore the impact of including an active exercise
component. However, before progression to a RCT, further work is undoubtedly necessary to optimise
the content of such an intervention,330 including exploring the mechanisms of action for psychoeducation
components for CYP. Such work should be conducted in consultation with CYP. What is clear is that
any future RCTs of preventative mental health interventions must be well designed and include an
economic evaluation.
Further research on the importance of control conditions for all public health interventions should
also be a priority. Until then, we echo Merry and Hetrick’s331 conclusions and suggest that RCTs of
interventions to prevent CMDs should use an active control (attention control or alternative
intervention) and that waiting list controls should be discouraged.
112

It has been suggested that intervention effects can emerge over a longer time period in public health.332,333
However, the majority of studies included in this report reported a post-intervention time point only,
and we are not able to confirm or refute this observation. For anxiety and depression, only 18 trials
from the 137 included had outcomes available at > 12 months post intervention and only seven trials
reported time points at > 24 months. Follow-up periods were longer for the conduct disorder studies,
and the positive study-level findings from the 20-year follow-up of Fast Track247 suggest that school-
based RCTs should plan for longer follow-up periods. The possibility of using data linkage could be
considered as an adjunct or substitute for primary data collection where resources are a concern.
Future preventative intervention studies should also include measurements of potential harms and/or
side effects. However, it is not clear from our review what harms or side effects should be measured,
and further research on core outcome sets should consider this issue.334 Consideration of prevention
of common mental health disorders from a systems perspective335 may also help to identify such
unintended consequences.
Finally, the reporting of basic methodological aspects of the included studies was inadequate and scientific
journals should ensure that the Consolidated Standards of Reporting Trials (CONSORT) guidance,336
and its extension to Social and Psychological interventions,337 is fully adhered to. To improve reporting
of intervention components, authors should be encouraged to complete TIDieR reporting guideline
for complex interventions and comparator conditions. The work reported in this monograph contributes
to the growing literature around components of mental health interventions. However, the field lacks
consensus and future work should focus on agreeing a taxonomy for preventative mental health
interventions and control conditions.
Conclusions
With regard to the comparative effectiveness of school-based anxiety, depression and conduct disorder
prevention interventions, there is a lack of robust evidence that any one type of intervention can be
preferred across all populations and settings. However, in making this statement, we reiterate that the
present review specifically addressed prevention of clinically referenced disorders. These conclusions,
therefore, relate to a narrowly defined set of largely ‘downstream’ interventions, which focus on
changing an individual’s cognitions, emotions or behaviours, without addressing wider ‘upstream’ social
determinants of mental health (e.g. SES) or the complex, adaptive systems in which interventions
are implemented.288
113
Acknowledgements
T his work was undertaken with the support of DECIPHer, one of the UK Clinical Research
Collaboration Public Health Centres of Excellence. We thank the ALPHA young people’s public
input advisory group based in DECIPHer and the parents who attended the parenting PPI session in
Bargoed, Wales.
Contributions of authors
Deborah M Caldwell (https://orcid.org/0000-0001-8014-7480) (Senior Lecturer in Public Health)

co-conceived the project, co-led and contributed to the systematic review and components analysis,
conducted intervention-level NMAs and drafted the report.
Sarah R Davies (https://orcid.org/0000-0003-1321-7826) (Deputy Managing Editor, Cochrane

Developmental, Psychosocial and Learning Problems group) co-led and contributed to the systematic
review and component analysis and commented on the draft report.
Joanna C Thorn (https://orcid.org/0000-0001-8962-2428) (Research Fellow) led the economic

evaluation, drafted Chapter 8 and commented on report drafts.
Jennifer C Palmer (Senior Research Associate) and Paola Caro (PhD student) contributed to the
systematic review and commented on report drafts.
Sarah E Hetrick (https://orcid.org/0000-0003-2532-0142) (Associate Professor of Youth Mental

Health) co-conceived the project, contributed to the systematic review and components analysis, and
commented on report drafts.
David Gunnell (https://orcid.org/0000-0002-0829-6470) (Professor of Epidemiology) co-conceived the

project and commented on report drafts.
Sumayya Anwer (https://orcid.org/0000-0002-1740-0399) (Research Fellow) contributed to

component-level NMAs.
José A López-López (https://orcid.org/0000-0002-9655-3616) (Lecturer in Psychological Methods)

contributed to intervention-level NMAs and commented on the report.
Clare French (https://orcid.org/0000-0002-6943-7353) (Senior Research Associate) contributed to the

systematic review and commented on the report.
Judi Kidger (https://orcid.org/0000-0002-1054-6758) (Senior Lecturer in Public Health) co-conceived

the project, contributed to the components analysis and commented on the draft report.
Sarah Dawson (https://orcid.org/0000-0002-6682-063X) (Information Specialist) provided guidance on

and executed the electronic database searches.
Rachel Churchill (https://orcid.org/0000-0002-1751-0512) (Professor in Evidence Synthesis)

co-conceived the project and provided guidance and advice on project direction and the
component analysis.
James Thomas (https://orcid.org/0000-0003-4805-4190) (Professor of Social Research and Policy)

co-conceived the project and commented on the report.
115
ACKNOWLEDGEMENTS
Rona Campbell (https://orcid.org/0000-0002-1099-9319) (Professor of Public Health Research)

co-conceived the project and commented on the report.
Nicky J Welton (Professor in Statistical and Health Economic Modelling) co-conceived the project,
contributed to intervention-level NMAs, led component-level NMAs, supervised the economic
evaluation, drafted sections of the report and provided comments on the report.
Publication
Caldwell DM, Davies SR, Hetrick SE, Palmer JC, Caro P, López-López JA, et al. School-based
interventions to prevent anxiety and depression in children and young people: a systematic review
and network meta-analysis. Lancet Psychiatry 2019;6:1011–20.
Data-sharing statement
Requests for access to extracted study data should be addressed to the corresponding author. Intervention
and component-level NMA WinBUGS code is available from https://research-information.bris.ac.uk/en/
persons/deborah-m-caldwell/projects/ or by contacting the corresponding author.
116

References
1. Caldwell DM, Davies SR, Hetrick SE, Palmer JC, Caro P, López-López JA, et al. School-based
interventions to prevent anxiety and depression in children and young people: a systematic
review and network meta-analysis. Lancet Psychiatry 2019;6:1011–20. https://doi.org/10.1016/
S2215-0366(19)30403-1
2. World Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!):
Guidance to Support Country Implementation. Geneva: World Health Organization; 2017.
3. NHS Digital. Mental Health of Children and Young People in England, 2017 [PAS].
URL: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-
children-and-young-people-in-england/2017/2017 (accessed 31 December 2019).
4. Patton GC, Coffey C, Romaniuk H, Mackinnon A, Carlin JB, Degenhardt L, et al. The prognosis
of common mental disorders in adolescents: a 14-year prospective cohort study. Lancet
2014;383:1404–11. https://doi.org/10.1016/S0140-6736(13)62116-9
5. Gore FM, Bloem PJ, Patton GC, Ferguson J, Joseph V, Coffey C, et al. Global burden of disease
in young people aged 10-24 years: a systematic analysis. Lancet 2011;377:2093–102.
https://doi.org/10.1016/S0140-6736(11)60512-6
6. Perkins A, Ridler J, Browes D, Peryer G, Notley C, Hackmann C. Experiencing mental health
diagnosis: a systematic review of service user, clinician, and carer perspectives across clinical
settings. Lancet Psychiatry 2018;5:747–64. https://doi.org/10.1016/S2215-0366(18)30095-6
7. Martínez-Hernáez A, DiGiacomo SM, Carceller-Maicas N, Correa-Urquiza M, Martorell-Poveda MA.
Non-professional-help-seeking among young people with depression: a qualitative study. BMC
Psychiatry 2014;14:124. https://doi.org/10.1186/1471-244X-14-124
8. Carrellas NW, Biederman J, Uchida M. How prevalent and morbid are subthreshold
manifestations of major depression in adolescents? A literature review. J Affect Disord
2017;210:166–73. https://doi.org/10.1016/j.jad.2016.12.037
9. Cameron IM, Lawton K, Reid IC. Recognition and subsequent treatment of patients with
sub-threshold symptoms of depression in primary care. J Affect Disord 2011;130:99–105.
https://doi.org/10.1016/j.jad.2010.10.010
10. Kidger J, Heron J, Lewis G, Evans J, Gunnell D. Adolescent self-harm and suicidal thoughts
in the ALSPAC cohort: a self-report survey in England. BMC Psychiatry 2012;12:69.
https://doi.org/10.1186/1471-244X-12-69
11. National Collaborating Centre for Mental Health. Depression in Children and Young People:
Identification and Management in Primary, Community and Secondary Care. Leicester: British
Psychological Society; 2005.
12. Champion KE, Mather M, Spring B, Kay-Lambkin F, Teesson M, Newton NC. Clustering of
multiple risk behaviors among a sample of 18-year-old Australians and associations with
mental health outcomes: a latent class analysis. Front Public Health 2018;6:135. https://doi.org/
10.3389/fpubh.2018.00135
13. Pailing AN, Reniers RLEP. Depressive and socially anxious symptoms, psychosocial maturity,
and risk perception: associations with risk-taking behaviour. PLOS ONE 2018;13:e0202423.
https://doi.org/10.1371/journal.pone.0202423
117
REFERENCES
14. Bannink R, Broeren S, Heydelberg J, van’t Klooster E, Raat H. Depressive symptoms and
clustering of risk behaviours among adolescents and young adults attending vocational
education: a cross-sectional study. BMC Public Health 2015;15:396. https://doi.org/10.1186/
s12889-015-1692-7
15. Finning K, Ford T, Moore DA, Ukoumunne OC. Emotional disorder and absence from school:
findings from the 2004 British Child and Adolescent Mental Health Survey. Eur Child Adolesc
Psychiatry 2020;29:187–98. https://doi.org/10.1007/s00787-019-01342-4
16. Finning K, Moore D, Ukoumunne OC, Danielsson-Waters E, Ford T. The association between
child and adolescent emotional disorder and poor attendance at school: a systematic review
protocol. Syst Rev 2017;6:121. https://doi.org/10.1186/s13643-017-0523-6
17. Hagell A, Shah R, Viner R, Hargreaves D, Varnes L, Heys M. The Social Determinants of Young
People’s Health: Identifying the Key Issues and Assessing How Young People are Doing in the 2010s.
URL: www.health.org.uk/publications/the-social-determinants-of-young-people%E2%80%99s-health
(accessed 31 December 2019).
18. Gutman LM, Joshi H, Parsonage M, Schoon I. Children of the New Century: Mental Health
Findings from the Millennium Cohort Study. URL: www.centreformentalhealth.org.uk/sites/
default/files/2018-09/newcentury.pdf (accessed 31 December 2019).
19. Fergusson DM, Boden JM, Horwood LJ. Recurrence of major depression in adolescence and
early adulthood, and later mental health, educational and economic outcomes. Br J Psychiatry
2007;191:335–42. https://doi.org/10.1192/bjp.bp.107.036079
20. Bor W, Dean AJ, Najman J, Hayatbakhsh R. Are child and adolescent mental health problems
increasing in the 21st century? A systematic review. Aust N Z J Psychiatry 2014;48:606–16.
https://doi.org/10.1177/0004867414533834
21. Collishaw S. Annual research review: secular trends in child and adolescent mental health.
J Child Psychol Psychiatry 2015;56:370–93. https://doi.org/10.1111/jcpp.12372
22. Royal College of Psychiatrists. No Health Without Public Mental Health: The Case for
Action. Position Statement PS4/2010. URL: www.rcpsych.ac.uk/docs/default-source/
improving-care/better-mh-policy/position-statements/ps04_2010.pdf?sfvrsn=b7316b7_4
23. Rocha TB, Graeff-Martins AS, Kieling C, Rohde LA. Provision of mental healthcare for children
and adolescents: a worldwide view. Curr Opin Psychiatry 2015;28:330–5. https://doi.org/
10.1097/YCO.0000000000000169
24. Local Government Association. CAMHS – Facts and Figures. URL: www.local.gov.uk/about/
campaigns/bright-futures/bright-futures-camhs/child-and-adolescent-mental-health-and
25. Andrews G, Issakidis C, Sanderson K, Corry J, Lapsley H. Utilising survey data to inform
public policy: comparison of the cost-effectiveness of treatment of ten mental disorders.
Br J Psychiatry 2004;184:526–33. https://doi.org/10.1192/bjp.184.6.526
26. Institute of Medicine, Committee on Prevention of Mental Disorders. Mrazek PJ, Haggerty RJ,
editors. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research.
Washington, DC: National Academies Press; 1994.
27. National Research Council and Institute of Medicine. Preventing Mental, Emotional, and
Behavioral Disorders Among Young People Progress and Possibilities. Washington, DC: National
Academies Press; 2009.
118

28. Arango C, Díaz-Caneja CM, McGorry PD, Rapoport J, Sommer IE, Vorstman JA, et al.
Preventive strategies for mental health. Lancet Psychiatry 2018;5:591–604. https://doi.org/
10.1016/S2215-0366(18)30057-9
29. Department of Health and Social Care, Department for Education. Transforming Children
and Young People’s Mental Health Provision: A Green Paper. URL: www.gov.uk/government/
consultations/transforming-children-and-young-peoples-mental-health-provision-a-green-paper
30. Cabinet Office, Department of Health and Social Care. Advancing our Health: Prevention in
the 2020s. URL: www.gov.uk/government/consultations/advancing-our-health-prevention-in-
the-2020s (accessed 31 December 2019).
31. UK Government. School Leaving Age. URL: www.gov.uk/know-when-you-can-leave-school
32. Department for Education. Schools, Pupils and their Characteristics: January 2019.
URL: www.gov.uk/government/statistics/schools-pupils-and-their-characteristics-january-2019
33. Scottish Government Learning Directorate. Summary Statistics for Schools in Scotland no. 10:
2019 Edition. URL: www.gov.scot/publications/summary-statistics-schools-scotland-no-10-
2019-edition/ (accessed 31 December 2019).
34. Welsh Government StatsWales. Pupils Present on Census Day by Local Authority and Sector.
URL: https://statswales.gov.wales/Catalogue/Education-and-Skills/Schools-and-Teachers/
Schools-Census/Pupil-Level-Annual-School-Census/Pupils/pupilspresentcensusday-by-
localauthorityregion-sector (accessed 31 December 2019).
35. Department for Education Northern Ireland. School Enrolments – Northern Ireland Summary Data.
URL: www.education-ni.gov.uk/publications/school-enrolments-northern-ireland-summary-data
36. Werner-Seidler A, Perry Y, Calear AL, Newby JM, Christensen H. School-based depression
and anxiety prevention programs for young people: a systematic review and meta-analysis.
Clin Psychol Rev 2017;51:30–47. https://doi.org/10.1016/j.cpr.2016.10.005
37. Johnstone KM, Kemps E, Chen J. A meta-analysis of universal school-based prevention
programs for anxiety and depression in children. Clin Child Fam Psychol Rev 2018;21:466–81.
https://doi.org/10.1007/s10567-018-0266-5
38. Stockings EA, Degenhardt L, Dobbins T, Lee YY, Erskine HE, Whiteford HA, Patton G.
Preventing depression and anxiety in young people: a review of the joint efficacy of universal,
selective and indicated prevention. Psychol Med 2016;46:11–26. https://doi.org/10.1017/
S0033291715001725
39. Rasing SPA, Creemers DHM, Janssens JMAM, Scholte RHJ. Depression and anxiety
prevention based on cognitive behavioral therapy for at-risk adolescents: a meta-analytic
review. Front Psychol 2017;8:1066. https://doi.org/10.3389/fpsyg.2017.01066
40. Piquero AR, Jennings WG, Diamond B, Farrington DP, Tremblay RE, Welsh BC, et al. A meta-
analysis update on the effects of early family/parent training programs on antisocial behavior
and delinquency. J Exp Criminol 2016;12:229–48. https://doi.org/10.1007/s11292-016-9256-0
41. Wilson SJ, Lipsey MW. School-based interventions for aggressive and disruptive behavior:
update of a meta-analysis. Am J Prev Med 2007;33(Suppl. 2):130–43. https://doi.org/10.1016/
j.amepre.2007.04.011
42. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses.
BMJ 2003;327:557–60. https://doi.org/10.1136/bmj.327.7414.557
119
REFERENCES
43. Ades AE, Lu G, Higgins JP. The interpretation of random-effects meta-analysis in decision
models. Med Decis Making 2005;25:646–54. https://doi.org/10.1177/0272989X05282643
44. Caldwell DM, Welton NJ. Approaches for synthesising complex mental health interventions in
meta-analysis. Evid Based Ment Health 2016;19:16–21. https://doi.org/10.1136/eb-2015-102275
45. Caldwell DM, Ades AE, Higgins JP. Simultaneous comparison of multiple treatments: combining
direct and indirect evidence. BMJ 2005;331:897–900. https://doi.org/10.1136/bmj.331.7521.897
46. Welton NJ, Caldwell DM, Adamopoulos E, Vedhara K. Mixed treatment comparison meta-analysis
of complex interventions: psychological interventions in coronary heart disease. Am J Epidemiol
2009;169:1158–65. https://doi.org/10.1093/aje/kwp014
47. Higgins JPT, López-López JA, Becker BJ, Davies SR, Dawson S, Grimshaw JM, et al.
Synthesising quantitative evidence in systematic reviews of complex health interventions.
BMJ Global Health 2019;4:e000858. https://doi.org/10.1136/bmjgh-2018-000858
48. Melendez-Torres GJ, Bonell C, Thomas J. Emergent approaches to the meta-analysis of
multiple heterogeneous complex interventions. BMC Med Res Methodol 2015;15:47.
https://doi.org/10.1186/s12874-015-0040-z
49. Achana F, Hubbard S, Sutton A, Kendrick D, Cooper N. An exploration of synthesis methods
in public health evaluations of interventions concludes that the use of modern statistical
methods would be beneficial. J Clin Epidemiol 2014;67:376–90. https://doi.org/10.1016/
j.jclinepi.2013.09.018
50. Lefebvre C, Glanville J, Briscoe S, Littlewood A, Marshall C, Metzendorf MI, et al. Chapter 4:
Searching for and Selecting Studies. In Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T,
Page MJ, Welch VA, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 6.0
(Updated July 2019). URL: www.training.cochrane.org/handbook (accessed 31 December 2019).
51. Higgins JPT, Lasserson T, Chandler J, Tovey D, Thomas J, Flemyng E, Churchill R. Methodological
Expectations of Cochrane Intervention Reviews (MECIR). URL: https://community.cochrane.org/
mecir-manual (accessed 20 August 2020).
52. Booth A. How much searching is enough? Comprehensive versus optimal retrieval for
technology assessments. Int J Technol Assess Health Care 2010;26:431–5. https://doi.org/
10.1017/S0266462310000966
53. Nussbaumer-Streit B, Klerings I, Wagner G, Heise TL, Dobrescu AI, Armijo-Olivo S, et al.
Abbreviated literature searches were viable alternatives to comprehensive searches:
a meta-epidemiological study. J Clin Epidemiol 2018;102:1–11. https://doi.org/10.1016/
j.jclinepi.2018.05.022
54. Halladay CW, Trikalinos TA, Schmid IT, Schmid CH, Dahabreh IJ. Using data sources beyond
PubMed has a modest impact on the results of systematic reviews of therapeutic interventions.
J Clin Epidemiol 2015;68:1076–84. https://doi.org/10.1016/j.jclinepi.2014.12.017
55. DECIPHer. Advice Leading to Public Health Advancement: ALPHA – DECIPHer’s Research Advisory
Group of Young People. URL: https://decipher.uk.net/public-health-improvement-research-
networks-phirns/public-involvement-alpha/ (accessed 20 August 2020).
56. The Parent Network Caerphilly County Borough. Why We Got Together. URL: www.parentcaer.org.uk/
(accessed 20 August 2020).
57. Dias S, Ades AE, Welton NJ, Jansen JP, Sutton AJ. Network Meta Analysis for Decision-Making.
Hoboken, NJ: John Wiley & Sons, Inc.; 2018. https://doi.org/10.1002/9781118951651
120

58. Jansen JP, Naci H. Is network meta-analysis as valid as standard pairwise meta-analysis?
It all depends on the distribution of effect modifiers. BMC Med 2013;11:159. https://doi.org/
10.1186/1741-7015-11-159
59. Chaimani A, Caldwell DM, Li T, Higgins JPT, Salanti G. Chapter 11: Undertaking Network
Meta-analyses. In Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA,
editors. Cochrane Handbook for Systematic Reviews of Interventions Version 6.0 (Updated
July 2019). URL: www.training.cochrane.org/handbook (accessed 31 December 2019).
60. Salanti G. Indirect and mixed-treatment comparison, network, or multiple-treatments
meta-analysis: many names, many benefits, many concerns for the next generation evidence
synthesis tool. Res Synth Methods 2012;3:80–97. https://doi.org/10.1002/jrsm.1037
61. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition. Washington, DC: American Psychiatric Association; 2013. https://doi.org/10.1176/
appi.books.9780890425596
62. The World Bank Group. World Bank Country and Lending Group. URL: https://datahelpdesk.
worldbank.org/ (accessed 20 August 2020).
63. Haworth CM, Carter K, Eley TC, Plomin R. Understanding the genetic and environmental
specificity and overlap between well-being and internalizing symptoms in adolescence. Dev Sci
2017;20:e12376. https://doi.org/10.1111/desc.12376
64. Patalay P, Fitzsimons E. Correlates of mental illness and wellbeing in children: are they the
same? Results from the UK Millennium Cohort Study. J Am Acad Child Adolesc Psychiatry
2016;55:771–83. https://doi.org/10.1016/j.jaac.2016.05.019
65. Clarke M, Williamson PR. Core outcome sets and systematic reviews. Syst Rev 2016;5:11.
https://doi.org/10.1186/s13643-016-0188-6
66. Farber G, Wolpert M, Kemmer D. Common Measures for Mental Health Science: Laying the
Foundations. June 2020. URL: https://wellcome.ac.uk/sites/default/files/CMB-and-CMA-
July-2020-pdf.pdf (accessed 19 August 2020).
67. Whelan J, Love P, Pettman T, Doyle J, Booth S, Smith E, Waters E. Cochrane update:
predicting sustainability of intervention effects in public health evidence: identifying key
elements to provide guidance. J Public Health 2014;36:347–51. https://doi.org/10.1093/
pubmed/fdu027
68. Hetrick SE, Cox GR, Witt KG, Bir JJ, Merry SN. Cognitive behavioural therapy (CBT), third-
wave CBT and interpersonal therapy (IPT) based interventions for preventing depression in
children and adolescents. Cochrane Database Syst Rev 2016;8:CD003380. https://doi.org/
10.1002/14651858.CD003380.pub4
69. Barth J, Munder T, Gerger H, Nüesch E, Trelle S, Znoj H, et al. Comparative efficacy of seven
psychotherapeutic interventions for patients with depression: a network meta-analysis.
PLOS Med 2013;10:e1001454. https://doi.org/10.1371/journal.pmed.1001454
70. Hunot V, Moore TH, Caldwell DM, Furukawa TA, Davies P, Jones H, et al. ‘Third wave’ cognitive
and behavioural therapies versus other psychological therapies for depression. Cochrane Database
Syst Rev 2013;10:CD008704. https://doi.org/10.1002/14651858.CD008704.pub2
71. Shinohara K, Honyashiki M, Imai H, Hunot V, Caldwell DM, Davies P, et al. Behavioural
therapies versus other psychological therapies for depression. Cochrane Database Syst Rev
2013;10:CD008696. https://doi.org/10.1002/14651858.CD008696.pub2
72. Pompoli A, Furukawa TA, Efthimiou O, Imai H, Tajika A, Salanti G. Dismantling cognitive–behaviour
therapy for panic disorder: a systematic review and component network meta-analysis. Psychol Med
2018;48:1945–53. https://doi.org/10.1017/S0033291717003919
121
REFERENCES
73. Furukawa TA, Noma H, Caldwell DM, Honyashiki M, Shinohara K, Imai H, et al. Waiting list
may be a nocebo condition in psychotherapy trials: a contribution from network meta-analysis.
Acta Psychiatr Scand 2014;130:181–92. https://doi.org/10.1111/acps.12275
74. Cuijpers P, Cristea IA. How to prove that your therapy is effective, even when it is not: a guideline.
Epidemiol Psychiatr Sci 2016;25:428–35. https://doi.org/10.1017/S2045796015000864
75. Sutcliffe K, Thomas J, Stokes G, Hinds K, Bangpan M. Intervention Component Analysis (ICA):
a pragmatic approach for identifying the critical features of complex interventions. Syst Rev
2015;4:140. https://doi.org/10.1186/s13643-015-0126-z
76. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of
interventions: template for intervention description and replication (TIDieR) checklist and
guide. BMJ 2014;348:g1687. https://doi.org/10.1136/bmj.g1687
77. Hetrick SE, Bailey A, Rice SM, Simmons MB, McKenzie JE, Montague AE, Parker AG. A
qualitative analysis of the descriptions of cognitive behavioural therapy (CBT) tested in clinical
trials of depressed young people. J Depress Anxiety 2015;4:1. https://doi.org/10.4172/
2167-1044.1000172
78. Jacobson NS, Dobson KS, Truax PA, Addis ME, Koerner K, Gollan JK, et al. A component
analysis of cognitive-behavioral treatment for depression. J Consult Clin Psychol 1996;64:295–304.
https://doi.org/10.1037//0022-006x.64.2.295
79. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane
Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928.
https://doi.org/10.1136/bmj.d5928
80. Borenstein M, Hedges LV, Higgins JPT, Rothstein H. Introduction to Meta Analysis. Hoboken, NJ:
John Wiley & Sons, Inc.; 2009. https://doi.org/10.1002/9780470743386
81. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions
Version 5.1.0 [Updated March 2011]. The Cochrane Collaboration, 2011. URL: www.handbook.
cochrane.org (accessed 31 December 2019).
82. López-López JA, Davies SR, Caldwell DM, Churchill R, Peters TJ, Tallon D, et al. The process
and delivery of CBT for depression in adults: a systematic review and network meta-analysis.
Psychol Med 2019;49:1937–47. https://doi.org/10.1017/S003329171900120X
83. Langford R, Bonell C, Jones H, Pouliou T, Murphy S, Waters E, et al. The World Health
Organization’s Health Promoting Schools framework: a Cochrane systematic review and
meta-analysis. BMC Public Health 2015;15:130. https://doi.org/10.1186/s12889-015-1360-y
84. MacArthur G, Caldwell DM, Redmore J, Watkins SH, Kipping R, White J, et al. Individual-, family-,
and school-level interventions targeting multiple risk behaviours in young people. Cochrane
Database Syst Rev 2018;10:CD009927. https://doi.org/10.1002/14651858.CD009927.pub2
85. Arikpo D, Edet ES, Chibuzor MT, Odey F, Caldwell DM. Educational interventions for
improving primary caregiver complementary feeding practices for children aged 24 months
and under. Cochrane Database Syst Rev 2018;5:CD011768. https://doi.org/10.1002/14651858.
CD011768.pub2
86. Higgins JP, Whitehead A. Borrowing strength from external trials in a meta-analysis. Stat Med
1996;15:2733–49. https://doi.org/10.1002/(SICI)1097-0258(19961230)15:24<2733::AID-
SIM562>3.0.CO;2-0
87. National Institute for Health and Care Excellence. Guide to the Methods of Technology Appraisal
2013. Process and Methods [PMG9]. URL: www.nice.org.uk/process/pmg9/resources/guide-to-
the-methods-of-technology-appraisal-2013-pdf-2007975843781 (accessed 20 August 2020).
122

88. National Institute for Health and Care Excellence. Developing NICE Guidelines: The Manual.
Process and Methods [PMG20]. URL: www.nice.org.uk/process/pmg20/chapter/introduction
89. Cipriani A, Higgins JP, Geddes JR, Salanti G. Conceptual and technical challenges in network
meta-analysis. Ann Intern Med 2013;159:130–7. https://doi.org/10.7326/0003-4819-159-2-
201307160-00008
90. Mavridis D, Giannatsi M, Cipriani A, Salanti G. A primer on network meta-analysis with
emphasis on mental health. Evid Based Ment Health 2015;18:40–6. https://doi.org/10.1136/
eb-2015-102088
91. Leucht S, Chaimani A, Cipriani AS, Davis JM, Furukawa TA, Salanti G. Network meta-analyses
should be the highest level of evidence in treatment guidelines. Eur Arch Psychiatry Clin Neurosci
2016;266:477–80. https://doi.org/10.1007/s00406-016-0715-4
92. Molloy GJ, Noone C, Caldwell D, Welton NJ, Newell J. Network meta-analysis in health
psychology and behavioural medicine: a primer. Health Psychol Rev 2018;12:254–70.
https://doi.org/10.1080/17437199.2018.1457449
93. Salanti G, Kavvoura FK, Ioannidis JP. Exploring the geometry of treatment networks. Ann
Intern Med 2008;148:544–53. https://doi.org/10.7326/0003-4819-148-7-200804010-00011
94. Lahey BB, Rathouz PJ, Van Hulle C, Urbano RC, Krueger RF, Applegate B, et al. Testing
structural models of DSM-IV symptoms of common forms of child and adolescent
psychopathology. J Abnorm Child Psychol 2008;36:187–206. https://doi.org/10.1007/s10802-
007-9169-5
95. Krueger RF, Caspi A, Moffitt TE, Silva PA. The structure and stability of common mental
disorders (DSM-III-R): a longitudinal-epidemiological study. J Abnorm Psychol 1998;107:216–27.
https://doi.org/10.1037//0021-843x.107.2.216
96. Eaton NR, Rodriguez-Seijas C, Carragher N, Krueger RF. Transdiagnostic factors of
psychopathology and substance use disorders: a review. Soc Psychiatry Psychiatr Epidemiol
2015;50:171–82. https://doi.org/10.1007/s00127-014-1001-2
97. Forbes MK, Tackett JL, Markon KE, Krueger RF. Beyond comorbidity: toward a dimensional
and hierarchical approach to understanding psychopathology across the life span. Dev
Psychopathol 2016;28:971–86. https://doi.org/10.1017/S0954579416000651
98. Chaimani A, Higgins JP, Mavridis D, Spyridonos P, Salanti G. Graphical tools for network
meta-analysis in STATA. PLOS ONE 2013;8:e76654. https://doi.org/10.1371/journal.pone.
0076654
99. Lunn DJ, Thomas A, Best N, Spiegelhalter D. WinBUGS – a Bayesian modelling framework:
concepts, structure, and extensibility. Stat Comput 2000;10:325–37. https://doi.org/10.1023/
A:1008929526011
100. Lu G, Ades AE. Combination of direct and indirect evidence in mixed treatment comparisons.
Stat Med 2004;23:3105–24. https://doi.org/10.1002/sim.1875
101. Spiegelhalter DJ, Best NG, Carlin BP, van der Linde A. Bayesian measures of model complexity
and fit. J R Statist Soc 2002;64:583–639. https://doi.org/10.1111/1467-9868.00353
102. Dias S, Sutton AJ, Welton NJ, Ades AE. Heterogeneity: Subgroups, Meta-Regression, Bias and Bias-
Adjustment [Internet]. NICE DSU Technical Support Document No. 3. London: National Institute
for Health and Care Excellence; 2012.
123
REFERENCES
103. Dias S, Sutton AJ, Welton NJ, Ades AE. Evidence synthesis for decision making 3:
heterogeneity – subgroups, meta-regression, bias, and bias-adjustment. Med Decis Making
2013;33:618–40. https://doi.org/10.1177/0272989X13485157
104. Schünemann HJ, Vist GE, Higgins JPT, Santesso N, Deeks JJ, Glasziou P, et al. Chapter 15:
Interpreting Results and Drawing Conclusions. In Higgins JPT, Thomas J, Chandler J,
Cumpston M, Li T, Page MJ, Welch VA, editors. Cochrane Handbook for Systematic Reviews of
Interventions Version 6.0 (Updated July 2019). URL: www.training.cochrane.org/handbook
105. Sterne JA, Davey Smith G. Sifting the evidence – what’s wrong with significance tests? BMJ
2001;322:226. https://doi.org/10.1136/bmj.322.7280.226
106. Kirkwood BR, Sterne JAC. Essential Medical Statistics. 2nd edn. Hoboken, NJ: John Wiley &
Sons, Inc.; 2003.
107. Schünemann HJ, Higgins JPT, Vist GE, Glasziou P, Akl EA, Skoetz N, Guyatt GH. Chapter 14:
Completing ‘Summary of Findings’ Tables and Grading the Certainty of the Evidence. In
Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editors. Cochrane
Handbook for Systematic Reviews of Interventions Version 6.0 (Updated July 2019). URL: www.
training.cochrane.org/handbook (accessed 31 December 2019).
108. Corrieri S, Heider D, Conrad I, Blume A, König HH, Riedel-Heller SG. School-based prevention
programs for depression and anxiety in adolescence: a systematic review. Health Promot Int
2014;29:427–41. https://doi.org/10.1093/heapro/dat001
109. Calear AL, Christensen H. Systematic review of school-based prevention and early
intervention programs for depression. J Adolesc 2010;33:429–38. https://doi.org/10.1016/
j.adolescence.2009.07.004
110. Moreno-Peral P, Conejo-Cerón S, Rubio-Valera M, Fernández A, Navas-Campaña D,
Rodríguez-Morejón A, et al. Effectiveness of psychological and/or educational interventions
in the prevention of anxiety: a systematic review, meta-analysis, and meta-regression.
JAMA Psychiatry 2017;74:1021–9. https://doi.org/10.1001/jamapsychiatry.2017.2509
111. Neil AL, Christensen H. Australian school-based prevention and early intervention programs
for anxiety and depression: a systematic review. Med J Aust 2007;186:305–8. https://doi.org/
10.5694/j.1326-5377.2007.tb00906.x
112. Neil AL, Christensen H. Efficacy and effectiveness of school-based prevention and early
intervention programs for anxiety. Clin Psychol Rev 2009;29:208–15. https://doi.org/10.1016/
j.cpr.2009.01.002
113. Stice E, Shaw H, Bohon C, Marti CN, Rohde P. A meta-analytic review of depression prevention
programs for children and adolescents: factors that predict magnitude of intervention effects.
J Consult Clin Psychol 2009;77:486–503. https://doi.org/10.1037/a0015168
114. Fitzgerald A, Rawdon C, Dooley B. A randomized controlled trial of attention bias modification
training for socially anxious adolescents. Behav Res Ther 2016;84:1–8. https://doi.org/10.1016/
j.brat.2016.06.003
115. Schoneveld EA, Malmberg M, Lichtwarck-Aschoff A, Verheijen GP, Engels RC, Granic I.
A neurofeedback video game (MindLight) to prevent anxiety in children: a randomized
controlled trial. Comput Hum Behav 2016;63:321–33. https://doi.org/10.1016/j.chb.2016.05.005
116. Schoneveld EA, Lichtwarck-Aschoff A, Granic I. Preventing childhood anxiety disorders:
is an applied game as effective as a cognitive behavioral therapy-based program? Prev Sci
2018;19:220–32. https://doi.org/10.1007/s11121-017-0843-8
124

117. Sportel BE, de Hullu E, de Jong PJ, Nauta MH. Cognitive bias modification versus CBT in
reducing adolescent social anxiety: a randomized controlled trial. PLOS ONE 2013;8:e64355.
https://doi.org/10.1371/journal.pone.0064355
118. Araya R, Fritsch R, Spears M, Rojas G, Martinez V, Barroilhet S, et al. School intervention to
improve mental health of students in Santiago, Chile: a randomized clinical trial. JAMA Pediatr
2013;167:1004–10. https://doi.org/10.1001/jamapediatrics.2013.2361
119. Aune T, Stiles TC. Universal-based prevention of syndromal and subsyndromal social anxiety:
a randomized controlled study. J Consult Clin Psychol 2009;77:867–79. https://doi.org/10.1037/
a0015813
120. Baker SB, Butler JN. Effects of preventive cognitive self-instruction training on adolescent
attitudes, experiences, and state anxiety. J Prim Prev 1984;5:17–26. https://doi.org/10.1007/
BF01332030
121. Barrett P, Lock S, Farrell L. Developmental differences in universal preventive intervention
for child anxiety. Clin Child Psychol Psychiatry 2005;10:539–55. https://doi.org/10.1177/
1359104505056317
122. Bonhauser M, Fernandez G, Püschel K, Yañez F, Montero J, Thompson B, Coronado G.
Improving physical fitness and emotional well-being in adolescents of low socioeconomic
status in Chile: results of a school-based controlled trial. Health Promot Int 2005;20:113–22.
https://doi.org/10.1093/heapro/dah603
123. Britton WB, Lepp NE, Niles HF, Rocha T, Fisher NE, Gold JS. A randomized controlled pilot
trial of classroom-based mindfulness meditation compared to an active control condition in
sixth-grade children. J Sch Psychol 2014;52:263–78. https://doi.org/10.1016/j.jsp.2014.03.002
124. Burckhardt R, Manicavasagar V, Batterham PJ, Miller LM, Talbot E, Lum A. A web-based
adolescent positive psychology program in schools: randomized controlled trial. J Med Internet
Res 2015;17:e187. https://doi.org/10.2196/jmir.4329
125. Calear AL, Christensen H, Mackinnon A, Griffiths KM, O’Kearney R. The YouthMood Project:
a cluster randomized controlled trial of an online cognitive behavioral program with adolescents.
J Consult Clin Psychol 2009;77:1021–32. https://doi.org/10.1037/a0017391
126. Calear AL, Batterham PJ, Poyser CT, Mackinnon AJ, Griffiths KM, Christensen H. Cluster
randomised controlled trial of the e-couch Anxiety and Worry program in schools. J Affect
Disord 2016;196:210–17. https://doi.org/10.1016/j.jad.2016.02.049
127. Calear AL, Christensen H, Brewer J, Mackinnon A, Griffiths KM. A pilot randomized controlled
trial of the e-couch anxiety and worry program in schools. Internet Interv 2016;6:1–5.
https://doi.org/10.1016/j.invent.2016.08.003
128. Gillham JE, Reivich KJ, Freres DR, Lascher M, Litzinger S, Shatté A, Seligman MEP. School-
based prevention of depression and anxiety symptoms in early adolescence: a pilot of a
parent intervention component. School Psychol Q 2006;21:323–48. https://doi.org/10.1521/
scpq.2006.21.3.323
129. Gucht K, Griffith JW, Hellemans R, Bockstaele M, Pascal-Claes F, Raes F. Acceptance and
Commitment Therapy (ACT) for adolescents: outcomes of a large-sample, school-based,
cluster-randomized controlled trial. Mindfulness 2017;8:408–16. https://doi.org/10.1007/
s12671-016-0612-y
130. Hiebert BA, Kirby B, Jaknavorian A. School-based relaxation: attempting primary prevention.
Can J Couns 1989;23:273–87.
125
REFERENCES
131. Hodas R. An investigation of the relationship between positive and negative mental
health factors and academic performance among early adolescent girls. Diss Ab Int B Sci Eng
2016;76(12-B(E)).
132. Johnson C, Burke C, Brinkman S, Wade T. Effectiveness of a school-based mindfulness
program for transdiagnostic prevention in young adolescents. Behav Res Ther 2016;81:1–11.
https://doi.org/10.1016/j.brat.2016.03.002
133. Johnson C, Burke C, Brinkman S, Wade T. A randomized controlled evaluation of a secondary
school mindfulness program for early adolescents: do we have the recipe right yet? Behav Res
Ther 2017;99:37–46. https://doi.org/10.1016/j.brat.2017.09.001
134. Lock S, Barrett PM. A longitudinal study of developmental differences in universal preventive
intervention for child anxiety. Behav Change 2003;20:183–99. https://doi.org/10.1375/
bech.20.4.183.29383
135. Lowry-Webster HM, Barrett PM, Dadds MR. A universal prevention trial of anxiety and
depressive symptomatology in childhood: preliminary data from an Australian study. Behav
Change 2001;18:36–50. https://doi.org/10.1375/bech.18.1.36
136. Perry Y, Werner-Seidler A, Calear A, Mackinnon A, King C, Scott J, et al. Preventing depression
in final year secondary students: school-based randomized controlled trial. J Med Internet Res
2017;19:e369. https://doi.org/10.2196/jmir.8241
137. Potek R. Mindfulness as a school-based prevention program and its effect on adolescent
stress, anxiety and emotion regulation. Diss Abs Int B Sci Eng 2012;73:3272.
138. Roberts C, Kane R, Thomson H, Bishop B, Hart B. The prevention of depressive symptoms in
rural school children: a randomized controlled trial. J Consult Clin Psychol 2003;71:622–8.
https://doi.org/10.1037/0022-006x.71.3.622
139. Roberts CM, Kane R, Bishop B, Cross D, Fenton J, Hart B. The prevention of anxiety
and depression in children from disadvantaged schools. Behav Res Ther 2010;48:68–73.
140. Rodgers A, Dunsmuir S. A controlled evaluation of the ‘FRIENDS for Life’ emotional resiliency
programme on overall anxiety levels, anxiety subtype levels and school adjustment. Child
Adolesc Ment Health 2015;20:13–19. https://doi.org/10.1111/camh.12030
141. Sheffield JK, Spence SH, Rapee RM, Kowalenko N, Wignall A, Davis A, McLoone J. Evaluation
of universal, indicated, and combined cognitive-behavioral approaches to the prevention of
depression among adolescents. J Consult Clin Psychol 2006;74:66–79. https://doi.org/10.1037/
0022-006X.74.1.66
142. Stallard P, Phillips R, Montgomery AA, Spears M, Anderson R, Taylor J, et al. A cluster
randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of
classroom-based cognitive-behavioural therapy (CBT) in reducing symptoms of depression in
high-risk adolescents. Health Technol Assess 2013;17(47). https://doi.org/10.3310/hta17470
143. Tomba E, Belaise C, Ottolini F, Ruini C, Bravi A, Albieri E, et al. Differential effects of
well-being promoting and anxiety-management strategies in a non-clinical school setting.
J Anxiety Disord 2010;24:326–33. https://doi.org/10.1016/j.janxdis.2010.01.005
144. Wong N, Kady L, Mewton L, Sunderland M, Andrews G. Preventing anxiety and depression
in adolescents: a randomised controlled trial of two school-based internet-delivered
cognitive behavioural therapy programmes. Internet Interv 2014;1:90–4. https://doi.org/10.1016/
j.invent.2014.05.004
126

145. Ahlen J, Hursti T, Tanner L, Tokay Z, Ghaderi A. Prevention of anxiety and depression in
Swedish school children: a cluster-randomized effectiveness study. Prev Sci 2018;19:147–58.
https://doi.org/10.1007/s11121-017-0821-1
146. Attwood M, Meadows S, Stallard P, Richardson T. Universal and targeted computerised
cognitive behavioural therapy (Think, Feel, Do) for emotional health in schools: results from
two exploratory studies. Child Adolesc Ment Health 2012;17:173–8. https://doi.org/10.1111/
j.1475-3588.2011.00627.x
147. Barrett P, Turner C. Prevention of anxiety symptoms in primary school children: preliminary
results from a universal school-based trial. Br J Clin Psychol 2001;40:399–410. https://doi.org/
10.1348/014466501163887
148. Bouchard S, Gervais J, Gagnier N, Loranger C. Evaluation of a primary prevention program for
anxiety disorders using story books with children aged 9–12 years. J Prim Prev 2013;34:345–58.
https://doi.org/10.1007/s10935-013-0317-0
149. Collins S, Marks Woolfson L, Durkin K. Effects on coping skills and anxiety of a universal
school-based mental health intervention delivered in Scottish primary schools. School Psychol
Int 2014;35:85–100. https://doi.org/10.1177/0143034312469157
150. Essau CA, Conradt J, Sasagawa S, Ollendick TH. Prevention of anxiety symptoms in children:
results from a universal school-based trial. Behav Ther 2012;43:450–64. https://doi.org/
10.1016/j.beth.2011.08.003
151. Gallegos J. Preventing Childhood Anxiety and Depression: Testing the Effectiveness of a School-
based Program in Mexico (Order No. 3341564). PhD thesis. Austin, TX: The University of Texas
at Austin; 2008.
152. Johnstone J, Rooney RM, Hassan S, Kane RT. Prevention of depression and anxiety symptoms
in adolescents: 42 and 54 months follow-up of the Aussie Optimism Program-Positive
Thinking Skills. Front Psychol 2014;5:364. https://doi.org/10.3389/fpsyg.2014.00364
153. Miller LD, Short C, Garland EJ, Clark S. The ABCs of CBT (cognitive behavior therapy):
evidence-based approaches to child anxiety in public school settings. J Couns Dev
2010;88:432–9. https://doi.org/10.1002/j.1556-6678.2010.tb00043.x
154. Miller LD, Laye-Gindhu A, Liu Y, March JS, Thordarson DS, Garland EJ. Evaluation of a
preventive intervention for child anxiety in two randomized attention-control school trials.
Behav Res Ther 2011;49:315–23. https://doi.org/10.1016/j.brat.2011.02.006
155. Pattison C, Lynd-Stevenson R. The prevention of depressive symptoms in children: the
immediate and long-term outcomes of a school-based program. Behav Change 2001;18:92–102.
https://doi.org/10.1375/bech.18.2.92
156. Pophillat E, Rooney RM, Nesa M, Davis MC, Baughman N, Hassan S, Kane RT. Preventing
internalizing problems in 6–8 year old children: a universal school-based program. Front Psychol
2016;7:1928. https://doi.org/10.3389/fpsyg.2016.01928
157. Rooney R, Roberts C, Kane R, Pike L, Winsor A, White J, Brown A. The prevention of
depression in 8- to 9-year-old children: a pilot study. Aust J Guidance Couns 2006;16:76–90.
https://doi.org/10.1375/ajgc.16.1.76
158. Ruttledge R, Devitt E, Greene G, Mullany M, Charles E, Frehill J, Moriarty M. A randomised
controlled trial of the FRIENDS for Life emotional resilience programme delivered by teachers
in Irish primary schools. Educ Child Psychol 2016;33:69–89.
127
REFERENCES
159. Stallard P, Skryabina E, Taylor G, Phillips R, Daniels H, Anderson R, Simpson N. Classroom-

based cognitive behaviour therapy (FRIENDS): a cluster randomised controlled trial to Prevent
Anxiety in Children through Education in Schools (PACES). Lancet Psychiatry 2014;1:185–92.
https://doi.org/10.1016/S2215-0366(14)70244-5
160. Balle M, Tortella-Feliu M. Efficacy of a brief school-based program for selective prevention
of childhood anxiety. Anxiety Stress Coping 2010;23:71–85. https://doi.org/10.1080/
10615800802590652
161. Berry K, Hunt CJ. Evaluation of an intervention program for anxious adolescent boys
who are bullied at school. J Adolesc Health 2009;45:376–82. https://doi.org/10.1016/
j.jadohealth.2009.04.023
162. Cova F, Rincon P, Melipillan R. Evaluation of the efficacy of a prevention program for
depression in female adolescents. Ter Psicol 2011;29:245–50. https://doi.org/10.4067/
S0718-48082011000200011
163. Dobson KS, Hopkins JA, Fata L, Scherrer M, Allan LC. The prevention of depression and
anxiety in a sample of high-risk adolescents: a randomized controlled trial. Can J Sch Psychol
2010;25:291–310. https://doi.org/10.1177/0829573510386449
164. Gaete J, Martinez V, Fritsch R, Rojas G, Montgomery AA, Araya R. Indicated school-based
intervention to improve depressive symptoms among at risk Chilean adolescents: a randomized
controlled trial. BMC Psychiatry 2016;16:276. https://doi.org/10.1186/s12888-016-0985-4
165. Gillham JE, Reivich KJ, Brunwasser SM, Freres DR, Chajon ND, Kash-Macdonald VM, et al.
Evaluation of a group cognitive-behavioral depression prevention program for young
adolescents: a randomized effectiveness trial. J Clin Child Adolesc Psychol 2012;41:621–39.
https://doi.org/10.1080/15374416.2012.706517
166. Hunt C, Andrews G, Crino R, Erskine A, Sakashita C. Randomized controlled trial of an early
intervention programme for adolescent anxiety disorders. Aust N Z J Psychiatry 2009;43:300–4.
https://doi.org/10.1080/00048670902721152
167. Jordans MJ, Komproe IH, Tol WA, Kohrt BA, Luitel NP, Macy RD, de Jong JT. Evaluation of a
classroom-based psychosocial intervention in conflict-affected Nepal: a cluster randomized
controlled trial. J Child Psychol Psychiatry 2010;51:818–26. https://doi.org/10.1111/j.1469-
7610.2010.02209.x
168. Kiselica MS, Baker SB, Thomas RN, Reedy S. Effects of stress inoculation training on anxiety,
stress, and academic performance among adolescents. J Couns Psychol 1994;41:335–42.
https://doi.org/10.1037/0022-0167.41.3.335
169. Owen H, Lanning W. The effects of three treatment methods upon anxiety and inappropriate
attentional style among high school athletes. Int J Sport Psychol 1982;13:154–62.
170. Peng S, Qi A, Yuan F. Experimental study on the effects of exercise prescription on the mental
health of left-behind school children in rural areas. Rev Argent Clin Psicol 2015;24:267–76.
171. Rice CL. Reducing anxiety in middle school and high school students: a comparison of
cognitive–behavioral therapy and relaxation training approaches. Diss Ab Int A Humanit Soc Sci
2009;69:2607.
172. Scholten H, Malmberg M, Lobel A, Engels RC, Granic I. A randomized controlled trial to test
the effectiveness of an immersive 3D video game for anxiety prevention among adolescents.
PLOS ONE 2016;11:e0147763. https://doi.org/10.1371/journal.pone.0147763
128

173. Topper M, Emmelkamp PM, Watkins E, Ehring T. Prevention of anxiety disorders and
depression by targeting excessive worry and rumination in adolescents and young adults:
a randomized controlled trial. Behav Res Ther 2017;90:123–36. https://doi.org/10.1016/
j.brat.2016.12.015
174. Cooley-Strickland MR, Griffin RS, Darney D, Otte K, Ko J. Urban African American youth
exposed to community violence: a school-based anxiety preventive intervention efficacy study.
J Prev Interv Community 2011;39:149–66. https://doi.org/10.1080/10852352.2011.556573
175. Manassis K, Wilansky-Traynor P, Farzan N, Kleiman V, Parker K, Sanford M. The feelings club:
randomized controlled evaluation of school-based CBT for anxious or depressive symptoms.
Depress Anxiety 2010;27:945–52. https://doi.org/10.1002/da.20724
176. McLoone JK, Rapee RM. Comparison of an anxiety management program for children
implemented at home and school: lessons learned. Sch Ment Health 2012;4:231–42.
https://doi.org/10.1007/s12310-012-9088-7
177. Mifsud C, Rapee RM. Early intervention for childhood anxiety in a school setting: outcomes for an
economically disadvantaged population. J Am Acad Child Adolesc Psychiatry 2005;44:996–1004.
https://doi.org/10.1097/01.chi.0000173294.13441.87
178. Miller LD, Laye-Gindhu A, Bennett JL, Liu Y, Gold S, March JS, et al. An effectiveness study
of a culturally enriched school-based CBT anxiety prevention program. J Clin Child Adolesc
Psychol 2011;40:618–29. https://doi.org/10.1080/15374416.2011.581619
179. Simpson AT. The roles of self-regulation and coping in a preventative cognitive–behavioural
intervention for school-age children at-risk for internalizing disorders. Diss Ab Int B Sci Eng
2008;69:3862.
180. Siu FYA. Internalizing problems among primary school children in Hong Kong: Prevalence and
treatment. Diss Ab Int A Humanit Soc Sci 2008;69:115.
181. Tokolahi E, Vandal AC, Kersten P, Pearson J, Hocking C. Cluster-randomised controlled trial
of an occupational therapy intervention for children aged 11–13 years, designed to increase
participation to prevent symptoms of mental illness. Child Adolesc Ment Health 2018;23:313–27.
https://doi.org/10.1111/camh.12270
182. van Starrenburg ML, Kuijpers RC, Kleinjan M, Hutschemaekers GJ, Engels RC. Effectiveness of
a cognitive behavioral therapy-based indicated prevention program for children with elevated
anxiety levels: a randomized controlled trial. Prev Sci 2017;18:31–9. https://doi.org/10.1007/
s11121-016-0725-5
183. Cui L, He F, Han Z, Yang R, Xiao J, Oei TP. A brief group cognitive–behavioral program for
the prevention of depressive symptoms in Chinese college students. Int J Group Psychother
2016;66:291–307. https://doi.org/10.1080/00207284.2015.1111098
184. Ellis L, Campbell A, Sethi S, O’Dea B. Comparative randomized trial of an online cognitive–
behavioral therapy program and an online support group for depression and anxiety. J Cyber
Ther Rehabil 2011;4:461–7.
185. Higgins DM. Preventing generalized anxiety disorder in an at-risk sample of college students:
a brief cognitive–behavioral approach. Diss Ab Int B Sci Eng 2007;67:5406.
186. Seligman MEP, Schulman P, DeRubeis RJ, Hollon SD. The prevention of depression and anxiety.
Prev Treat 1999;2. https://doi.org/10.1037//1522-3736.2.0008a
187. Seligman ME, Schulman P, Tryon AM. Group prevention of depression and anxiety symptoms.
129
REFERENCES
188. Liddle I, Macmillan S. Evaluating the FRIENDS programme in a Scottish setting. Educ Psychol
Pract 2010;26:53–67. https://doi.org/10.1080/02667360903522785
189. Velásquez AM, López MA, Quiñonez N, Paba DP. Yoga for the prevention of depression,
anxiety, and aggression and the promotion of socio-emotional competencies in school-aged
children. Educ Res Eval 2015;21:407–21. https://doi.org/10.1080/13803611.2015.1111804
190. Barry M, Murphy M, O’Donovan H. Assessing the effectiveness of a cognitive behavioural
group coaching intervention in reducing symptoms of depression among adolescent males
in a school setting. Int Coach Psychol Rev 2017;12:101–9.
191. Burckhardt R, Manicavasagar V, Batterham PJ, Hadzi-Pavlovic D. A randomized controlled
trial of strong minds: a school-based mental health program combining acceptance and
commitment therapy and positive psychology. J Sch Psychol 2016;57:41–52. https://doi.org/
10.1016/j.jsp.2016.05.008
192. Chaplin TM, Gillham JE, Reivich K, Elkon AG, Samuels B, Freres DR, et al. Depression
prevention for early adolescent girls: a pilot study of all girls versus co-ed groups. J Early
Adolesc 2006;26:110–26. https://doi.org/10.1177/0272431605282655
193. Clarke GN, Hawkins W, Murphy M, Sheeber L. School-based primary prevention of depressive
symptomatology in adolescents: findings from two studies. J Adolesc Res 1993;8:183–204.
https://doi.org/10.1177/074355489382004
194. Gillham JE, Reivich KJ, Freres DR, Chaplin TM, Shatté AJ, Samuels B, et al. School-based
prevention of depressive symptoms: a randomized controlled study of the effectiveness and
specificity of the Penn Resiliency Program. J Consult Clin Psychol 2007;75:9–19. https://doi.org/
10.1037/0022-006X.75.1.9
195. Horowitz JL, Garber J, Ciesla JA, Young JF, Mufson L. Prevention of depressive symptoms in
adolescents: a randomized trial of cognitive-behavioral and interpersonal prevention programs.
J Consult Clin Psychol 2007;75:693–706. https://doi.org/10.1037/0022-006X.75.5.693
196. Kindt KC, Kleinjan M, Janssens JM, Scholte RH. Evaluation of a school-based depression
prevention program among adolescents from low-income areas: a randomized controlled
effectiveness trial. Int J Environ Res Public Health 2014;11:5273–93. https://doi.org/10.3390/
ijerph110505273
197. Merry S, McDowell H, Wild CJ, Bir J, Cunliffe R. A randomized placebo-controlled trial of a
school-based depression prevention program. J Am Acad Child Adolesc Psychiatry 2004;43:538–47.
https://doi.org/10.1097/00004583-200405000-00007
198. Pössel P, Horn AB, Groen G, Hautzinger M. School-based prevention of depressive symptoms
in adolescents: a 6-month follow-up. J Am Acad Child Adolesc Psychiatry 2004;43:1003–10.
https://doi.org/10.1097/01.chi.0000126975.56955.98
199. Pössel P, Adelson JL, Hautzinger M. A randomized trial to evaluate the course of effects
of a program to prevent adolescent depressive symptoms over 12 months. Behav Res Ther
2011;49:838–51. https://doi.org/10.1016/j.brat.2011.09.010
200. Pössel P, Martin NC, Garber J, Hautzinger M. A randomized controlled trial of a cognitive–
behavioral program for the prevention of depression in adolescents compared with nonspecific
and no-intervention control conditions. J Couns Psychol 2013;60:432–8. https://doi.org/
10.1037/a0032308
201. Raes F, Griffith JW, Van der Gucht K, Williams JMG. School-based prevention and reduction of
depression in adolescents: a cluster-randomized controlled trial of a mindfulness group program.
Mindfulness 2014;5:477–86. https://doi.org/10.1007/s12671-013-0202-1
130

202. Rivet-Duval E, Heriot S, Hunt C. Preventing adolescent depression in Mauritius: a universal

school-based program. Child Adolesc Ment Health 2011;16:86–91. https://doi.org/10.1111/
j.1475-3588.2010.00584.x
203. Rose K, Hawes DJ, Hunt CJ. Randomized controlled trial of a friendship skills intervention
on adolescent depressive symptoms. J Consult Clin Psychol 2014;82:510–20. https://doi.org/
10.1037/a0035827
204. Sawyer MG, Pfeiffer S, Spence SH, Bond L, Graetz B, Kay D, et al. School-based prevention
of depression: a randomised controlled study of the beyond blue schools research initiative.
J Child Psychol Psychiatry 2010;51:199–209. https://doi.org/10.1111/j.1469-7610.2009.02136.x
205. Shatté AJ. Prevention of depressive symptoms in adolescents: issues of dissemination and
mechanisms of change. Diss Ab Int B Sci Eng 1997;57:7236.
206. Spence SH, Sheffield JK, Donovan CL. Preventing adolescent depression: an evaluation of
the problem solving for life program. J Consult Clin Psychol 2003;71:3–13. https://doi.org/
10.1037//0022-006x.71.1.3
207. Tak YR, Lichtwarck-Aschoff A, Gillham JE, Van Zundert RM, Engels RC. Universal school-
based depression prevention ‘Op Volle Kracht’: a longitudinal cluster randomized controlled
trial. J Abnorm Child Psychol 2016;44:949–61. https://doi.org/10.1007/s10802-015-0080-1
208. Cardemil EV, Reivich KJ, Beevers CG, Seligman ME, James J. The prevention of depressive
symptoms in low-income, minority children: two-year follow-up. Behav Res Ther 2007;45:313–27.
209. Gillham JE. Preventing depressive symptoms in school children. Diss Ab Int B Sci Eng
1995;55:4119.
210. Mendelson T, Greenberg MT, Dariotis JK, Gould LF, Rhoades BL, Leaf PJ. Feasibility and
preliminary outcomes of a school-based mindfulness intervention for urban youth. J Abnorm
Child Psychol 2010;38:985–94. https://doi.org/10.1007/s10802-010-9418-x
211. Quayle D, Dziurawiec S, Roberts C, Kane R, Ebsworthy G. The effect of an optimism and
lifeskills program on depressive symptoms in preadolescence. Behav Change 2001;18:194–203.
https://doi.org/10.1375/bech.18.4.194
212. Soffer AG. School-based Social Skills Training to Reduce Children’s Depressive Symptomatology
PhD thesis. New York, NY: City University New York; 2003.
213. Arnarson EO, Craighead WE. Prevention of depression among Icelandic adolescents. Behav Res
Ther 2009;47:577–85. https://doi.org/10.1016/j.brat.2009.03.011
214. Clarke GN, Hawkins W, Murphy M, Sheeber LB, Lewinsohn PM, Seeley JR. Targeted
prevention of unipolar depressive disorder in an at-risk sample of high school adolescents:
a randomized trial of a group cognitive intervention. J Am Acad Child Adolesc Psychiatry
1995;34:312–21. https://doi.org/10.1097/00004583-199503000-00016
215. Congleton AB. The Effect of a Cognitive–Behavioral Group Intervention on the Locus of Control,
Attributional Style, and Depressive Symptoms of Middle School Students. PhD thesis. Lexington, KY:
University of Kentucky; 1995.
216. Fung J, Guo S, Jin J, Bear L, Lau A. A pilot randomized trial evaluating a school-based
mindfulness intervention for ethnic minority youth. Mindfulness 2016;7:819–28. https://doi.org/
10.1007/s12671-016-0519-7
217. Livheim F, Hayes L, Ghaderi A, Magnusdottir T, Högfeldt A, Rowse J, et al. The effectiveness
of acceptance and commitment therapy for adolescent mental health: Swedish and Australian
pilot outcomes. J Child Fam Stud 2015;24:1016–30. https://doi.org/10.1007/s10826-014-9912-9
131
REFERENCES
218. McCarty CA, Violette HD, McCauley E. Feasibility of the positive thoughts and actions
prevention program for middle schoolers at risk for depression. Depress Res Treat
2011;2011:241386. https://doi.org/10.1155/2011/241386
219. McCarty CA, Violette HD, Duong MT, Cruz RA, McCauley E. A randomized trial of the
Positive Thoughts and Action program for depression among early adolescents. J Clin Child
Adolesc Psychol 2013;42:554–63. https://doi.org/10.1080/15374416.2013.782817
220. Noël LT, Rost K, Gromer J. Depression prevention among rural preadolescent girls: a randomized
controlled trial. Sch Soc Work J 2013;38:1–18.
221. Poppelaars M, Tak YR, Lichtwarck-Aschoff A, Engels RC, Lobel A, Merry SN, et al. A randomized
controlled trial comparing two cognitive–behavioral programs for adolescent girls with subclinical
depression: a school-based program (Op Volle Kracht) and a computerized program (SPARX).
222. Puskar K, Sereika S, Tusaie-Mumford K. Effect of the Teaching Kids to Cope (TKC) program on
outcomes of depression and coping among rural adolescents. J Child Adolesc Psychiatr Nurs
2003;16:71–80. https://doi.org/10.1111/j.1744-6171.2003.tb00350.x
223. Rohde P, Stice E, Shaw H, Brière FN. Indicated cognitive behavioral group depression prevention
compared to bibliotherapy and brochure control: acute effects of an effectiveness trial with
adolescents. J Consult Clin Psychol 2014;82:65–74. https://doi.org/10.1037/a0034640
224. Stice E, Rohde P, Seeley JR, Gau JM. Brief cognitive–behavioral depression prevention
program for high-risk adolescents outperforms two alternative interventions: a randomized
efficacy trial. J Consult Clin Psychol 2008;76:595–606. https://doi.org/10.1037/a0012645
225. Stoppelbein LA. Primary prevention: an evaluation of a high-school based cognitive–behavioral
program. Diss Ab Int B Sci Eng 2004;64:4066.
226. Wijnhoven LA, Creemers DH, Vermulst AA, Scholte RH, Engels RC. Randomized controlled
trial testing the effectiveness of a depression prevention program (‘Op Volle Kracht’) among
adolescent girls with elevated depressive symptoms. J Abnorm Child Psychol 2014;42:217–28.
https://doi.org/10.1007/s10802-013-9773-5
227. Woods B, Jose P. Effectiveness of a school-based indicated early intervention program for Maori
and Pacific adolescents. J Pac Rim Psychol 2011;5:40–50. https://doi.org/10.1375/prp.5.1.40
228. Young JF, Mufson L, Davies M. Efficacy of Interpersonal Psychotherapy-Adolescent Skills
Training: an indicated preventive intervention for depression. J Child Psychol Psychiatry
2006;47:1254–62. https://doi.org/10.1111/j.1469-7610.2006.01667.x
229. Young JF, Mufson L, Gallop R. Preventing depression: a randomized trial of interpersonal
psychotherapy-adolescent skills training. Depress Anxiety 2010;27:426–33. https://doi.org/
10.1002/da.20664
230. Young JF, Benas JS, Schueler CM, Gallop R, Gillham JE, Mufson L. A randomized depression
prevention trial comparing interpersonal psychotherapy – adolescent skills training to group
counseling in schools. Prev Sci 2016;17:314–24. https://doi.org/10.1007/s11121-015-0620-5
231. Cowell JM, McNaughton D, Ailey S, Gross D, Fogg L. Clinical trial outcomes of the Mexican
American Problem Solving program (MAPS). Hisp Health Care Int 2009;7:179–89. https://doi.org/
10.1891/1540-4153.7.4.178
232. Jaycox LH, Reivich KJ, Gillham J, Seligman ME. Prevention of depressive symptoms in school
children. Behav Res Ther 1994;32:801–16. https://doi.org/10.1016/0005-7967(94)90160-0
132

233. Reynolds EK, Macpherson L, Tull MT, Baruch DE, Lejuez CW. Integration of the brief
behavioral activation treatment for depression (BATD) into a college orientation program:
depression and alcohol outcomes. J Couns Psychol 2011;58:555–64. https://doi.org/10.1037/
a0024634
234. Peden AR, Hall LA, Rayens MK, Beebe LL. Reducing negative thinking and depressive symptoms
in college women. J Nurs Scholarsh 2000;32:145–51. https://doi.org/10.1111/j.1547-5069.2000.
00145.x
235. Takagaki K, Okamoto Y, Jinnin R, Mori A, Nishiyama Y, Yamamura T, et al. Behavioral
activation for late adolescents with subthreshold depression: a randomized controlled trial.
Eur Child Adolesc Psychiatry 2016;25:1171–82. https://doi.org/10.1007/s00787-016-0842-5
236. McLaughlin C. Evaluating the effect of an empirically-supported group intervention for
students at-risk for depression in a rural school district. Diss Ab Int B Sci Eng 2011;71:5820.
237. Stice E, Burton E, Bearman SK, Rohde P. Randomized trial of a brief depression prevention
program: an elusive search for a psychosocial placebo control condition. Behav Res Ther
2007;45:863–76. https://doi.org/10.1016/j.brat.2006.08.008
238. Yu L. Preventing depressive symptoms in Chinese children. Diss Abs Int B Sci Eng 2000;60:6389.
239. Khalsa SB, Hickey-Schultz L, Cohen D, Steiner N, Cope S. Evaluation of the mental health
benefits of yoga in a secondary school: a preliminary randomized controlled trial. J Behav
Health Serv Res 2012;39:80–90. https://doi.org/10.1007/s11414-011-9249-8
240. Roberts CM, Kane RT, Rooney RM, Pintabona Y, Baughman N, Hassan S, et al. Efficacy of the
Aussie Optimism Program: promoting pro-social behavior and preventing suicidality in primary
school students. A randomised-controlled trial. Front Psychol 2018;8:1392. https://doi.org/
10.3389/fpsyg.2017.01392
241. Lorenc T, Petticrew M, Welch V, Tugwell P. What types of interventions generate inequalities?
Evidence from systematic reviews. J Epidemiol Community Health 2013;67:190–3. https://doi.org/
10.1136/jech-2012-201257
242. Pahl KM, Barrett PM. Preventing anxiety and promoting social and emotional strength in
preschool children: a universal evaluation of the Fun FRIENDS Program. Adv Sch Ment Health
Promot 2010;3:14–25. https://doi.org/10.1080/1754730X.2010.9715683
243. Kyranides MN, Fanti KA, Katsimicha E, Georgiou G. Preventing conduct disorder and callous
unemotional traits: preliminary results of a school based pilot training program. J Abnorm Child
Psychol 2018;46:291–303. https://doi.org/10.1007/s10802-017-0273-x
244. August GJ, Hektner JM, Egan EA, Realmuto GM, Bloomquist ML. The early risers longitudinal
prevention trial: examination of 3-year outcomes in aggressive children with intent-to-treat
and as-intended analyses. Psychol Addict Behav 2002;16:S27–39. https://doi.org/10.1037/
0893-164x.16.4s.s27
245. Baker-Henningham H, Scott S, Jones K, Walker S. Reducing child conduct problems and
promoting social skills in a middle-income country: cluster randomised controlled trial.
Br J Psychiatry 2012;201:101–8. https://doi.org/10.1192/bjp.bp.111.096834
246. Havighurst SS, Duncombe M, Frankling E, Holland K, Kehoe C, Stargatt R. An emotion-focused
early intervention for children with emerging conduct problems. J Abnorm Child Psychol
2015;43:749–60. https://doi.org/10.1007/s10802-014-9944-z
247. The Conduct Problems Prevention Research Group. Initial impact of the Fast Track prevention
trial for conduct problems: I. The high-risk sample. J Consult Clin Psychol 1999;67:631–47.
https://doi.org/10.1037/0022-006X.67.5.631
133
REFERENCES
248. Wilson DB. Practical Meta-Analysis Effect Size Calculator [Online Calculator].
URL: https://campbellcollaboration.org/research-resources/effect-size-calculator.html
249. Conduct Problems Prevention Research Group. Using the Fast-Track randomized prevention
trial to test the early-starter model of the development of serious conduct problems.
Dev Psychopathol 2002;14:925–43. https://doi.org/10.1017/S0954579402004133
250. Foster EM. Costs and effectiveness of the fast track intervention for antisocial behavior.
J Ment Health Policy Econ 2010;13:101–19.
251. Battagliese G, Caccetta M, Luppino OI, Baglioni C, Cardi V, Mancini F, Buonanno C.
Cognitive–behavioral therapy for externalizing disorders: a meta-analysis of treatment
effectiveness. Behav Res Ther 2015;75:60–71. https://doi.org/10.1016/j.brat.2015.10.008
252. Atkinson LZ, Cipriani A. How to carry out a literature search for a systematic review:
a practical guide. BJPsych Adv 2018;24:74–82. https://doi.org/10.1192/bja.2017.3
253. Martín-Martín A, Orduna-Malea E, Thelwall M, Delgado López-Cózar E. Google Scholar, Web
of Science, and Scopus: a systematic comparison of citations in 252 subject categories. J Informetr
2018;12:1160–77. https://doi.org/10.1016/j.joi.2018.09.002
254. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the Economic
Evaluation of Health Care Programmes. Oxford: Oxford University Press; 2015.
255. Philips Z, Ginnelly L, Sculpher M, Claxton K, Golder S, Riemsma R, et al. Review of guidelines
for good practice in decision-analytic modelling in health technology assessment. Health
Technol Assess 2004;8(36). https://doi.org/10.3310/hta8360
256. Organisation for Economic Co-operation and Development (OECD). Purchasing Power
Parities (PPP). URL: https://data.oecd.org/conversion/purchasing-power-parities-ppp.
htm#indicator-chart (accessed 20 November 2019).
257. Bank of England. Inflation Calculator. URL: www.bankofengland.co.uk/monetary-policy/inflation/
inflation-calculator (accessed 20 November 2019).
258. National Institute for Health and Care Excellence (NICE). Common Mental Health Problems:
Identification and Pathways to Care. Clinical Guideline [CG123]. London: NICE; 2011.
259. Lee YY, Barendregt JJ, Stockings EA, Ferrari AJ, Whiteford HA, Patton GA, Mihalopoulos C.
The population cost-effectiveness of delivering universal and indicated school-based
interventions to prevent the onset of major depression among youth in Australia. Epidemiol
Psychiatr Sci 2017;26:545–64. https://doi.org/10.1017/S2045796016000469
260. Mihalopoulos C, Vos T, Pirkis J, Carter R. The population cost-effectiveness of interventions
designed to prevent childhood depression. Pediatrics 2012;129:e723–30. https://doi.org/
10.1542/peds.2011-1823
261. Anderson R, Ukoumunne OC, Sayal K, Phillips R, Taylor JA, Spears M, et al. Cost-effectiveness
of classroom-based cognitive behaviour therapy in reducing symptoms of depression in
adolescents: a trial-based analysis. J Child Psychol Psychiatry 2014;55:1390–7. https://doi.org/
10.1111/jcpp.12248
262. Stallard P, Skryabina E, Taylor G, Anderson R, Ukoumunne OC, Daniels H, et al. A cluster
randomised controlled trial comparing the effectiveness and cost-effectiveness of a school-
based cognitive-behavioural therapy programme (FRIENDS) in the reduction of anxiety and
improvement in mood in children aged 9/10 years Public Health Res 2015;3(14). https://doi.org/
10.3310/phr03140
134

263. Foster EM, Jones D, Conduct Problems Prevention Research Group. Can a costly intervention
be cost-effective?: an analysis of violence prevention. Arch Gen Psychiatry 2006;63:1284–91.
https://doi.org/10.1001/archpsyc.63.11.1284
264. Foster EM, Jones DE. The economic analysis of prevention: an illustration involving children’s
behavior problems. J Ment Health Policy Econ 2007;10:165–75.
265. Suhrcke M, Pillas D, Selai C. Economic Aspects of Mental Health in Children and Adolescents.
In Social Cohesion for Mental Wellbeing Among Adolescents. Copenhagen: WHO Regional Office
for Europe; 2008. pp. 43–64.
266. Page MJ, Higgins JPT, Sterne JAC. Chapter 13: Assessing Risk of Bias due to Missing Results
in a Synthesis. In Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA,
editors. Cochrane Handbook for Systematic Reviews of Interventions Version 6.0 (Updated July 2019).
URL: www.training.cochrane.org/handbook (accessed 31 December 2019). https://doi.org/
10.1002/9781119536604
267. Wood L, Egger M, Gluud LL, Schulz KF, Jüni P, Altman DG, et al. Empirical evidence of
bias in treatment effect estimates in controlled trials with different interventions and
outcomes: meta-epidemiological study. BMJ 2008;336:601–5. https://doi.org/10.1136/
bmj.39465.451748.AD
268. Schäfer T, Schwarz MA. The meaningfulness of effect sizes in psychological research:
differences between sub-disciplines and the impact of potential biases. Front Psychol
2019;10:813. https://doi.org/10.3389/fpsyg.2019.00813
269. Dias S, Welton NJ, Marinho VCC, Salanti G, Higgins JPT, Ades AE. Estimation and adjustment
of bias in randomized evidence by using mixed treatment comparison meta-analysis. J R Statist
Soc 2010;173:613–29. https://doi.org/10.1111/j.1467-985X.2010.00639.x
270. Higgins JP. Commentary: Heterogeneity in meta-analysis should be expected and
appropriately quantified. Int J Epidemiol 2008;37:1158–60. https://doi.org/10.1093/ije/dyn204
271. Higgins JP, Thompson SG, Spiegelhalter DJ. A re-evaluation of random-effects meta-analysis. J R
Stat Soc Ser A Stat Soc 2009;172:137–59. https://doi.org/10.1111/j.1467-985X.2008.00552.x
272. Riley RD, Higgins JP, Deeks JJ. Interpretation of random effects meta-analyses. BMJ
2011;342:d549. https://doi.org/10.1136/bmj.d549
273. Zhou X, Hetrick SE, Cuijpers P, Qin B, Barth J, Whittington CJ, et al. Comparative efficacy and
acceptability of psychotherapies for depression in children and adolescents: a systematic
review and network meta-analysis. World Psychiatry 2015;14:207–22. https://doi.org/10.1002/
wps.20217
274. Zhou X, Zhang Y, Furukawa TA, Cuijpers P, Pu J, Weisz JR, et al. Different types and
acceptability of psychotherapies for acute anxiety disorders in children and adolescents:
a network meta-analysis. JAMA Psychiatry 2019;76:41–50. https://doi.org/10.1001/
jamapsychiatry.2018.3070
275. Waddell C, Hua JM, Garland OM, Peters RD, McEwan K. Preventing mental disorders in
children: a systematic review to inform policy-making. Can J Public Health 2007;98:166–73.
https://doi.org/10.1007/BF03403706
276. Teubert D. A meta-analytic review on the prevention of symptoms of anxiety in children and
adolescents. J Anxiety Disord 2011;25:1046–59. https://doi.org/10.1016/j.janxdis.2011.07.001
277. Bernaras E, Jaureguizar J, Garaigordobil M. Child and adolescent depression: a review of theories,
evaluation instruments, prevention programs, and treatments. Front Psychol 2019;10:543.
https://doi.org/10.3389/fpsyg.2019.00543
135
REFERENCES
278. Lawrence PJ, Rooke SM, Creswell C. Review: Prevention of anxiety among at-risk children and
adolescents – a systematic review and meta-analysis. Child Adolesc Ment Health 2017;22:118–30.
https://doi.org/10.1111/camh.12226
279. Gorman DM. ‘Everything works’: the need to address confirmation bias in evaluations of drug
misuse prevention interventions for adolescents. Addiction 2015;110:1539–40. https://doi.org/
10.1111/add.12954
280. Gøtzsche PC, Ioannidis JPA. Content area experts as authors: helpful or harmful for systematic
reviews and meta-analyses? BMJ 2012;345:e7031. https://doi.org/10.1136/bmj.e7031
281. Panagiotou OA, Ioannidis JP. Primary study authors of significant studies are more likely to
believe that a strong association exists in a heterogeneous meta-analysis compared with
methodologists. J Clin Epidemiol 2012;65:740–7. https://doi.org/10.1016/j.jclinepi.2012.01.008
282. Gorman DM, Conde E. Conflict of interest in the evaluation and dissemination of ‘model’
school-based drug and violence prevention programs. Eval Program Plann 2007;30:422–9.
https://doi.org/10.1016/j.evalprogplan.2007.06.004
283. Holder H. Prevention programs in the 21st century: what we do not discuss in public.
Addiction 2010;105:578–81. https://doi.org/10.1111/j.1360-0443.2009.02752.x
284. Chalmers I, Glasziou P. Avoidable waste in the production and reporting of research evidence.
Lancet 2009;374:86–9. https://doi.org/10.1016/S0140-6736(09)60329-9
285. Horowitz JL, Garber J. The prevention of depressive symptoms in children and adolescents:
a meta-analytic review. J Consult Clin Psychol 2006;74:401–15. https://doi.org/10.1037/
0022-006X.74.3.401
286. Durlak JA. How to select, calculate, and interpret effect sizes. J Pediatr Psychol 2009;34:917–28.
https://doi.org/10.1093/jpepsy/jsp004
287. Spiegelhalter DJ, Myles JP, Jones DR, Abrams KR. Bayesian methods in health technology
assessment: a review. Health Technol Assess 2000;4(38). https://doi.org/10.3310/hta4380
288. Petitclerc A, Tremblay RE. Childhood disruptive behaviour disorders: review of their origin,
development, and prevention. Can J Psychiatry 2009;54:222–31. https://doi.org/10.1177/
070674370905400403
289. National Collaborating Centre for Mental Health. Antisocial Behaviour and Conduct Disorders in
Children and Young People: Recognition, Intervention and Management. National Clinical Guideline
Number 158. Leicester: The British Psychological Society; 2013.
290. Miller LS. Preventive interventions for conduct disorders: a review. Child Adolesc Psychiatr Clin
N Am 1994;3:405–20. https://doi.org/10.1016/S1056-4993(18)30507-8
291. Boyle MH, Offord DR. Primary prevention of conduct disorder: issues and prospects. J Am Acad
Child Adolesc Psychiatry 1990;29:227–33. https://doi.org/10.1097/00004583-199003000-00011
292. Kamps DM, Tankersley M. Prevention of behavioral and conduct disorders: trends and
research issues. Behav Disord 1996;22:41–8. https://doi.org/10.1177/019874299602200103
293. Tremblay RE, LeMarquand D, Vitaro F. The Prevention of Oppositional Defiant Disorder and
Conduct Disorder. In Quay HC, Hogan AE, editors. Handbook of Disruptive Behavior Disorders.
New York, NY: Springer Science+Business Media; 1999. pp. 525–55. https://doi.org/10.1007/
978-1-4615-4881-2_25
294. Reid JB. Prevention of conduct disorder before and after school entry: relating interventions
to developmental findings. Dev Psychopathol 1993;5:243–62. https://doi.org/10.1017/
S0954579400004375
136

295. Wilson DB, Gottfredson DC, Najaka SS. School-based prevention of problem behaviors: a
meta-analysis. J Quant Criminol 2001;17:247–72. https://doi.org/10.1023/A:1011050217296
296. Park-Higgerson HK, Perumean-Chaney SE, Bartolucci AA, Grimley DM, Singh KP. The evaluation
of school-based violence prevention programs: a meta-analysis. J Sch Health 2008;78:465–79.
https://doi.org/10.1111/j.1746-1561.2008.00332.x
297. de Vries SL, Hoeve M, Assink M, Stams GJ, Asscher JJ. Practitioner review: Effective ingredients
of prevention programs for youth at risk of persistent juvenile delinquency – recommendations
for clinical practice. J Child Psychol Psychiatry 2015;56:108–21. https://doi.org/10.1111/
jcpp.12320
298. Bramer WM, Rethlefsen ML, Kleijnen J, Franco OH. Optimal database combinations for
literature searches in systematic reviews: a prospective exploratory study. Syst Rev 2017;6:245.
https://doi.org/10.1186/s13643-017-0644-y
299. Ross-White A, Godfrey C. Is there an optimum number needed to retrieve to justify inclusion
of a database in a systematic review search? Health Info Libr J 2017;34:217–24. https://doi.org/
10.1111/hir.12185
300. Lorenzetti DL, Topfer LA, Dennett L, Clement F. Value of databases other than medline for
rapid health technology assessments. Int J Technol Assess Health Care 2014;30:173–8.
https://doi.org/10.1017/S0266462314000166
301. Shemilt I, Khan N, Park S, Thomas J. Use of cost-effectiveness analysis to compare the
efficiency of study identification methods in systematic reviews. Syst Rev 2016;5:140.
https://doi.org/10.1186/s13643-016-0315-4
302. O’Mara-Eves A, Thomas J, McNaught J, Miwa M, Ananiadou S. Using text mining for study
identification in systematic reviews: a systematic review of current approaches. Syst Rev
2015;4:5. https://doi.org/10.1186/2046-4053-4-5
303. Dadds MR, Roth JH. Prevention of anxiety disorders: results of a universal trial with young
children. J Child Fam Stud 2008;17:320–35. https://doi.org/10.1007/s10826-007-9144-3
304. Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14:32–8. https://doi.org/
10.1093/ije/14.1.32
305. Fairchild G, Hawes DJ, Frick PJ, Copeland WE, Odgers CL, Franke B, et al. Conduct disorder.
Nat Rev Dis Primers 2019;5:43. https://doi.org/10.1038/s41572-019-0095-y
306. Epstein RA, Fonnesbeck C, Potter S, Rizzone KH, McPheeters M. Psychosocial interventions
for child disruptive behaviors: a meta-analysis. Pediatrics 2015;136:947–60. https://doi.org/
10.1542/peds.2015-2577
307. Ford T, Hayes R, Byford S, Edwards V, Fletcher M, Logan S, et al. Training teachers in classroom
management to improve mental health in primary school children: the STARS cluster RCT.
Public Health Res 2019;7(6). https://doi.org/10.3310/phr07060
308. Keshavarz N, Nutbeam D, Rowling L, Khavarpour F. Schools as social complex adaptive
systems: a new way to understand the challenges of introducing the health promoting schools
concept. Soc Sci Med 2010;70:1467–74. https://doi.org/10.1016/j.socscimed.2010.01.034
309. Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission
on global mental health and sustainable development. Lancet 2018;392:1553–98. https://doi.org/
10.1016/S0140-6736(18)31612-X
310. Shah JL, Scott J, McGorry PD, Cross SPM, Keshavan MS, Nelson B, et al. Transdiagnostic
clinical staging in youth mental health: a first international consensus statement. World Psychiatry
2020;19:233–42. https://doi.org/10.1002/wps.20745
137
REFERENCES
311. Ialongo NS, Rogosch FA, Cicchetti D, Toth SL, Buckley J, Petras H, et al. A Developmental
Psychopathology Approach to the Prevention of Mental Health Disorders. In Cicchetti D,
Cohen DJ, editors. Developmental Psychopathology: Theory and Method, Volume 1. 2nd edn.
Hoboken, NJ: John Wiley & Sons, Inc.; 2006. pp. 968–1018. https://doi.org/10.1002/
9780470939383.ch24
312. Conway CC, Forbes MK, Forbush KT, Fried EI, Hallquist MN, Kotov R, et al. A hierarchical
taxonomy of psychopathology can transform mental health research. Perspect Psychol Sci
2019;14:419–36. https://doi.org/10.1177/1745691618810696
313. Kotov R, Krueger RF, Watson D. A paradigm shift in psychiatric classification: the Hierarchical
Taxonomy Of Psychopathology (HiTOP). World Psychiatry 2018;17:24–5. https://doi.org/
10.1002/wps.20478
314. Cuthbert BN. The RDoC framework: facilitating transition from ICD/DSM to dimensional
approaches that integrate neuroscience and psychopathology. World Psychiatry 2014;13:28–35.
https://doi.org/10.1002/wps.20087
315. Goldberg JM, Sklad M, Elfrink TR, Schreurs KMG, Bohlmeijer ET, Clarke AM. Effectiveness
of interventions adopting a whole school approach to enhancing social and emotional
development: a meta-analysis. Eur J Psychol Educ 2019;34:755–82. https://doi.org/10.1007/
s10212-018-0406-9
316. Kidger J, Araya R, Donovan J, Gunnell D. The effect of the school environment on the emotional
health of adolescents: a systematic review. Pediatrics 2012;129:925–49. https://doi.org/10.1542/
peds.2011-2248
317. Rith-Najarian LR, Boustani MM, Chorpita BF. A systematic review of prevention programs
targeting depression, anxiety, and stress in university students. J Affect Disord 2019;257:568–84.
https://doi.org/10.1016/j.jad.2019.06.035
318. Achenbach TM, McConaughy SH, Howell CT. Child/adolescent behavioral and emotional
problems: implications of cross-informant correlations for situational specificity. Psychol Bull
1987;101:213–32. https://doi.org/10.1037/0033-2909.101.2.213
319. Sourander A, Helstelä L, Helenius H. Parent-adolescent agreement on emotional and behavioral
problems. Soc Psychiatry Psychiatr Epidemiol 1999;34:657–63. https://doi.org/10.1007/
s001270050189
320. De Los Reyes A, Kazdin AE. Informant discrepancies in the assessment of childhood
psychopathology: a critical review, theoretical framework, and recommendations for further study.
Psychol Bull 2005;131:483–509. https://doi.org/10.1037/0033-2909.131.4.483
321. James A, Yavchitz A, Ravaud P, Boutron I. Node-making process in network meta-analysis
of nonpharmacological treatment are poorly reported. J Clin Epidemiol 2018;97:95–102.
https://doi.org/10.1016/j.jclinepi.2017.11.018
322. Stallard P, Sayal K, Phillips R, Taylor JA, Spears M, Anderson R, et al. Classroom based
cognitive behavioural therapy in reducing symptoms of depression in high risk adolescents:
pragmatic cluster randomised controlled trial. BMJ 2012;345:e6058. https://doi.org/10.1136/
bmj.e6058
323. Sense about Science. Brain Gym. URL: https://archive.senseaboutscience.org/data/files/
resources/55/braingym_final.pdf (accessed 31 December 2019).
324. Macnamara B. Schools are Buying ‘Growth Mindset’ Interventions Despite Scant Evidence That They
Work Well. URL: https://theconversation.com/schools-are-buying-growth-mindset-interventions-
despite-scant-evidence-that-they-work-well-96001 (accessed 31 December 2019).
138

325. Evidence 4 Impact (E4I). What is Evidence 4 Impact? URL: www.evidence4impact.org.uk/

326. Early Intervention Foundation. Early Intervention Foundation. URL: www.eif.org.uk/
327. Fuse: The Centre for Translational Research in Public Health. AskFuse. URL: www.fuse.ac.uk/
askfuse/ (accessed 31 December 2019).
328. Avon and Wiltshire Mental Health Partnership NHS Trust. About BEST. URL: http://best.awp.
nhs.uk/about-best/ (accessed 31 December 2019).
329. Lorenc T, Oliver K. Adverse effects of public health interventions: a conceptual framework.
J Epidemiol Community Health 2014;68:288–90. https://doi.org/10.1136/jech-2013-203118
330. Collins LM, Baker TB, Mermelstein RJ, Piper ME, Jorenby DE, Smith SS, et al. The multiphase
optimization strategy for engineering effective tobacco use interventions. Ann Behav Med
2011;41:208–26. https://doi.org/10.1007/s12160-010-9253-x
331. Merry S, Hetrick S. Prevention of depression and anxiety: is the whole better than the sum
of the parts? Evid Based Ment Health 2017;20:e1. https://doi.org/10.1136/eb-2016-102425
332. Waters E, Doyle J, Jackson N, Howes F, Brunton G, Oakley A, Cochrane Collaboration.
Evaluating the effectiveness of public health interventions: the role and activities of the
Cochrane Collaboration. J Epidemiol Community Health 2006;60:285–9. https://doi.org/
10.1136/jech.2003.015354
333. Walugembe DR, Sibbald S, Le Ber MJ, Kothari A. Sustainability of public health interventions: where
are the gaps? Health Res Policy Syst 2019;17:8. https://doi.org/10.1186/s12961-018-0405-y
334. National Institute for Health Research School for Public Health Research. Identifying and
Validating a Core Public Mental Health Outcome Set. URL: https://sphr.nihr.ac.uk/research/public-
mental-health/identifying-and-validating-a-core-public-mental-health-outcome-set-pmh-wp2/
335. Rutter H, Savona N, Glonti K, Bibby J, Cummins S, Finegood DT, et al. The need for a complex
systems model of evidence for public health. Lancet 2017;390:2602–4. https://doi.org/
10.1016/S0140-6736(17)31267-9
336. Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, et al. CONSORT
2010 explanation and elaboration: updated guidelines for reporting parallel group randomised
trials. BMJ 2010:340:c869. https://doi.org/10.1136/bmj.c869
337. Grant S, Mayo-Wilson E, Montgomery P, Macdonald G, Michie S, Hopewell S, Moher D.
CONSORT-SPI 2018 Explanation and Elaboration: Guidance for reporting social and
psychological intervention trials. Trials 2018:19;406. https://doi.org/10.1186/s13063-018-
2735-z
338. Dias S, Welton NJ, Sutton AJ, Ades AE. NICE DSU Technical Support Document 2: A Generalised
Linear Modelling Framework for Pairwise and Network Meta-Analysis of Randomised Controlled
Trials. Report by the Decision Support Unit. URL: http://nicedsu.org.uk/wp-content/uploads/
2017/05/TSD2-General-meta-analysis-corrected-2Sep2016v2.pdf (accessed 22 March 2021).
339. Anticich SAJ, Barrett PM, Silverman W, Lacherez P, Gillies R. The prevention of childhood
anxiety and promotion of resilience among preschool-aged children: a universal school-based
trial. Adv Sch Ment Health Promot 2013;6:93–121. https://doi.org/10.1080/1754730X.2013.
784616
139
REFERENCES
340. Eather N, Morgan PJ, Lubans DR. Effects of exercise on mental health outcomes in
adolescents: findings from the CrossFit™ teens randomized controlled trial. Psychol Sport Exerc
2016;26:14–23. https://doi.org/10.1016/j.psychsport.2016.05.008
341. Haden SC, Daly L, Hagins M. A randomised controlled trial comparing the impact of yoga and
physical education on the emotional and behavioural functioning of middle school children.
Focus Altern Complement Ther 2014;19:148–55. https://doi.org/10.1111/fct.12130
342. Department for Education. School Workforce in England: November 2018. URL: https://assets.
publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/811622/
SWFC_MainText.pdf (accessed 6 April 2021).
343. HM Revenue and Customs. Rates and Thresholds for Employers 2018 to 2019. URL: www.gov.
uk/guidance/rates-and-thresholds-for-employers-2018-to-2019 (accessed 6 April 2021).
344. Department for Education. Pension Grants for Schools, Local Authorities and Music Education
Hubs. URL: www.gov.uk/government/publications/teachers-pension-employer-contribution-
grant-tpecg/pension-grant-methodology (accessed 6 April 2021).
345. Department for Education. School Teachers’ Pay and Conditions Document 2019 and Guidance on
School Teachers’ Pay and Conditions. URL: https://assets.publishing.service.gov.uk/government/
uploads/system/uploads/attachment_data/file/832634/School_teachers_pay_and_conditions_
2019.pdf (accessed 6 April 2021).
346. Willis Palmer. Government Announces Mental Health Training for Teachers. URL: www.willispalmer.
com/government-announces-mental-health-training-for-teachers/ (accessed 6 April 2021).
347. Department for Education. Schools, Pupils and their Characteristics: January 2018. URL: https://
assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/
719226/Schools_Pupils_and_their_Characteristics_2018_Main_Text.pdf (accessed 6 April 2021).
348. Fisak BJ Jr, Richard D, Mann A. The prevention of child and adolescent anxiety: a meta-
analytic review. Prev Sci 2011;12:255–68. https://doi.org/10.1007/s11121-011-0210-0
349. Ahlen J, Lenhard F, Ghaderi A. Universal prevention for anxiety and depressive symptoms
in children: a meta-analysis of randomized and cluster-randomized trials. J Prim Prev
2015;36:387–403. https://doi.org/10.1007/s10935-015-0405-4
350. Brunwasser SM, Garber J. Programs for the prevention of youth depression: evaluation of
efficacy, effectiveness, and readiness for dissemination. J Clin Child Adolesc Psychol
2016;45:763–83. https://doi.org/10.1080/15374416.2015.1020541
351. Waldron SM, Stallard P, Grist R, Hamilton-Giachritsis C. The ‘long-term’ effects of universal
school-based anxiety prevention trials: a systematic review. Mental Health Prevent
2018;11:8–15. https://doi.org/10.1016/j.mhp.2018.04.003
140

Appendix 1 Methods for systematic

Decision rule for choosing between multiple-report scales
Decision rule for depression scales
l Scores that combine depression and other symptoms will be excluded (e.g. scales that measure
‘internalising symptoms’ or combined anxiety and depression scores).
l Choice between multiple scales:
¢ use self-reports in preference to clinician-rated scales

¢ use instruments with well-studied psychometric properties
¢ use inventories aimed at paediatric populations in preference to inventories aimed at the
general population
¢ use instruments specifically targeted to measure depressive symptoms in preference to
instruments with a broader scope
¢ use most commonly reported scale across studies.
Decision rule for anxiety scales
l Scores that combine anxiety and other symptoms will be excluded (e.g. total RCADS score would
be excluded as it is a combined depression and anxiety score, whereas the RCADS total anxiety
subscale score would be included in preference).
l Use total anxiety scores when available:
¢ If total anxiety score is not available but a generalised anxiety subscale score is available,
we will use the subscale score. (For universal populations, we think that most interventions
are likely to be targeting non-specific anxiety and are not sure what the importance of
separation and social anxiety are. Furthermore, some other subscales, e.g. post-traumatic
stress disorder, obsessive–compulsive disorder, are no longer considered anxiety disorders
in the DSM-5.)
l Choice between multiple scales:
¢ use inventories of general symptoms in preference to instruments targeting specific

anxiety domains.
¢ if several inventories of general symptoms are available, use those aimed at the general
population in preference to instruments aimed at identifying patients with anxiety disorders.
¢ use most commonly reported scale across studies.
Search strategies used for each database
MEDLINE
Date range searched: inception to 4 April 2018.
Date searched: 4 April 2018.
141
APPENDIX 1
Search strategy
1. CHILD, PRESCHOOL/or CHILD/or ADOLESCENT/or YOUNG ADULT/

2. (child* or boy* or girl* or kids or juvenil* or minors or paediatric* or pediatric* or adolesc* or
preadolesc* or preadolesc* or pubert* or pubescen* or prepube* or prepube* or teen* or (young adj
(adult* or people or patient* or men* or women* or male or female or survivor* or offender* or
minorit*)) or youth* or student* or undergrad*).ti,ab,kf.
3. (child* or adolesc* or paediatr* or pediatr*).jn.
4. or/13
5. EDUCATION/
6. SCHOOLS/or SCHOOLS, NURSERY/
7. SCHOOL HEALTH SERVICES/or SCHOOL NURSING/
8. STUDENTS/or UNIVERSITIES/
9. (preschool or kindergarten or school* or college* or campus* or classroom* or curricul* or teacher
or gatekeeper or pupil*).ti,ab,kf.
10. PEER GROUP/
11. ((peer or peers) adj (education or group or relation* or support* or intervention* or leader*)).ti,ab,kf.
12. student* union.ti,ab,kf.
13. ((church or communit* or holiday* or religi* or spiritual* or youth or vacation) adj2 (camp or club or
group)).ti,ab,kf.
14. ((church or communit* or holiday* or religi* or spiritual* or youth or vacation) adj based).ti,ab,kf.
15. or/5-14
16. ADAPTATION, PSYCHOLOGICAL/
17. EMOTIONS/
18. MENTAL HEALTH/
19. SOCIAL ADJUSTMENT/
20. exp STRESS, PSYCHOLOGICAL/
21. (mental health or mental* ill* or psychiatric).ti,ab,kf.
22. (wellbeing or well being).ti,ab,kf.
23. (stress* or distress*).ti,ab,kf.
24. or/16-23
25. DEPRESSION/
26. DEPRESSIVE DISORDER
27. MOOD DISORDERS
28. (depress* or dysthymi* or affective disorder* or affective symptom* or mood* or mental).ti.
29. (depress* adj2 (adolescent* or child* or anaclitic* or episode* or disorder or scale* or score* or
symptom* or unipolar)).ti,ab,kf.
30. ((depress*or mood* or mental or psychological or wellbeing or well being or emotion*) adj2
(improve* or onset or prevent* or reduc*)).ti,ab,kf.
31. ((Axis 1 or Axis I) adj disorder*).ab.
32. or/25-31
33. exp ANXIETY DISORDERS/
34. ANXIETY/
35. anxi*.ti.
36. (anxi* adj3 (adolescent* or child* or disorder* or general* or interpersonal or separation or
social*)).ti,ab,kf.
37. (phobi* or agoraphobi* or PTSD or post trauma* or posttrauma or panic* or OCD or obsess* or
compulsi* or GAD or stress disorder* or stress reaction* or acute stress or neurosis or neuroses or
neurotic or psychoneuro* or (school adj2 (refusal or avoid*)) or social avoidance or mutism).ti,ab,kf.
38. (((anxi* or fear or fright) adj3 (perform* or athlet* or music* or act* or test* or exam*)) or math*
anxiety).ti,ab,kf.
39. (public adj3 (speak* or speech)).ti,ab,kf.
40. or/33-39
142

41. CONDUCT DISORDER/

42. CHILD BEHAVIOR DISORDERS/
43. JUVENILE DELINQUENCY/
44. SOCIAL BEHAVIOR/
45. SOCIAL BEHAVIOR DISORDERS/
46. ((behavi* or conduct or personalit*) adj2 (agressi* or nonagressi* or antisocial or anti social or
dyssocial or defiant or delinquen* or disturb* or disrupt* or disorder* or internali#ing or
externali#ing or problem*)).ti,ab,kf.
47. ((conduct or behavi* or antisocial or anti social or dyssocial or emotional* or internali#ing or
externali#ing) adj3 (problem* of difficult* or psychopathol*)).ti,ab,kf.
48. (oppositional adj3 (defiant* or disorder*)).ti,ab,kf.
49. or/41-48
50. PREVENTIVE HEALTH SERVICES/or “EARLY INTERVENTION (education)”/or HEALTH LITERACY/
or PATIENT EDUCATION AS TOPIC/or HEALTH PROMOTION/or PRIMARY PREVENTION/or
SECONDARY PREVENTION/
51. prevention & control.fs.
52. prevent*.ti,kf.
53. prevention of.ab,kf.
54. (prevent* adj2 (intervention or educat* or pilot or program* or project or protocol* or training or
universal or targeted or primary or secondary or selective or indicated or study or trial)).ti,ab,kf.
55. ((early or brief) adj intervention*).ti,ab,kf. 56 ((universal or targeted) adj2 (program* or
intervention*)).ti,ab,kf.
56. (vulnerabl* or at risk or (risk adj2 reduc*)).ti,ab,kf.
57. RISK/or RISK FACTORS/
58. exp ACCIDENTS/
59. BEREAVEMENT/or GRIEF/
60. SOCIAL PROBLEMS/
61. BULLYING/
62. CHILD OF IMPAIRED PARENTS/
63. CHILD, ORPHANED/
64. CRIME VICTIMS/
65. exp DISASTERS/
66. DIVORCE/
67. LIFE CHANGE EVENTS/
68. RUNAWAY BEHAVIOR/
69. URBAN POPULATION/
70. RURAL POPULATION/
71. SURVIVORS/
72. VIOLENCE/
73. WARFARE/
74. social problems/or exp civil disorders/or exp crime/or exp human rights abuses/or exp parental
death/or poverty/or exp social behavior disorders/or domestic violence/or exp child abuse/or exp
ethnic violence/or physical abuse/or exp terrorism/or torture/or exposure to violence/or exp
“warfare and armed conflicts”/
75. “dissent and disputes”/or family conflict/or psychosocial deprivation/
76. or/50-76
77. RANDOMIZED CONTROLLED TRIAL/or PRAGMATIC CLINICAL TRIAL/
78. Randomized Controlled Trial.pt.
79. (randomi#ed or randomi#ation).ab,ti,kf.
80. (RCT or (random* adj3 (administ* or allocat* or assign* or class* or cluster* or control* or
determine* or divide* or distribut* or expose* or fashion or number* or place* or recruit* or
subsitut* or treat*))).ab.
81. at random.ab.
143
APPENDIX 1
82. placebo.ab.
83. trial.ti,kf.
84. or/78-84
85. (treatmentasusual or (treatment* adj2 usual) or (standard adj2 care) or (standard adj2 treatment)
or (routine adj2 care) or (usual adj2 medication*) or (usual adj2 care) or TAU).ti,ab,kf.
86. (waitlist* or waitlist* or waitinglist* or wait* list* or (waiting adj (condition or control)) or WLC).ti,ab,kf.
87. (((delay* adj3 (start or treatment*)) or no intervention or no treatment* or notreatment or non
treatment* or nontreatment* or nontreatment or minim* treatment* or untreated group* or
untreated control* or without any treatment) and (control* or group*)).ti,ab,kf.
88. ((no intervention* or non intervention* or nonintervention* or without any intervention*) and
(control* or group*)).ti,ab,kf.
89. or/86-89
90. 85 or 90
91. 4 and 15 and (24 or 32 or 40 or 49) and 77 and 91
92. ((universal or indicated or targeted or at risk) and prevent* and (anxiety or depress* or conduct)
and (child* or adolesc* or school*)).mp.
93. ((prevent* adj (program* or intervention)) and (anxiety or depress* or conduct) and (child* or
adolesc* or school*)).mp.
94. 93 or 94.
PsycInfo
Search strategy
1. “3580”.cc. [= Classification Code: Educational/Vocational Counseling & Student Services]

2. exp school based intervention/
3. school*.ti.
4. or/1-3
preadolesc* or pre-adolesc* or pubert* or pubescen* or prepube* or pre-pube* or teen* or (young
adj (adult* or people or patient* or men* or women* or male or female or survivor* or offender* or
minorit*)) or youth* or student* or undergrad*).ti,ab,id.
6. pediatrics/
7. child psychiatry/or child psychopathology/or child psychology/
8. adolescent psychiatry/or adolescent psychopathology/or adolescent psychology/
9. child psychotherapy/or adolescent psychotherapy/
10. childhood development/or early childhood development/or adolescent development/
11. students.hw.
12. (“160” or “180” or “200” or “320”).ag. [= Age Group Field/Codes: preschool 2–5; school age 6–12;
adolescence 13–17; young adulthood 18–29]
13. or/5-12
14. education/
15. education/or elementary education/or high school education/or higher education/or middle school
education/or multicultural education/or nontraditional education/or preschool education/or
private school education/or public school education/or secondary education/or special education/
16. schools/or academic settings/or boarding schools/or charter schools/or exp colleges/or
elementary schools/or graduate schools/or high schools/or institutional schools/or junior high
schools/or kindergartens/or middle schools/or nongraded schools/or nursery schools/
17. school environment/or college environment/
18. school facilities/or campuses/or classrooms/or “learning centers (educational)”/or school libraries/
19. community facilities/or community mental health centers/or exp libraries/
144

20. “summer camps (recreation)”/

21. curriculum/
22. exp extracurricular activities/or exp after school programs/
23. (preschool or nursery or kindergarten or school* or college* or university or universities or
campus* or classroom* or curricul* or gatekeeper or pupil*).ti,ab,id.
24. peers/or peer counseling/or peer tutoring/
25. ((peer or peers) adj (education or group or relation* or support* or intervention* or leader*)).ti,ab,id.
26. student* union.ti,ab,id.
27. ((church or communit* or holiday* or religi* or spiritual* or youth or vacation) adj3 (camp* or
club*1 or group*1)).ti,ab,id.
28. ((primary or secondary or tertiary) adj educat*).ti,ab,id.
29. ((detention or refugee*) adj (camp*1 or centre*1 or center*1)).ti,ab,id.
30. or/14-29
31. “3300”.cc. [ = Classification Code: Health & Mental Health Treatment & Prevention]
32. primary mental health prevention/
33. mental health/or well being/
34. Stress/or Distress/
35. emotional adjustment/
36. “resilience (psychological)”/or coping behavior/or psychological stress/
37. *affective disorders/
38. major depression/or dysthymic disorder/or reactive depression/or “depression (emotion)”/
39. (depress* adj3 (adolescent* or infant* or child* or student* or anaclitic* or episode* or disorder or
scale* or score* or symptom* or unipolar)).ti,ab,id.
40. ((depress* or mood* or mental or psychological or wellbeing or well being or emotion*) adj3
(improve* or onset or prevent* or reduc*)).ti,ab,id.
41. (depress* or dysthymi* or affective disorder* or affective symptom* or mood* or mental).ti,id.
42. ((axis 1 or axis I) adj disorder*).ti,ab,id.
43. exp anxiety/
44. anxiety disorders/or acute stress disorder/or death anxiety/or generalized anxiety disorder/or exp
obsessive compulsive disorder/or panic disorder/or post-traumatic stress/or exp posttraumatic
stress disorder/or separation anxiety disorder/
45. phobias/or acrophobia/or agoraphobia/or claustrophobia/or ophidiophobia/or school phobia/or
social phobia/
46. fear/or panic/or panic attack/
social*)).ti,ab,id.
48. (phobi* or agoraphobi* or PTSD or post trauma* or posttrauma* or panic* or OCD or obsess* or
neurotic or psychoneuro* or (school adj3 (refusal or avoid*)) or social avoidance or mutism).ti,ab,id.
anxiety).ti,ab,id.
50. (public adj3 (speak* or speech)).ti,ab,id.
51. conduct disorder/or explosive disorder/or oppositional defiant disorder/
52. *behavior disorders/
53. exp juvenile delinquency/
54. exp antisocial behavior/
dyssocial or defiant or delinquen* or disturb* or disrupt* or disorder* or internalizing or
externalizing or internalising or externalising or problem*)).ti,ab,id.
56. ((conduct or behavi* or antisocial or anti social or dyssocial or emotional* or internalizing or
externalizing or internalising or externalising) adj3 (problem* of difficult* or psychopathol*)).ti,ab,id.
57. (oppositional adj3 (defiant* or disorder*)).ti,ab,id.
58. or/33-57
145
APPENDIX 1
59. early intervention/

60. “onset (disorders)”/
61. health promotion/or exp health education/or health knowledge/or health literacy/
62. mental health programs/
63. public health/
64. prevention/or preventive medicine/
65. “3365”.cc.
66. prevent*.ti,id.
67. prevention of.ab.
universal or targeted or primary or secondary or selective or indicated or study or trial)).ti,ab,id.
69. ((early or brief) adj3 intervention*).ti,ab,id.
70. ((universal or targeted) adj3 (program* or intervention*)).ti,ab,id.
71. (vulnerabl* or at risk or (risk adj3 reduc*)).ti,ab,id.
72. at risk populations/or predisposition/or risk factors/or “susceptibility (disorders)”/
73. orphans/or orphanages/
74. bullying/or conflict/or emotional abuse/or school violence/or teasing/or threat/or victimization/
75. school dropouts/
76. runaway behavior/
77. exp Crime Victims/
78. exp violent crime/
79. exp violence/
80. trauma/
81. rural environments/
82. urban environments/
83. exp neighborhoods/
84. exp social issues/
85. war/or conflict/
86. accidents/or exp disasters/
87. exp transportation accidents/
88. survivors/
89. bereavement/or grief/
90. divorce/or child custody/
91. parental death/or exp parental absence/
92. life changes/
93. child abuse/or abandonment/or child neglect/
94. family conflict/or domestic violence/or emotional abuse/
95. (bereave* or bullying or divorce or foster care or grief or humanitarian or orphan* or RTA or
refugee* or survivor* or victim* or war).ti,ab,id.
96. (stigma or help seeking).ti,ab,id,hw.
97. or/59-96
98. treatment effectiveness evaluation.sh.
99. clinical trials.sh.
100. mental health program evaluation.sh.
101. placebo.sh.
102. randomi#ed.ti,ab.
103. (random* adj3 (administ* or class* or control* or determine* or divide* or distribut* or expose* or
fashion or number* or place* or recruit* or subsitut* or treat*)).ab.
104. RCT.ab,id.
105. (waitlist* or wait-list* or waiting-list* or wait* list* or (waiting adj (condition or control)) or
WLC).ti,ab,id.
106. placebo.ti,ab,id.
107. at random.ab.
146

108. ((no intervention* or non intervention* or non-intervention* or without any intervention*) adj3
(control* or group*)).ti,ab,id.
109. (reference group or observation group or control group).ti,ab,id.
110. trial.ti.
111. or/98-110
112. (4 or (13 and 30)) and (31 or 58) and 97 and 111
113. (4 or (13 and 30)) and 32 and 111
114. 4 and 58 and 111
115. or/112-114.
EMBASE
Search strategy
1. juvenile/or exp child/or exp adolescent/or young adult/

preadolesc* or preadolesc* or pubert* or pubescen* or prepube* or prepube* or teen* or (young adj
minorit*)) or youth* or student* or undergrad*).ti,ab,kw.
3. (child* or adolesc* or paediatr* or pediatr*).jn.
4. or/1-3
5. school/or college/or community college/or high school/or kindergarten/or middle school/or nursery
school/or primary school/or university/
6. education/or curriculum/or education program/or learning environment/or exp special education/
7. school health service/
8. exp student/
9. (preschool or kindergarten or school* or college* or campus* or classroom* or curricul* or teacher
or gatekeeper or pupil*).ti,ab,kw.
10. peer group/
11. ((peer or peers) adj (education or group or relation* or support* or intervention* or leader*)).ti,ab,kw.
12. student* union.ti,ab,kw.
13. ((church or communit* or holiday* or religi* or spiritual* or youth or vacation) adj2 (camp or club or
group)).ti,ab,kw.
14. ((church or communit* or holiday* or religi* or spiritual* or youth or vacation) adj based).ti,ab,kw.
15. or/5-14
16. mental health/or community mental health/or psychological well being/
17. mental stress/or *stress/
18. (mental health or mental* ill* or psychiatric).ti,kw.
19. (wellbeing or well being).ti,kw.
20. (stress* or distress*).ti,kw.
21. *wellbeing/
22. or/16-21
23. depression/or dysthymia/or *major depression/or “mixed anxiety and depression”/
24. mood disorder/
25. mood/or *emotion/
26. (depress* or dysthymi* or affective disorder* or affective symptom* or mood* or mental).ti.
27. (depress* adj2 (adolescent* or child* or anaclitic* or episode* or disorder or scale* or score* or
symptom* or unipolar)).ti,ab,kw.
28. ((depress* or mood* or mental or psychological or wellbeing or well being or emotion*) adj2
(improve* or onset or prevent* or reduc*)).ti,ab,kw.
147
APPENDIX 1
29. ((Axis 1 or Axis I) adj disorder*).ab.

30. or/23-29
31. *anxiety/
32. exp anxiety disorder/
33. anxi*.ti.
social*)).ti,ab,kw.
neurotic or psychoneuro* or (school adj2 (refusal or avoid*)) or social avoidance or mutism).ti,ab,kw.
anxiety).ti,ab,kw.
37. (public adj3 (speak* or speech)).ti,ab,kw.
38. or/31-37
39. conduct disorder/
40. *behavior disorder/
41. psychosocial disorder/
42. juvenile delinquency/or delinquency/
43. problem behavior/
44. *social adaptation/
dyssocial or defiant or delinquen* or disturb* or disrupt* or disorder* or internali#ing or
externali#ing or problem*)).ti,ab,kw.
46. ((conduct or behavi* or antisocial or anti social or dyssocial or emotional* or internali#ing or
externali#ing) adj3 (problem* of difficult* or psychopathol*)).ti,ab,kw.
47. (oppositional adj3 (defiant* or disorder*)).ti,ab,kw.
48. oppositional defiant disorder/
49. or/39-48
50. Prevention/or Preventive Medicine/
51. Prophylaxis/
52. primary prevention/or secondary prevention/
53. health promotion/or health education/or health literacy/
54. pc.fs.
55. prevent*.ti,kw.
56. prevention of.ab.
universal or targeted or primary or secondary or selective or indicated or study or trial)).ti,ab,kw.
58. ((early or brief) adj intervention*).ti,ab,kw.
59. ((universal or targeted) adj2 (program* or intervention*)).ti,ab,kw.
60. (vulnerabl* or at risk or (risk adj2 reduc*)).ti,ab,kw.
61. risk/or risk factor/
62. risk of developing.ab.
63. exp “accidents and accident related phenomena”/
64. exp emotional deprivation/
65. exp grief/
66. social problem/or exp abuse/or bullying/or exp crime/or divorce/or exp human rights abuse/or exp
social discrimination/or exp social exclusion/or exp violence/
67. orphaned child/
68. exp victim/
69. exp disaster/
70. life event/
71. coping behavior/or runaway behavior/
148

72. “population and population related phenomena”/or high risk population/or minority group/or rural
population/or urban population/or vulnerable population/
73. exp survivor/
74. exp warfare/
75. conflict/or family conflict/
76. early intervention/
77. or/50-76
78. randomized controlled trial/
79. (randomi#ed or randomi#ation).ab,ti,kw.
80. (RCT or (random* adj3 (administ* or allocat* or assign* or class* or cluster* or control* or
determine* or divide* or distribut* or expose* or fashion or number* or place* or recruit* or
subsitut* or treat*))).ab.
81. at random.ab.
82. trial.ti,kw.
83. or/78-82
84. 4 and 15 and (22 or 30 or 38 or 49) and 77 and 83.
Cochrane Central Register of Controlled Trials

Search strategy
#1 MeSH descriptor: [Child] explode all trees
#2 MeSH descriptor: [Adolescent] this term only
#3 MeSH descriptor: [Young Adult] this term only
#4 (child* or boy* or girl* or kids or juvenil* or minors or paediatric* or pediatric* or adolesc* or

preadolesc* or pre-adolesc* or pubert* or pubescen* or prepube* or pre-pube* or teen* or (young next
minorit*)) or youth* or student* or undergrad*):ti,ab,kw (Word variations have been searched)
#5 child* or adolesc* or paediatr* or pediatr*:so
#6 (#1 or #2 or #3 or #4 or #5)
#7 MeSH descriptor: [Education] this term only
#8 MeSH descriptor: [Schools] this term only
#9 MeSH descriptor: [Schools, Nursery] this term only
#10 MeSH descriptor: [Students] this term only
#11 MeSH descriptor: [Universities] this term only
#12 (preschool or kindergarten or school* or college* or campus* or classroom* or curricul* or teacher

or gatekeeper or pupil*):ti,ab,kw (Word variations have been searched)
#13 MeSH descriptor: [Peer Group] this term only
149
APPENDIX 1
#14 ((peer or peers) next (education or group or relation* or support* or intervention* or leader*)):ti,ab,kw
(Word variations have been searched)
#15 “student* union”:ti,ab,kw (Word variations have been searched)
#16 ((church or communit* or holiday* or religi* or spiritual* or youth or vacation) near/3 (camp or
club or group)):ti,ab,kw (Word variations have been searched)
#17 ((church or communit* or holiday* or religi* or spiritual* or youth or vacation) near/3 based):ti,ab,kw
(Word variations have been searched)
#18 university or universities:ti,ab,kw (Word variations have been searched)
#19 (primary or secondary or tertiary) next educat*:ti,ab,kw (Word variations have been searched)
#20 (#7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19)
#21 MeSH descriptor: [Depression] this term only
#22 MeSH descriptor: [Depressive Disorder] this term only
#23 MeSH descriptor: [Mood Disorders] this term only
#24 depress* or dysthymi* or affective disorder* or affective symptom* or mood* or mental:ti (Word
variations have been searched)
#25 depress* near/3 (adolescent* or child* or anaclitic* or episode* or disorder or scale* or score* or
symptom* or unipolar):ti,ab,kw (Word variations have been searched)
#26 ((depress* or mood* or mental or psychological or wellbeing or well being or emotion*) near/3
(improve* or onset or prevent* or reduc*)):ti,ab,kw
#27 (axis 1 or axis I) next disorder*
#28 MeSH descriptor: [Anxiety Disorders] explode all trees
#29 MeSH descriptor: [Anxiety] this term only
#30 MeSH descriptor: [Performance Anxiety] this term only
#31 (anxi* near/3 (adolescent* or child* or disorder* or general* or interpersonal or separation

or social*))
#32 (phobi* or agoraphobi* or PTSD or post trauma* or posttrauma or panic* or OCD or obsess*
or compulsi* or GAD or stress disorder* or stress reaction* or acute stress or neurosis or neuroses
or neurotic or psychoneuro* or (school near/3 (refusal or avoid*)) or social avoidance or mutism)
#33 (((anxi* or fear or fright) near/3 (perform* or athlet* or music* or act* or test* or exam*)) or
math* anxiety)
#34 (public near/3 (speak* or speech))
#35 MeSH descriptor: [Conduct Disorder] this term only
150

#36 MeSH descriptor: [Child Behavior Disorders] this term only
#37 MeSH descriptor: [Juvenile Delinquency] this term only
#38 MeSH descriptor: [Social Behavior] this term only
#39 MeSH descriptor: [Social Behavior Disorders] explode all trees
#40 ((behavi* or conduct or personalit*) near/3 (agressi* or nonagressi* or antisocial or anti social or
dyssocial or defiant or delinquen* or disturb* or disrupt* or disorder* or internalizing or externalizing or
internalising or externalising or problem*))
#41 ((conduct or behavi* or antisocial or anti social or dyssocial or emotional* or internalizing or

externalizing or internalising or externalising) adj3 (problem* of difficult* or psychopathol*))
#42 (oppositional near/3 (defiant* or disorder*))
#43 ((conduct disorder*) near/3 (onset or prevent*))
#44 MeSH descriptor: [Adaptation, Physiological] this term only
#45 MeSH descriptor: [Emotions] this term only
#46 MeSH descriptor: [Mental Health] this term only
#47 MeSH descriptor: [Social Adjustment] this term only
#48 MeSH descriptor: [Stress, Psychological] this term only
#49 (mental health or mental* ill* or psychiatric)
#50 (wellbeing or well-being or “well being”)
#51 stress* or distress*
#52 (#21 or #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32 or #33 or
#34 or #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42 or #43 or #44 or #45 or #46 or #47 or
#48 or #49 or #50 or #51)
#53 (#6 and #20 and #52) [Population + Setting + Condition] (n = 10686 Trials)
[Prevention/Risk Factors]
#54 MeSH descriptor: [Preventive Health Services] this term only
#55 MeSH descriptor: [Early Intervention (Education)] this term only
#56 MeSH descriptor: [Health Literacy] this term only
#57 MeSH descriptor: [Patient Education as Topic] this term only
#58 MeSH descriptor: [Health Promotion] this term only
151
APPENDIX 1
#59 MeSH descriptor: [Primary Prevention] this term only
#60 MeSH descriptor: [Secondary Prevention] this term only
#61 prevent*:ti (Word variations have been searched)
#62 prevent*:kw (Word variations have been searched)
#63 “prevention of”
#64 (prevent* near/3 (intervention or educat* or pilot or program* or project or protocol* or training
or universal or targeted or primary or secondary or selective or indicated or study or trial))
#65 ((early or brief) next intervention*)
#66 ((universal or targeted) near/3 (program* or intervention*))
#67 (vulnerabl* or “at risk” or (risk near/3 reduc*))
#68 MeSH descriptor: [Risk] explode all trees
#69 MeSH descriptor: [Accidents] explode all trees
#70 MeSH descriptor: [Bereavement] explode all trees
#71 MeSH descriptor: [Bullying] this term only
#72 MeSH descriptor: [Child of Impaired Parents] this term only
#73 MeSH descriptor: [Child, Orphaned] this term only
#74 MeSH descriptor: [Crime Victims] this term only
#75 MeSH descriptor: [Disasters] explode all trees
#76 MeSH descriptor: [Divorce] explode all trees
#77 MeSH descriptor: [Life Change Events] this term only
#78 MeSH descriptor: [Runaway Behavior] this term only
#79 MeSH descriptor: [Urban Population] this term only
#80 MeSH descriptor: [Rural Population] this term only
#81 MeSH descriptor: [Survivors] this term only
#82 MeSH descriptor: [Violence] explode all trees
#83 MeSH descriptor: [Warfare] explode all trees
#84 MeSH descriptor: [Family Conflict] this term only
152

#85 MeSH descriptor: [Psychosocial Deprivation] this term only
#86 MeSH descriptor: [Poverty] this term only
#87 (bereave* or bullying or divorce or foster care or grief or humanitarian or orphan* or RTA or
refugee* or survivor* or victim* or war)
#88 (#54 or #55 or #56 or #57 or #58 or #59 or #60 or #61 or #62 or #63 or #64 or #65 or #66 or
#67 or #68 or #69 or #70 or #71 or #72 or #73 or #74 or #75 or #76 or #77 or #78 or #79 or #80 or
#81 or #82 or #83 or #84 or #85 or #86 or #87 or #87)
#89 #53 and #88 [Population + Setting + Condition + Prevention/Risk Factors] (n = 3575)
#90 (#26 or #43) and #6 and #20 [(MH or Conduct Disorder Prevention) + Population + Setting]
(n = 1273)
#91 #89 or #90.
Scoping searches of educational databases
Following our updated protocol, a scoping search of the ERIC was conducted. A simple search
was conducted on 29 March 2018 and no further relevant studies were identified. On this basis,
we considered the likely ‘law of diminishing returns’52 and determined that further formal literature
searches would be increasingly unlikely to return further eligible citations. However, in response
to reviewers’ comments on the draft version of this report, we conducted formal scoping searches
on 11 April 2020 using the ERIC and BEI. The full search strategy is described subsequently. The total
citations returned were 2570. One reviewer screened the titles and abstracts of a random 10% of
the citations returned and 18 full texts were retrieved. Of these, eight studies were identified as eligible
for inclusion in the review. However, all had been identified via the original search strategy and were
previously included.
We used EBSCOhost databases to search the ERIC and BEI. The following search terms were used:
S26 S19 AND S25 (n = 2570)
S25 (S20 OR S21 OR S22 OR S23 OR S24) [Prevention/Promotion or Risk Factors]
S24 TI (orphan* or “school dropout*” or runaway* or “run away*” or bullying or conflict or abuse or
abused or abandonment or “abandoned child*” or (child* N2 neglect*) or “foster care” or (parent* N2
absen*) or violence or teasing or threatened or victim* or crime or criminal or trauma or rural or urban
or environment* or neighborhood* or neighbourhood* or “social issues” or poverty or war or accidents
or RTA or humanitarian or refugee* or disaster* or survivor* or death or bereavement or grief or
grieving or divorce or custody or stigma or “help seeking”) OR AB (orphan* or “school dropout*” or
runaway* or “run away*” or bullying or conflict or abuse or abused or abandonment or “abandoned
child*” or “child neglect” or “edge of care” or “foster care” or (parent* N2 absen*) or violence or
teasing or threatened or victim* or crime or criminal or trauma or rural or urban or environment*
or neighborhood* or neighbourhood* or “social issues” or poverty or war or accidents or RTA or
humanitarian or refugee* or disaster* or survivor* or death or bereavement or grief or grieving or
divorce or custody or stigma or “help seeking”)
153
APPENDIX 1
S23 TI (vulnerabl* or “at risk” or (risk N3 reduc*)) or “risk population*” or predisposition or pre-
disposition or “risk factor” or “susceptibility) OR AB (vulnerabl* or “at risk” or (risk N3 reduc*)) or “risk
population*” or predisposition or pre-disposition or “risk factor” or “susceptibility)
S22 TI (intervention or ((universal or targeted) W3 (program* or intervention*))) OR AB ((universal or

targeted) W3 (program* or intervention*)) OR SU Intervention
S21 TI (promot* or prevent*) OR AB (prevention OR (prevent* N3 (intervention or educat* or pilot

or program* or project or protocol* or training or universal or targeted or primary or secondary or
selective or indicated or study or trial)))
S20 TI (onset or ((early or brief) N3 intervention*) or “health promotion” or “health education” or

“health knowledge” or “health literacy” or “mental health program*” or “public health”) OR AB (((early
or brief) N3 (onset or intervention*)) or “health promotion” or “health education” or “health knowledge”
or “health literacy” or “mental health program*” or “public health”)
S19 (S10 AND S18)
S18 (S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17) [RCT Filter]
S17 TI (trial) OR AB (trial)
S16 TI (placebo) OR AB (placebo)
S15 TI (“reference group” or “observation group” or “control group”) OR AB (“reference group” or

“observation group” or “control group”)
S14 TI ((“no intervention*” or “non intervention*” or “without any intervention*”) and (control* or group*))
OR AB ((“no intervention*” or “non intervention*” or “without any intervention*”) and (control* or group*))
S13 TI (WLC or waitlist* or (wait* W2 (list or condition or control))) OR AB (WLC or waitlist* or

(wait* W2 (list or condition or control)))
S12 TI (randomized or randomised or “at random” or RCT or (random* N3 (administ* or class* or

control* or determine* or divide* or distribut* or expose* or fashion or number* or place* or recruit*
or subsitut* or treat*))) OR AB (randomized or randomised or “at random” or RCT or (random* N3
(administ* or class* or control* or determine* or divide* or distribut* or expose* or fashion or number*
or place* or recruit* or subsitut* or treat*)))
S11 TI ((program* N3 (evaluat* or effectiveness))
S10 (S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9) [Depression/Anxiety/Conduct]
S9 TI ((behavi* or dyssocial or emotional* or internalizing or externalizing or internalising or

externalising) N3 (problem* of difficult* or psychopathol*)) OR AB ((conduct or behavi* or antisocial or
“anti social” or dyssocial or emotional* or internalizing or externalizing or internalising or externalising)
N3 (problem* of difficult* or psychopathol*))
S8 TI ((behavi* or conduct or personalit*) N3 (agressi* or nonagressi* or dyssocial or defiant

or delinquen* or disturb* or disrupt* or disorder* or internalizing or externalizing or internalising or
externalising or problem*)) OR AB ((behavi* or conduct or personalit*) N3 (agressi* or nonagressi*
or antisocial or “anti social” or dyssocial or defiant or delinquen* or disturb* or disrupt* or disorder*
or internalizing or externalizing or internalising or externalising or problem*))
154

S7 TI (conduct or delinquen* or defiant or antisocial* or anti-social* or “explosive disorder*” or

(behavio* W2 disorder*) OR AB (“conduct disorder*” or “explosive disorder*” or (oppositional W3
(defiant or disorder*)) or (behavio* W2 disorder*) or “juvenile delinquency” or “antisocial behavior”)
S6 TI (PTSD or “post-trauma*” or posttrauma* or “stress disorder*” or “stress reaction*” or “acute

stress”) OR AB (PTSD or “post-trauma*” or posttrauma* or “stress disorder*” or “stress reaction*” or
“acute stress”)
S5 TI (neurosis or neuroses or neurotic or psychoneuro* or (school N3 (refusal or avoid*)) or “social

avoidance” or mutism) OR AB (neurosis or neuroses or neurotic or psychoneuro* or (school N3 (refusal
or avoid*)) or “social avoidance” or mutism)
S4 TI (anxiety or GAD or fear or panic or phobi* or acrophobi* or agoraphobi* or claustrophobi* or

ophidiophobi* or obsess* or compulsi or OCD) OR AB (anxiety or GAD or fear or panic or phobi* or
acrophobi* or agoraphobi* or claustrophobi* or ophidiophobi* or obsess* or compulsi or OCD)
S3 TI ((affective W2 disorder*) or depressi* or depressed or dysthymi* or mood* or ((“axis 1” or “axis I”)

W2 disorder*)) OR AB ((affective W2 disorder*) or depressi* or depressed or dysthymi* or mood* or
((“axis 1” or “axis I”) W2 disorder*))
S2 TI (distress or “psychological stress” or “psychological adjustment” or “emotional adjustment” or

resilience or (coping N2 behavio*)) OR AB (“psychological distress” or “psychological stress” or
“psychological adjustment” or “emotional adjustment” or (coping N2 behavio*))
S1 TI (mental* or psychological or wellbeing or “well being”) OR AB ((mental* or psychological) W2

(health* or wellbeing or “well being”).
Further statistical details for intervention-level and component-level

network meta-analysis models
For each study i and arm k, the mean outcome is denoted by yi,k with SE sei,k. The baseline SD pooled
across arms is sdi and Hedges’ g adjustment factor:

3
Ji = 1− , (1)
4(ni, 1 + ni, 2 ) − 9
where ni,k is the number assessed in study i and arm k (i.e. complete cases).
The likelihood for the observed data is assumed to be normally distributed:
y i, k ∼Normal(θi, k si Ji , se2i, k ), (2)
where θi,k is the standardised mean outcome for the intervention in arm k. The NMA model is put on
the standardised mean scale so that intervention effects are SMDs.
We fitted three different NMA models that differed in the level of detail with which the intervention
effects were modelled: (1) an intervention-level model, (2) an additive component model and (3) a full
interaction component model. These three models are described subsequently. The models are fitted
using a Bayesian Monte Carlo Markov chain approach evaluated in WinBUGS. WinBUGS code differed
slightly for each population and outcome because of the evidence available for each of the possible
intervention/component combinations.
155
APPENDIX 1
Intervention-level network meta-analysis model

The intervention-level model is the standard NMA model,338 whereby the effect of each intervention is
estimated as a ‘clinically meaningful’ unit. For example, here we estimate a CBT effect that is assumed
to be the same regardless of the components comprising the CBT interventions. We describe a
random-effects model because, although fixed-effects models were fitted, there was substantial
heterogeneity, and so only results from random-effects models are presented. The standardised mean
outcome for study i, arm k, is the sum of a standardised mean outcome on arm 1, µi, and a SMD, δi,k, for
the intervention on arm k relative to the intervention on arm 1:
θi, k = µi + δi, k . (3)
The random-effects NMA model assumes that the SMDs, δi,k, come from a common normal distribution
with a mean that represents the appropriate SMD for the intervention comparison made, and a
between-study SD, τ:
δi, k ∼ Normal(dInt , − dInt , , τ2 ),

i k i 1
(4)
where Inti,k indicates the intervention on arm k of study i, and dk is the pooled estimate of intervention k.
Flat normal priors are given to the µi and dk parameters, and a uniform(0,5) prior is given to τ. A standard
correction is applied to incorporate correlations in the estimates from trials with three or more arms.
Additive component level (nested within interventions)

For a given intervention, the SMD comprises a sum of SMDs for the components that it includes
(see Welton et al.46). Equation 4 then becomes:
δi, k ∼ Normal((dInt , + βInt , , 1 C i, k, 1 + βInt , , 2 C i, k, 2 + :::) −(dInt , + βInt , , 1 Ci, 1, 1 + βInt , , 2 C i, 1, 2 + :::), τ2 ),
i k i k i k i 1 i 1 i 1
(5)
where Ci,k,j is an indicator for whether the intervention on arm k of study i contains component j
(Ci,k,j = 1) or not (Ci,k,j = 0), and βk,j is the additional SMD for intervention k when component j
is included. Flat normal priors are given to the βk,j parameters, and all other priors are as for the
intervention-level model.
Note that, for the model to be identifiable, a reference combination of components is defined for
each intervention, with SMD dk, and the regression coefficients βk,j are only estimated for additional
components over and above the reference combination of components. For example, for universal
interventions in the secondary population with anxiety as an outcome, all CBT interventions contain
a cognitive and a behavioural component, and so this (cognitive + behavioural) forms the reference
CBT intervention. Additional effects of psychoeducation, mindfulness and relaxation are estimated.
For some interventions, sets of components always co-occur, and so only a single regression coefficient
can be estimated for the joint inclusion of components in that set. For example, for universal interventions
in the secondary population with anxiety as an outcome, third-wave interventions were either with or
without both mindfulness and relaxation components. Third-wave without any additional components,
therefore, forms the reference intervention, and an additional effect is estimated for the addition of both
mindfulness and relaxation components.
Full interaction component model (nested within interventions)

Equation 5 assumes that the inclusion of additional components has an additive effect, so that, for
example, adding a psychoeducation component to a CBT intervention with cognitive and behavioural
components has the same change in SMD as addition of a psychoeducation component to a CBT with
156

cognitive, behavioural and relaxation components. The full interaction model46 relaxes this assumption
and estimates a separate effect for each combination of components. Equation 5 then becomes:
δi, k ∼ Normal((dInt , + βInt , , C , , , C , , , ::: ) − (dInt , + βInt , , C , , , C , , , ::: ), τ2 ),

i k i k i k 1 i k 2 i 1 i 1 i k 1 i k 2
(6)
where βk, c , c is the additional SMD for intervention k when components are included as indicated
1 2
by c1,c2. Flat normal priors are given to the βk, c , c parameters, and all other priors are as for the
1 2
intervention-level model.
Note that, as for the additive model, a reference combination of components is defined for each
intervention, with SMD dk, and the regression coefficients βk, c , c are estimated only for combinations 1 2
of components that are different from the reference combination.
Code for the network meta-analysis components models
The code on which the component level models are based is available in Dias et al.338 The adaptation to
component-level NMA is based on WinBUGS code reported in Welton et al.46
The WinBUGS code for all three models implemented in this report and an example dataset are
available from https://research-information.bris.ac.uk/en/persons/deborah-m-caldwell/projects
or by contacting the corresponding author.
157
Appendix 2 Results from systematic review

Primary reference for studies included in the review
This list of references provides the primary reference only for the studies included in the review.
Ahlen J, Hursti T, Tanner L, Tokay Z, Ghaderi A. Prevention of anxiety and depression in Swedish
school children: a cluster-randomized effectiveness study. Prev Sci 2018;19:147–58.145
Anticich SAJ, Barrett PM, Silverman W, Lacherez P, Gillies R. The prevention of childhood anxiety and
promotion of resilience among preschool-aged children: a universal school-based trial. Adv Sch Ment
Health Promot 2013;6:93–121.339
Araya R, Fritsch R, Spears M, Rojas G, Martinez V, Barroilhet S, et al. School intervention to improve mental
health of students in Santiago, Chile: a randomized clinical trial. JAMA Pediatr 2013;167:1004–10.118
Attwood M, Meadows S, Stallard P, Richardson T. Universal and targeted computerised cognitive

behavioural therapy (Think, Feel, Do) for emotional health in schools: results from two exploratory
studies. Child Adolesc Ment Health 2012;17:173–8.146
Aune T, Stiles TC. Universal-based prevention of syndromal and subsyndromal social anxiety:
a randomized controlled study. J Consult Clin Psychol 2009;77:867–79.119
Baker SB, Butler JN. Effects of preventive cognitive self-instruction training on adolescent attitudes,
experiences, and state anxiety. J Prim Prev 1984;5:17–26.120
Barrett P, Turner C. Prevention of anxiety symptoms in primary school children: preliminary results
from a universal school-based trial. Br J Clin Psychol 2001;40:399–410.147
Barrett P, Lock S, Farrell L. Developmental differences in universal preventive intervention for child
anxiety. Clin Child Psychol Psychiatry 2005;10:539–55.121
Barry M, Murphy M, O’Donovan H. Assessing the effectiveness of a cognitive behavioural group

coaching intervention in reducing symptoms of depression among adolescent males in a school setting.
Int Coach Psychol Rev 2017;12:101–9.190
Bonhauser M, Fernandez G, Püschel K, Yañez F, Montero J, Thompson B, Coronado G. Improving

physical fitness and emotional well-being in adolescents of low socioeconomic status in Chile: results
of a school-based controlled trial. Health Promot Int 2005;20:113–22.122
Bouchard S, Gervais J, Gagnier N, Loranger C. Evaluation of a primary prevention program for anxiety
disorders using story books with children aged 9–12 years. J Prim Prev 2013;34:345–58.148
Britton WB, Lepp NE, Niles HF, Rocha T, Fisher NE, Gold JS. A randomized controlled pilot trial of
classroom-based mindfulness meditation compared to an active control condition in sixth-grade
children. J Sch Psychol 2014;52:263–78.123
Burckhardt R, Manicavasagar V, Batterham PJ, Miller LM, Talbot E, Lum A. A web-based adolescent
positive psychology program in schools: randomized controlled trial. J Med Internet Res 2015;17:e187.124
159
APPENDIX 2
Burckhardt R, Manicavasagar V, Batterham PJ, Hadzi-Pavlovic D. A randomized controlled trial of

strong minds: a school-based mental health program combining acceptance and commitment therapy
and positive psychology. J Sch Psychol 2016;57:41–52.191
Calear AL, Christensen H, Mackinnon A, Griffiths KM, O’Kearney R. The YouthMood Project: a cluster
randomized controlled trial of an online cognitive behavioral program with adolescents. J Consult Clin
Psychol 2009;77:1021–32.125
Calear AL, Batterham PJ, Poyser CT, Mackinnon AJ, Griffiths KM, Christensen H. Cluster randomised
controlled trial of the e-couch Anxiety and Worry program in schools. J Affect Disord 2016;196:210–17.126
Calear AL, Christensen H, Brewer J, Mackinnon A, Griffiths KM. A pilot randomized controlled trial of
the e-couch anxiety and worry program in schools. Internet Interv 2016;6:1–5.127
Cardemil EV, Reivich KJ, Beevers CG, Seligman ME, James J. The prevention of depressive symptoms in
low-income, minority children: two-year follow-up. Behav Res Ther 2007;45:313–27.208
Chaplin TM, Gillham JE, Reivich K, Elkon AG, Samuels B, Freres DR, et al. Depression prevention for
early adolescent girls: a pilot study of all girls versus co-ed groups. J Early Adolesc 2006;26:110–26.192
Clarke GN, Hawkins W, Murphy M, Sheeber L. School-based primary prevention of depressive

symptomatology in adolescents: findings from two studies. J Adolesc Res 1993;8:183–204.193
Collins S, Marks Woolfson L, Durkin K. Effects on coping skills and anxiety of a universal school-based
mental health intervention delivered in Scottish primary schools. School Psychol Int 2014;35:85–100.149
Dadds MR, Roth JH. Prevention of anxiety disorders: results of a universal trial with young children.
J Child Fam Stud 2008;17:320–35.303
Eather N, Morgan PJ, Lubans DR. Effects of exercise on mental health outcomes in adolescents:
findings from the CrossFit™ teens randomized controlled trial. Psychol Sport Exerc 2016;26:14–23.340
Essau CA, Conradt J, Sasagawa S, Ollendick TH. Prevention of anxiety symptoms in children: results
from a universal school-based trial. Behav Ther 2012;43:450–64.150
Gallegos J. Preventing Childhood Anxiety and Depression: Testing the Effectiveness of a School-based
Program in Mexico. PhD thesis. Austin, TX: The University of Texas at Austin; 2008.151
Gillham JE. Preventing depressive symptoms in school children. Diss Ab Int B Sci Eng 1995;55:4119.209
Gillham JE, Reivich KJ, Freres DR, Lascher M, Litzinger S, Shatté A, Seligman MEP. School-based
prevention of depression and anxiety symptoms in early adolescence: a pilot of a parent intervention
component. School Psychol Q 2006;21:323–48.128
Gillham JE, Reivich KJ, Freres DR, Chaplin TM, Shatté AJ, Samuels B, et al. School-based prevention of
depressive symptoms: a randomized controlled study of the effectiveness and specificity of the Penn
Resiliency Program. J Consult Clin Psychol 2007;75:9–19.194
Gucht K, Griffith JW, Hellemans R, Bockstaele M, Pascal-Claes F, Raes F. Acceptance and Commitment
Therapy (ACT) for adolescents: outcomes of a large-sample, school-based, cluster-randomized
controlled trial. Mindfulness 2017;8:408–16.129
160

Haden SC, Daly L, Hagins M. A randomised controlled trial comparing the impact of yoga and physical
education on the emotional and behavioural functioning of middle school children. Focus Altern
Complement Ther 2014;19:148–55.341
Hiebert BA, Kirby B, Jaknavorian A. School-based relaxation: attempting primary prevention.

Can J Couns 1989;23:273–87.130
Hodas R. An investigation of the relationship between positive and negative mental health factors and
academic performance among early adolescent girls. Diss Ab Int B Sci Eng 2016;76(12-B(E)).131
Horowitz JL, Garber J, Ciesla JA, Young JF, Mufson L. Prevention of depressive symptoms in adolescents:
a randomized trial of cognitive-behavioral and interpersonal prevention programs. J Consult Clin Psychol
2007;75:693–706.195
Johnson C, Burke C, Brinkman S, Wade T. Effectiveness of a school-based mindfulness program for

transdiagnostic prevention in young adolescents. Behav Res Ther 2016;81:1–11.132
Johnson C, Burke C, Brinkman S, Wade T. A randomized controlled evaluation of a secondary

school mindfulness program for early adolescents: do we have the recipe right yet? Behav Res Ther
2017;99:37–46.133
Johnstone J, Rooney RM, Hassan S, Kane RT. Prevention of depression and anxiety symptoms in
adolescents: 42 and 54 months follow-up of the Aussie Optimism Program-Positive Thinking Skills.
Front Psychol 2014;5:364.152
Khalsa SB, Hickey-Schultz L, Cohen D, Steiner N, Cope S. Evaluation of the mental health benefits
of yoga in a secondary school: a preliminary randomized controlled trial. J Behav Health Serv Res
2012;39:80–90.239
Kindt KC, Kleinjan M, Janssens JM, Scholte RH. Evaluation of a school-based depression prevention
program among adolescents from low-income areas: a randomized controlled effectiveness trial.
Int J Environ Res Public Health 2014;11:5273–93.196
Lock S, Barrett PM. A longitudinal study of developmental differences in universal preventive

intervention for child anxiety. Behav Change 2003;20:183–99.134
Lowry-Webster HM, Barrett PM, Dadds MR. A universal prevention trial of anxiety and depressive
symptomatology in childhood: preliminary data from an Australian study. Behav Change 2001;18:36–50.135
Mendelson T, Greenberg MT, Dariotis JK, Gould LF, Rhoades BL, Leaf PJ. Feasibility and preliminary
outcomes of a school-based mindfulness intervention for urban youth. J Abnorm Child Psychol
2010;38:985–94.210
Merry S, McDowell H, Wild CJ, Bir J, Cunliffe R. A randomized placebo-controlled trial of a school-
based depression prevention program. J Am Acad Child Adolesc Psychiatry 2004;43:538–47.197
Miller LD, Short C, Garland EJ, Clark S. The ABCs of CBT (cognitive behavior therapy): evidence-based
approaches to child anxiety in public school settings. J Couns Dev 2010;88:432–9.153
Miller LD, Laye-Gindhu A, Liu Y, March JS, Thordarson DS, Garland EJ. Evaluation of a preventive
intervention for child anxiety in two randomized attention-control school trials. Behav Res Ther
2011;49:315–23.154
161
APPENDIX 2
Pahl KM, Barrett PM. Preventing anxiety and promoting social and emotional strength in preschool
children: a universal evaluation of the Fun FRIENDS Program. Adv Sch Ment Health Promot
2010;3:14–25.242
Pattison C, Lynd-Stevenson R. The prevention of depressive symptoms in children: the immediate and
long-term outcomes of a school-based program. Behav Change 2001;18:92–102.155
Perry Y, Werner-Seidler A, Calear A, Mackinnon A, King C, Scott J, et al. Preventing depression in final
year secondary students: school-based randomized controlled trial. J Med Internet Res 2017;19:e369.136
Pophillat E, Rooney RM, Nesa M, Davis MC, Baughman N, Hassan S, Kane RT. Preventing internalizing
problems in 6–8 year old children: a universal school-based program. Front Psychol 2016;7:1928.156
Pössel P, Horn AB, Groen G, Hautzinger M. School-based prevention of depressive symptoms in

adolescents: a 6-month follow-up. J Am Acad Child Adolesc Psychiatry 2004;43:1003–10.198
Pössel P, Adelson JL, Hautzinger M. A randomized trial to evaluate the course of effects of a program
to prevent adolescent depressive symptoms over 12 months. Behav Res Ther 2011;49:838–51.199
Pössel P, Martin NC, Garber J, Hautzinger M. A randomized controlled trial of a cognitive–behavioral

program for the prevention of depression in adolescents compared with nonspecific and no-intervention
control conditions. J Couns Psychol 2013;60:432–8.200
Potek R. Mindfulness as a school-based prevention program and its effect on adolescent stress, anxiety
and emotion regulation. Diss Abs Int B Sci Eng 2012;73:3272.137
Quayle D, Dziurawiec S, Roberts C, Kane R, Ebsworthy G. The effect of an optimism and lifeskills
program on depressive symptoms in preadolescence. Behav Change 2001;18:194–203.211
Raes F, Griffith JW, Van der Gucht K, Williams JMG. School-based prevention and reduction of
depression in adolescents: a cluster-randomized controlled trial of a mindfulness group program.
Mindfulness 2014;5:477–86.201
Reynolds EK, Macpherson L, Tull MT, Baruch DE, Lejuez CW. Integration of the brief behavioral
activation treatment for depression (BATD) into a college orientation program: depression and alcohol
outcomes. J Couns Psychol 2011;58:555–64.233
Rivet-Duval E, Heriot S, Hunt C. Preventing adolescent depression in Mauritius: a universal

school-based program. Child Adolesc Ment Health 2011;16:86–91.202
Roberts C, Kane R, Thomson H, Bishop B, Hart B. The prevention of depressive symptoms in rural
school children: a randomized controlled trial. J Consult Clin Psychol 2003;71:622–8.138
Roberts CM, Kane R, Bishop B, Cross D, Fenton J, Hart B. The prevention of anxiety and depression in
children from disadvantaged schools. Behav Res Ther 2010;48:68–73.139
Roberts CM, Kane RT, Rooney RM, Pintabona Y, Baughman N, Hassan S, et al. Efficacy of the Aussie
Optimism Program: promoting pro-social behavior and preventing suicidality in primary school students.
A randomised-controlled trial. Front Psychol 2018;8:1392.240
Rodgers A, Dunsmuir S. A controlled evaluation of the ‘FRIENDS for Life’ emotional resiliency
programme on overall anxiety levels, anxiety subtype levels and school adjustment. Child Adolesc Ment
Health 2015;20:13–19.140
162

Rooney R, Roberts C, Kane R, Pike L, Winsor A, White J, Brown A. The prevention of depression in
8- to 9-year-old children: a pilot study. Aust J Guidance Couns 2006;16:76–90.157
Rose K, Hawes DJ, Hunt CJ. Randomized controlled trial of a friendship skills intervention on adolescent
depressive symptoms. J Consult Clin Psychol 2014;82:510–20.203
Ruttledge R, Devitt E, Greene G, Mullany M, Charles E, Frehill J, Moriarty M. A randomised controlled

trial of the FRIENDS for Life emotional resilience programme delivered by teachers in Irish primary
schools. Educ Child Psychol 2016;33:69–89.158
Sawyer MG, Pfeiffer S, Spence SH, Bond L, Graetz B, Kay D, et al. School-based prevention of
depression: a randomised controlled study of the beyond blue schools research initiative. J Child
Psychol Psychiatry 2010;51:199–209.204
Shatté AJ. Prevention of depressive symptoms in adolescents: issues of dissemination and mechanisms
of change. Diss Ab Int B Sci Eng 1997;57:7236.205
Sheffield JK, Spence SH, Rapee RM, Kowalenko N, Wignall A, Davis A, McLoone J. Evaluation of universal,
indicated, and combined cognitive-behavioral approaches to the prevention of depression among
adolescents. J Consult Clin Psychol 2006;74:66–79.141
Soffer AG. School-based Social Skills Training to Reduce Children's Depressive Symptomatology. PhD thesis.
New York, NY: City University New York; 2003.212
Spence SH, Sheffield JK, Donovan CL. Preventing adolescent depression: an evaluation of the problem
solving for life program. J Consult Clin Psychol 2003;71:3–13.206
Stallard P, Phillips R, Montgomery AA, Spears M, Anderson R, Taylor J, et al. A cluster randomised
controlled trial to determine the clinical effectiveness and cost-effectiveness of classroom-based
cognitive-behavioural therapy (CBT) in reducing symptoms of depression in high-risk adolescents.
Health Technol Assess 2013;17(47).142
Stallard P, Skryabina E, Taylor G, Phillips R, Daniels H, Anderson R, Simpson N. Classroom-based

cognitive behaviour therapy (FRIENDS): a cluster randomised controlled trial to Prevent Anxiety in
Children through Education in Schools (PACES). Lancet Psychiatry 2014;1:185–92.159
Tak YR, Lichtwarck-Aschoff A, Gillham JE, Van Zundert RM, Engels RC. Universal school-based
depression prevention ‘Op Volle Kracht’: a longitudinal cluster randomized controlled trial. J Abnorm
Child Psychol 2016;44:949–61.207
Tomba E, Belaise C, Ottolini F, Ruini C, Bravi A, Albieri E, et al. Differential effects of well-being
promoting and anxiety-management strategies in a non-clinical school setting. J Anxiety Disord
2010;24:326–33.143
Velásquez AM, López MA, Quiñonez N, Paba DP. Yoga for the prevention of depression, anxiety, and
aggression and the promotion of socio-emotional competencies in school-aged children. Educ Res Eval
2015;21:407–21.189
Wong N, Kady L, Mewton L, Sunderland M, Andrews G. Preventing anxiety and depression in

adolescents: a randomised controlled trial of two school-based internet-delivered cognitive behavioural
therapy programmes. Internet Interv 2014;1:90–4.144
163
APPENDIX 2
Arnarson EO, Craighead WE. Prevention of depression among Icelandic adolescents. Behav Res Ther
2009;47:577–85.213
Balle M, Tortella-Feliu M. Efficacy of a brief school-based program for selective prevention of

childhood anxiety. Anxiety Stress Coping 2010;23:71–85.160
Berry K, Hunt CJ. Evaluation of an intervention program for anxious adolescent boys who are bullied
at school. J Adolesc Health 2009;45:376–82.161
Clarke GN, Hawkins W, Murphy M, Sheeber LB, Lewinsohn PM, Seeley JR. Targeted prevention of
unipolar depressive disorder in an at-risk sample of high school adolescents: a randomized trial of a
group cognitive intervention. J Am Acad Child Adolesc Psychiatry 1995;34:312–21.214
Congleton AB. The Effect of a Cognitive–Behavioral Group Intervention on the Locus of Control, Attributional
Style, and Depressive Symptoms of Middle School Students. PhD thesis. Lexington, KY: University of
Kentucky; 1995.215
Cooley-Strickland MR, Griffin RS, Darney D, Otte K, Ko J. Urban African American youth exposed to
community violence: a school-based anxiety preventive intervention efficacy study. J Prev Interv
Community 2011;39:149–66.174
Cova F, Rincon P, Melipillan R. Evaluation of the efficacy of a prevention program for depression in
female adolescents. Ter Psicol 2011;29:245–50.162
Cowell JM, McNaughton D, Ailey S, Gross D, Fogg L. Clinical trial outcomes of the Mexican American
Problem Solving program (MAPS). Hisp Health Care Int 2009;7:179–89.231
Cui L, He F, Han Z, Yang R, Xiao J, Oei TP. A brief group cognitive–behavioral program for the
prevention of depressive symptoms in Chinese college students. Int J Group Psychother
2016;66:291–307.183
Dobson KS, Hopkins JA, Fata L, Scherrer M, Allan LC. The prevention of depression and anxiety in a
sample of high-risk adolescents: a randomized controlled trial. Can J Sch Psychol 2010;25:291–310.163
Ellis L, Campbell A, Sethi S, O’Dea B. Comparative randomized trial of an online cognitive–behavioral

therapy program and an online support group for depression and anxiety. J Cyber Ther Rehabil
2011;4:461–7.184
Fitzgerald A, Rawdon C, Dooley B. A randomized controlled trial of attention bias modification training
for socially anxious adolescents. Behav Res Ther 2016;84:1–8.114
Fung J, Guo S, Jin J, Bear L, Lau A. A pilot randomized trial evaluating a school-based mindfulness
intervention for ethnic minority youth. Mindfulness 2016;7:819–28.216
Gaete J, Martinez V, Fritsch R, Rojas G, Montgomery AA, Araya R. Indicated school-based intervention
to improve depressive symptoms among at risk Chilean adolescents: a randomized controlled trial.
BMC Psychiatry 2016;16:276.164
Gillham JE, Reivich KJ, Brunwasser SM, Freres DR, Chajon ND, Kash-Macdonald VM, et al. Evaluation
of a group cognitive-behavioral depression prevention program for young adolescents: a randomized
effectiveness trial. J Clin Child Adolesc Psychol 2012;41:621–39.165
164

Higgins DM. Preventing generalized anxiety disorder in an at-risk sample of college students: a brief
cognitive–behavioral approach. Diss Ab Int B Sci Eng 2007;67:5406.185
Hunt C, Andrews G, Crino R, Erskine A, Sakashita C. Randomized controlled trial of an early

intervention programme for adolescent anxiety disorders. Aust N Z J Psychiatry 2009;43:300–4.166
Jaycox LH, Reivich KJ, Gillham J, Seligman ME. Prevention of depressive symptoms in school children.
Behav Res Ther 1994;32:801–16.232
Jordans MJ, Komproe IH, Tol WA, Kohrt BA, Luitel NP, Macy RD, de Jong JT. Evaluation of a
classroom-based psychosocial intervention in conflict-affected Nepal: a cluster randomized controlled
trial. J Child Psychol Psychiatry 2010;51:818–26.167
Kiselica MS, Baker SB, Thomas RN, Reedy S. Effects of stress inoculation training on anxiety, stress,
and academic performance among adolescents. J Couns Psychol 1994;41:335–42.168
Liddle I, Macmillan S. Evaluating the FRIENDS programme in a Scottish setting. Educ Psychol Pract
2010;26:53–67.188
Livheim F, Hayes L, Ghaderi A, Magnusdottir T, Högfeldt A, Rowse J, et al. The effectiveness of

acceptance and commitment therapy for adolescent mental health: Swedish and Australian pilot
outcomes. J Child Fam Stud 2015;24:1016–30.217
Manassis K, Wilansky-Traynor P, Farzan N, Kleiman V, Parker K, Sanford M. The feelings club:

randomized controlled evaluation of school-based CBT for anxious or depressive symptoms.
Depress Anxiety 2010;27:945–52.175
McCarty CA, Violette HD, McCauley E. Feasibility of the positive thoughts and actions prevention
program for middle schoolers at risk for depression. Depress Res Treat 2011;2011:241386.218
McCarty CA, Violette HD, Duong MT, Cruz RA, McCauley E. A randomized trial of the Positive
Thoughts and Action program for depression among early adolescents. J Clin Child Adolesc Psychol
2013;42:554–63.219
McLaughlin C. Evaluating the effect of an empirically-supported group intervention for students at-risk
for depression in a rural school district. Diss Ab Int B Sci Eng 2011;71:5820.236
McLoone JK, Rapee RM. Comparison of an anxiety management program for children implemented at
home and school: lessons learned. Sch Ment Health 2012;4:231–42.176
Mifsud C, Rapee RM. Early intervention for childhood anxiety in a school setting: outcomes for an
economically disadvantaged population. J Am Acad Child Adolesc Psychiatry 2005;44:996–1004.177
Miller LD, Laye-Gindhu A, Bennett JL, Liu Y, Gold S, March JS, et al. An effectiveness study of a
culturally enriched school-based CBT anxiety prevention program. J Clin Child Adolesc Psychol
2011;40:618–29.178
Noël LT, Rost K, Gromer J. Depression prevention among rural preadolescent girls: a randomized
controlled trial. Sch Soc Work J 2013;38:1–18.220
Owen H, Lanning W. The effects of three treatment methods upon anxiety and inappropriate
attentional style among high school athletes. Int J Sport Psychol 1982;13:154–62.169
165
APPENDIX 2
Peden AR, Hall LA, Rayens MK, Beebe LL. Reducing negative thinking and depressive symptoms in
college women. J Nurs Scholarsh 2000;32:145–51.234
Peng S, Qi A, Yuan F. Experimental study on the effects of exercise prescription on the mental health of
left-behind school children in rural areas. Rev Argent Clin Psicol 2015;24:267–76.170
Poppelaars M, Tak YR, Lichtwarck-Aschoff A, Engels RC, Lobel A, Merry SN, et al. A randomized
controlled trial comparing two cognitive–behavioral programs for adolescent girls with subclinical
depression: a school-based program (Op Volle Kracht) and a computerized program (SPARX).
Behav Res Ther 2016;80:33–42.221
Puskar K, Sereika S, Tusaie-Mumford K. Effect of the Teaching Kids to Cope (TKC) program on outcomes
of depression and coping among rural adolescents. J Child Adolesc Psychiatr Nurs 2003;16:71–80.222
Rice CL. Reducing anxiety in middle school and high school students: a comparison of cognitive–behavioral
therapy and relaxation training approaches. Diss Ab Int A Humanit Soc Sci 2009;69:2607.171
Rohde P, Stice E, Shaw H, Brière FN. Indicated cognitive behavioral group depression prevention
compared to bibliotherapy and brochure control: acute effects of an effectiveness trial with
adolescents. J Consult Clin Psychol 2014;82:65–74.223
Scholten H, Malmberg M, Lobel A, Engels RC, Granic I. A randomized controlled trial to test the
effectiveness of an immersive 3D video game for anxiety prevention among adolescents. PLOS ONE
2016;11:e0147763.172
Schoneveld EA, Malmberg M, Lichtwarck-Aschoff A, Verheijen GP, Engels RC, Granic I. A neurofeedback
video game (MindLight) to prevent anxiety in children: a randomized controlled trial. Comput Hum Behav
2016;63:321–33.115
Schoneveld EA, Lichtwarck-Aschoff A, Granic I. Preventing childhood anxiety disorders: is an applied

game as effective as a cognitive behavioral therapy-based program? Prev Sci 2018;19:220–32.116
Seligman MEP, Schulman P, DeRubeis RJ, Hollon SD. The prevention of depression and anxiety.
Prev Treat 1999;2.186
Seligman ME, Schulman P, Tryon AM. Group prevention of depression and anxiety symptoms. Behav Res
Ther 2007;45:1111–26.187
Simpson AT. The roles of self-regulation and coping in a preventative cognitive–behavioural intervention
for school-age children at-risk for internalizing disorders. Diss Ab Int B Sci Eng 2008;69:3862.179
Siu FYA. Internalizing problems among primary school children in Hong Kong: prevalence and treatment.
Diss Ab Int A Humanit Soc Sci 2008;69:115.180
Sportel BE, de Hullu E, de Jong PJ, Nauta MH. Cognitive bias modification versus CBT in reducing
adolescent social anxiety: a randomized controlled trial. PLOS ONE 2013;8:e64355.117
Stice E, Burton E, Bearman SK, Rohde P. Randomized trial of a brief depression prevention program: an
elusive search for a psychosocial placebo control condition. Behav Res Ther 2007;45:863–76.237
Stice E, Rohde P, Seeley JR, Gau JM. Brief cognitive-behavioral depression prevention program for
high-risk adolescents outperforms two alternative interventions: a randomized efficacy trial. J Consult
Clin Psychol 2008;76:595–606.224
166

Stoppelbein LA. Primary prevention: an evaluation of a high-school based cognitive–behavioral program.

Diss Abs Int B Sci Eng 2004;64:4066.225
Takagaki K, Okamoto Y, Jinnin R, Mori A, Nishiyama Y, Yamamura T, et al. Behavioral activation for
late adolescents with subthreshold depression: a randomized controlled trial. Eur Child Adolesc Psychiatry
2016;25:1171–82.235
Tokolahi E, Vandal AC, Kersten P, Pearson J, Hocking C. Cluster-randomised controlled trial of an

occupational therapy intervention for children aged 11–13 years, designed to increase participation to
prevent symptoms of mental illness. Child Adolesc Ment Health 2018;23:313–27.181
Topper M, Emmelkamp PM, Watkins E, Ehring T. Prevention of anxiety disorders and depression by
targeting excessive worry and rumination in adolescents and young adults: a randomized controlled
trial. Behav Res Ther 2017;90:123–36.173
van Starrenburg ML, Kuijpers RC, Kleinjan M, Hutschemaekers GJ, Engels RC. Effectiveness of a
cognitive behavioral therapy-based indicated prevention program for children with elevated anxiety
levels: a randomized controlled trial. Prev Sci 2017;18:31–9.182
Wijnhoven LA, Creemers DH, Vermulst AA, Scholte RH, Engels RC. Randomized controlled trial testing
the effectiveness of a depression prevention program (‘Op Volle Kracht’) among adolescent girls with
elevated depressive symptoms. J Abnorm Child Psychol 2014;42:217–28.226
Woods B, Jose P. Effectiveness of a school-based indicated early intervention program for Maori and
Pacific adolescents. J Pac Rim Psychol 2011;5:40–50.227
Young JF, Mufson L, Davies M. Efficacy of Interpersonal Psychotherapy-Adolescent Skills Training: an

indicated preventive intervention for depression. J Child Psychol Psychiatry 2006;47:1254–62.228
Young JF, Mufson L, Gallop R. Preventing depression: a randomized trial of interpersonal

psychotherapy-adolescent skills training. Depress Anxiety 2010;27:426–33.229
Young JF, Benas JS, Schueler CM, Gallop R, Gillham JE, Mufson L. A randomized depression prevention
trial comparing interpersonal psychotherapy – adolescent skills training to group counseling in schools.
Prev Sci 2016;17:314–24.230
Yu L. Preventing depressive symptoms in Chinese children. Diss Abs Int B Sci Eng 2000;60:6389.238
August GJ, Hektner JM, Egan EA, Realmuto GM, Bloomquist ML. The early risers longitudinal prevention
trial: examination of 3-year outcomes in aggressive children with intent-to-treat and as-intended analyses.
Psychol Addict Behav 2002;16:S27–39.244
Baker-Henningham H, Scott S, Jones K, Walker S. Reducing child conduct problems and promoting social
skills in a middle-income country: cluster randomised controlled trial. Br J Psychiatry 2012;201:101–8.245
Havighurst SS, Duncombe M, Frankling E, Holland K, Kehoe C, Stargatt R. An emotion-focused early

intervention for children with emerging conduct problems. J Abnorm Child Psychol 2015;43:749–60.246
Kyranides MN, Fanti KA, Katsimicha E, Georgiou G. Preventing conduct disorder and callous
unemotional traits: preliminary results of a school based pilot training program. J Abnorm Child Psychol
2018;46:291–303.243
167
APPENDIX 2
The Conduct Problems Prevention Research Group. Initial impact of the Fast Track prevention trial for
conduct problems: I. The high-risk sample. J Consult Clin Psychol 1999;67:631–47.247
References to studies awaiting classification
Unable to locate full text

Boogar IR. [Effectiveness of the Teasdale Cognitive Therapy on depression reduction in guidance and
high school students.] Psychol Res 2012;14:25–40.
Dadsetan P, Anari A, Sedghpour BS. Social anxiety disorders and drama-therapy. J Iran Psychol
2008;4:115–123.
Diner MD. The differential effects of meditation and systematic desensitization on specific and general
anxiety. Diss Abs Int B Sci Eng 1978;39:1950.
Kahn RHC. The Effect of a Group Support Intervention Program on Depression, Social Adjustment, and
Self-esteem of Adolescents in an Overseas American International School. PhD thesis. Washington, DC:
The Catholic University of America; 1989.
Ma HX, Liu MT, Zhang FY. Improving the academic emotions of high-school students by rational-emotive
educational mode. Chin J Clin Psychol 2012;20:116–119.
Mirzamani SM, Azvar F, Dolatshahi B, Askari A. [Efficacy of life skills training on reduce depressive
symptoms in student population.] J Res Behav Sci 2012;10:124–32.
Moharreri F, Yazdi A. Evaluation of the effectiveness of the Friends for Life Program on children’s
anxiety and depression. Iran J Psychiatry 2017;12:272–280.
Short C. Universal Prevention Program for Anxiety Symptoms in School Aged Children: Taming Worry Dragons.
Master’s thesis. Vancouver, BC: University of British Columbia; 2005.
Zou M, Han RS. Attributive training in junior school students with high-level anxiety. Chin Ment
Health J 2008;3:358–371. Abstract available from http://en.cnki.com.cn/Article_en/CJFDTOTAL-
ZXWS200805016.html (accessed 18 May 2021).
No author details. Effectiveness of group cognitive–emotional skills training on improvement of anxiety

management in primary school children. Iran J Psychiatry 2012;7 (CENTRAL database).
Conference abstracts
Rezaei Ghalechi E, Sadeghi Movahhed F. Teaching Coping Skills Affects on Decreasing Mental Disorders
Symptoms of Students. EPA 2013 – 21st European Congress of Psychiatry, Nice, 6–9 April 2013.
Tze-Chun T, Shih-Yin H. Efficacy of school-based interpersonal psychotherapy to adolescents

of early detected depressive and suicide ideations: randomized control study. Early Interv Psychiatry
2010;4(Suppl. 1):1–200.
Davis H. Youth Clubs: Outcome of a Community-based Intervention for Prevention of Mental Health
Disorders in Adolescence. European Child Psychiatry Research Group – invitational meeting, Oslo,
5–7 September 1996 (found on the CENTRAL database).
168

Other
Eimecke S, Pauschardt J, Mattejat F. [Prevention of childhood anxiety and depression: efficacy of an
additional parent training program.] Verhaltenstherapie 2010;20:193–200.
Tsutsumi A. Effects of a psycho-educational program for preventing depression in junior high and high
school students. Jpn J Educ Psychol 2015;63:323–37.
St Onge J, Stephenson R, Kumar BS. Validation of the FRIENDS anxiety prevention program for
children in Canada. Can J Community Ment Health 2016;35:25–40.
Silvestri L, Dantonio M, Eason S. The effects of a self-development program and relaxation/imagery

training on the anxiety levels of at-risk fourth grade students. J Instr Psychol 1996;23:167–73.
Petersen A, Leffert A, Graham B, Alwin J, Ding S. Promoting Mental Health During the Transition into
Adolescence. In Schulenberg J, Maggs JL, Hierrelmann AK, editors. Health Risks and Developmental
Transitions During Adolescence. New York, NY: Cambridge University Press; 1997. pp. 471–97.
Details of studies included in systematic review of anxiety and

depression prevention
Tables 22 and 23 report the focus of the intervention, study design, population, setting and age range
(if reported) for 137 studies included in the review for depression and anxiety prevention. A total of 79
studies reported an anxiety outcome and 105 reported a depression outcome.
169
170
APPENDIX 2
TABLE 22 Study characteristics of included studies: anxiety
Follow-up time point(s) (months)
Age (SD) In Post

Study Target Study design Population Setting (years) Anxiety scale NMA?a intervention 1–5 6–12 13–24 ≥ 25
Aune and Stiles119 Anxiety Cluster Universal Secondary 10–15 SCARED Yes 0
2009 randomised
Baker and Butler120 Anxiety Cluster Universal Secondary 16–18 STAI Yes 0
1984 randomised
Calear et al.126 2016 Anxiety Cluster Universal Secondary 12–18 SCAS, GAD-7 Yes 0 6, 12
randomised
Calear et al.127 2016 Anxiety Cluster Universal Secondary 13–17 SCAS, GAD-7 Yes 0 3
randomised
Hiebert et al.130 1989 Anxiety Individually Universal Secondary 13–14 STAI Yes 0
randomised
Lock and Barrett134 Anxiety Cluster Universal Secondary Not clear RCMAS, SCAS Yes 0 12
2003 randomised
Potek137 2012 Anxiety Individually Universal Secondary 14–17 MASC Yes 0

randomised
Rodgers and Anxiety Individually Universal Secondary 12–13 SCAS Yes 0 4

Dunsmuir140 2015 randomised
Calear et al.125 2009 Anxiety and Cluster Universal Secondary 12–17 RCMAS Yes 0 6
depression randomised
Gillham et al.128 2006 Anxiety and Individually Universal Secondary 11–13 RCMAS Yes 0 6, 12
Gucht et al.129 2017 Anxiety and Cluster Universal Secondary 14–21 YSR-anxiety Yes 0 12
Hodas131 2016 Anxiety and Individually Universal Secondary 12–14 RCMAS Yes 0 6
Johnson et al.132 2016 Anxiety and Cluster Universal Secondary 13.63 DASS-anxiety Yes 0 3
depression randomised (0.43)
Johnson et al.133 2017 Anxiety and Cluster Universal Secondary 13.44 DASS-anxiety Yes 0 6,12
DOI: 10.3310/phr09080
Age (SD) In Post

Lowry-Webster Anxiety and Cluster Universal Secondary 10–13 RCMAS, SCAS Yes 0 12
et al.135 2001 depression randomised
Roberts et al.139 2010 Anxiety and Cluster Universal Secondary 11–13 RCMAS Yes 0 6 18
Tomba et al.143 2010 Anxiety and Cluster Universal Secondary 11.41 RCMAS Yes 0 6
Wong et al.144 2014 Anxiety and Cluster Universal Secondary 14–16 GAD-7 Yes 0
Araya et al.118 2013 Depression Cluster Universal Secondary 14.5 RCADS-anxiety Y-12 3 12
randomised (0.90)
Perry et al.136 2017 Depression Cluster Universal Secondary 16–17 SCAS Yes 0 6 18
randomised
Roberts et al.138 2003 Depression Cluster Universal Secondary 11–13 RCMAS Yes 0 6 18 30
randomised
Sheffield et al.141 2006 Depression Cluster Universal Secondary 13–15 SCAS Yes 0 6, 12
randomised
Stallard et al.142 2013 Depression Cluster Universal Secondary 12–16 RCADS-GA Y-12 6, 12

randomised
Barrett et al.121 2005 Anxiety Cluster Universal Secondary 9–16 SCAS No

randomised
Bonhauser et al.122 Anxiety and Cluster Universal Secondary 15.3 HADS No 0

2005 depression randomised (0.92)
Britton et al.123 2014 Anxiety and Individually Universal Secondary 11.79 STAI No 0
Burckhardt et al.124 Anxiety and Cluster Universal Secondary 14–16 DASS-anxiety No 0 5

2015 depression randomised
Attwood et al.146 2012 Anxiety Individually Universal Primary 10–12 SCAS Yes 0
randomised
continued
171
172
APPENDIX 2
TABLE 22 Study characteristics of included studies: anxiety (continued )
Age (SD) In Post

147
Barrett and Turner Anxiety Cluster Universal Primary 10–12 RCMAS, SCAS Yes 0
2001 randomised
Bouchard et al.148 2013 Anxiety Individually Universal Primary 9–12 MASC Yes 0
randomised
Collins et al.149 2014 Anxiety Cluster Universal Primary 9–10 SCAS Yes 0 6
randomised
Essau et al.150 2012 Anxiety Cluster Universal Primary 9–12 SCAS Yes 0 6, 12
randomised
Miller et al.153 2010 Anxiety Cluster Universal Primary 7–12 MASC Yes 0
randomised
Miller et al.154 2011 Anxiety Cluster Universal Primary 7–13 MASC Yes 0 6
randomised
Miller et al.154 2011 Anxiety Cluster Universal Primary 7–13 SCAS Yes 0 12
randomised
Ruttledge et al.158 Anxiety Cluster Universal Primary 9–13 SCAS Yes 0 3

2016 randomised
Stallard et al.159 2014 Anxiety Cluster Universal Primary 9–10 RCADS-GA Y-12 12 24
randomised
Ahlen et al.145 2018 Anxiety and Cluster Universal Primary 8–11 SCAS Yes 0 12
Gallegos151 2008 Anxiety and Cluster Universal Primary 9–11 SCAS Yes 0 6
Johnstone et al.152 Anxiety and Cluster Universal Primary 9–10 SCAS Yes 0 6 18 30,
2014 depression randomised 42,
54
Pophillat et al.156 2016 Anxiety and Cluster Universal Primary 6–8 SCAS Yes 0
Pattison and Lynd- Depression Individually Universal Primary 9–12 STAI Yes 0 8
Stevenson155 2001 randomised
DOI: 10.3310/phr09080
Age (SD) In Post

157
Rooney et al. 2006 Depression Cluster Universal Primary 8–9 RCMAS Yes 0 9 18
randomised
Velásquez et al.189 Anxiety and Individually Universal M NR Modified No 0

2015 depression randomised SDQ-anxiety
Balle and Tortella- Anxiety Individually Targeted Secondary 11–17 SCAS Yes 0 6
Feliu160 2010 randomised
Berry and Hunt161 Anxiety Cluster Targeted Secondary 12–15 SCARED Yes 0
2009 randomised
Fitzgerald et al.114 Anxiety Individually Targeted Secondary 15–18 SCARED Yes 0 3

2016 randomised
Hiebert et al.130 1989 Anxiety Individually Targeted Secondary 15–17 STAI Yes 0
randomised
Hunt et al.166 2009 Anxiety Cluster Targeted Secondary 11–13 RCMAS, SCAS Y-24 0 24 48
randomised
Kiselica et al.168 1994 Anxiety Individually Targeted Secondary 14–15 STAI Yes 0 3
randomised
Rice171 2009 Anxiety Individually Targeted Secondary 10–18 MASC Yes 0 2

randomised
Scholten et al.172 2016 Anxiety Individually Targeted Secondary 11–15 SCAS Yes 0 3
randomised
Sportel et al.117 2013 Anxiety Cluster Targeted Secondary 12–15 RCADS-social Yes 0 6, 12
randomised anxiety
Owen and Lanning169 Anxiety Individually Targeted Secondary 15–16 STAI No 0

1982 randomised
Dobson et al.163 2010 Anxiety and Individually Targeted Secondary 13–18 BAI Yes 0 3 6
Jordans et al.167 2010 Anxiety and Cluster Targeted Secondary 11–14 SCARED Yes 0
continued
173
174
APPENDIX 2
TABLE 22 Study characteristics of included studies: anxiety (continued )
Age (SD) In Post

170
Peng et al. 2015 Anxiety and Cluster Targeted Secondary 14.2 Mental Health Yes 0
depression randomised (2.34) Test-anxiety
Topper et al.173 2017 Anxiety and Individually Targeted Secondary 15–22 MASQ Yes 0 3 12
Cova et al.162 2011 Depression Individually Targeted Secondary 14–15 BAI Yes 0
randomised
Gaete et al.164 2016 Depression Individually Targeted Secondary 13–18 RCADS No 3

randomised
Gillham et al.165 2012 Depression Individually Targeted Secondary 10–15 RCMAS Yes 0 6
randomised
Sheffield et al.141 2006 Depression Cluster Targeted Secondary 13–15 SCAS Yes 0 6, 12
randomised
Cooley-Strickland Anxiety Individually Targeted Primary 9–10 RCMAS Yes 0

et al.174 2011 randomised
McLoone et al.176 2012 Anxiety Individually Targeted Primary 7–10 SCAS Yes 0 12
randomised
Mifsud and Rapee177 Anxiety Cluster Targeted Primary 8–11 SCAS Yes 0 6
2005 randomised
Miller et al.178 2011 Anxiety Cluster Targeted Primary 7–12 SCAS Yes 0 3 12
randomised
Schoneveld et al.115 Anxiety Individually Targeted Primary 8–13 SCAS Yes 0 3

2016 randomised
Schoneveld et al.116 Anxiety Individually Targeted Primary 7–12 SCAS Yes 0 3 6

2018 randomised
van Starrenburg Anxiety Individually Targeted Primary 7–13 SCAS Yes 0 3

et al.182 2017 randomised
Manassis et al.175 2010 Anxiety and Individually Targeted Primary 8–11 MASC Yes 0 12
DOI: 10.3310/phr09080
Age (SD) In Post

Simpson179 2008 Anxiety and Individually Targeted Primary 7–11 MASC Yes 0
Siu180 2007 Anxiety and Individually Targeted Primary 7–10 SCARED Yes 0
Tokolahi et al.181 2018 Anxiety and Cluster Targeted Primary 7–12 MASC Yes 0
Cui et al.183 2016 Depression Individually Targeted University 19.42 Zung Yes 0 6
randomised (1.66)
Ellis et al.184 2011 Depression Individually Targeted University 18–25 DASS-anxiety Yes 0
randomised
Higgins185 2007 Anxiety Individually Targeted University 17–19 BAI, GAD Yes 0 1 6, 12
randomised
Seligman et al.186 1999 Anxiety and Individually Targeted University 19 (NR) BAI Yes 0 3 36

Seligman et al.187 2007 Anxiety and Individually Targeted University 19 (NR) BAI Yes 0 1,3
Liddle and Anxiety Individually Targeted M 8–14 SCAS No 0

Macmillan188 2010 randomised
BAI, Beck Anxiety Inventory; DASS, Depression, Anxiety and Stress Scale; GA, generalised anxiety; GAD-7, Generalised Anxiety Disorder-7; HADS, Hospital Anxiety and Depression
Scale; M, mixed/multiple age groups; MASC, Multidimensional Anxiety Scale for Children; MASQ, Mood and Anxiety Symptom Questionnaire-D30; NR, not reported; RCMAS, Revised
Children’s Manifest Anxiety Scale; SCARED, Screen for Child Anxiety Related Disorders; SCAS, Spence Children’s Anxiety Scale; STAI, State–Trait Anxiety Inventory; YSR, Achenbach
Youth Self Report; Zung, Zung self-rating scale (anxiety and depression).
a Y-12 means that the study was included in the NMA but in the 12-month analysis only; Y-24 means it was in the 24-month NMA only.
Age is reported as a range, in years. If the range was not reported, we extracted the mean (SD) where available.
175
176
APPENDIX 2
TABLE 23 Study characteristics of included studies: depression
Age (SD) In Post

Study Target Study design Population Setting (years) Depression scale NMA? intervention 1–5 6–12 13–24 ≥ 25
Ahlen et al.145 2018 Anxiety and Cluster Universal Primary 8–11 CDI Yes 0 12
Araya et al.118 2013 Depression Cluster Universal Secondary 14.5 BDI Y-12 3 12
randomised (0.90)
Arnarson and Depression Individually Targeted Secondary 14–15 CDI No

Craighead213 2009 randomised
Aune and Stiles119 Anxiety Cluster Universal Secondary 10–15 SMFQ Yes 0
2009 randomised
Balle and Tortella- Anxiety Individually Targeted Secondary 11–17 CDI Yes 0 6
Feliu160 2010 randomised
Barrett and Turner147 Anxiety Cluster Universal Primary 10–12 CDI Yes 0
2001 randomised
Barrett et al.121 2005 Anxiety Cluster Universal Secondary 9–16 CDI No

randomised
Barry et al.190 2017 Depression Individually Universal Secondary 15–16 CES-D Yes 0
randomised
Berry and Hunt161 Anxiety Cluster Targeted Secondary 12–15 CES-D Yes 0
2009 randomised
Bonhauser et al.122 Anxiety and Cluster Universal Secondary 15.3 HADS No 0

2005 depression randomised (0.92)
Burckhardt et al.124 Anxiety and Cluster Universal Secondary 14–16 DASS-depression No 0 5

Burckhardt et al.191 Anxiety and Cluster Universal Secondary 15–18 DASS-depression No 0

Calear et al.125 2009 Anxiety and Cluster Universal Secondary 12–17 CES-D Yes 0 6
Calear et al.126 2016 Anxiety Cluster Universal Secondary 12–18 CES-D Yes 0 6, 12
randomised
DOI: 10.3310/phr09080
Age (SD) In Post

127
Calear et al. 2016 Anxiety Cluster Universal Secondary 13–17 CES-D Yes 0 3
randomised
Cardemil et al.208 2007 Depression Individually Universal Primary 10–12 CDI Yes 0 3 6
randomised
Chaplin et al.192 2006 Depression Individually Universal Secondary 11–14 CDI Yes 0
randomised
Clarke et al.193 1993 Depression Cluster Universal Secondary 14–16 CES-D Yes 0 3
randomised
Clarke et al.193 1993 Depression Cluster Universal Secondary 14–16 CES-D Yes 0 3
randomised
Clarke et al.214 1995 Depression Individually Targeted Secondary 14–16 CES-D Yes 0 6, 12
randomised
Congleton215 1995 Depression Individually Targeted Secondary 12–14 CDI Yes 0

randomised
Cova et al.162 2011 Depression Individually Targeted Secondary 14–15 BDI Yes 0
randomised
Cowell et al.231 2009 Depression Cluster Targeted Primary 10.4 CDI No 0 95

randomised (0.78)
Cui et al.183 2016 Depression Individually Targeted University 19.42 Zung Yes 0 6
randomised (2.43)
Dobson et al.163 2010 Anxiety and Individually Targeted Secondary 13–18 CDI, CES-D Yes 0 3 6
Ellis et al.184 2011 Depression Individually Targeted University 18–25 DASS-depression Yes 0
randomised
Essau et al.150 2012 Anxiety Cluster Universal Primary 9–12 RCADS- Yes 0 6, 12
randomised depression
Fitzgerald et al.114 Anxiety Individually Targeted Secondary 15–18 RCADS- Yes 0 3

2016 randomised depression
continued
177
178
APPENDIX 2
TABLE 23 Study characteristics of included studies: depression (continued )
Age (SD) In Post

216
Fung et al. 2016 Anxiety and Individually Targeted Secondary 12–14 PHQ-9 No 0
Gaete et al.164 2016 Depression Individually Targeted Secondary 13–18 BDI No 3

randomised
Gallegos151 2008 Anxiety and Cluster Universal Primary 9–11 CDI Yes 0 6
Gillham209 1994 Depression Individually Universal Primary 10–12 CDI Yes 0

randomised
Gillham et al.128 2006 Anxiety and Individually Universal Secondary 11–13 CDI, CDRS Yes 0 6, 12
Gillham et al.194 2007 Depression Individually Universal Secondary 11–14 CDI, CDRS Yes 0 6, 12 18, 24 36
randomised
Gillham et al.165 2012 Depression Individually Targeted Secondary 10–15 CDI, RADS Yes 0 6
randomised
Gucht et al.129 2017 Anxiety and Cluster Universal Secondary 14–21 YSR-affect Yes 0 12
Higgins185 2007 Anxiety Individually Targeted University 17–19 BDI Yes 0 1 6, 12

randomised
Hodas131 2016 Anxiety and Individually Universal Secondary 12–14 CDI Yes 0 6
Horowitz et al.195 2007 Depression Individually Universal Secondary 14–15 CDI, CES-D Yes 0 6
randomised
Hunt et al.166 2009 Anxiety Cluster Targeted Secondary 11–13 CDI Y-24 0 24 48
randomised
Jaycox et al.232 1994 Depression Cluster Targeted Primary 10–13 CDI, RCDS Yes 0 6, 12 18, 24
randomised
Johnson et al.132 2016 Anxiety and Cluster Universal Secondary 13.63 DASS-depression Yes 0 3
DOI: 10.3310/phr09080
Age (SD) In Post

Johnson et al.133 2017 Anxiety and Cluster Universal Secondary 13.44 DASS-depression Yes 0 6, 12
Johnstone et al.152 Anxiety and Cluster Universal Primary 9–10 CDI Yes 0 6 18 30,
2014 depression randomised 42,
54
Jordans et al.167 2010 Anxiety and Cluster Targeted Secondary 11–14 DSRS Yes 0
Kindt et al.196 2014 Depression Cluster Universal Secondary 11–16 CDI Yes 0 6, 12
randomised
Liddle and Anxiety Individually Targeted M 8–14 CDI No 0

Macmillan188 2010 randomised
Livheim et al.217 2015 Depression Individually Targeted Secondary 12–17 RADS Yes 0
randomised
Lock and Barrett134 Anxiety Cluster Universal Secondary NR CDI Yes 0 12

2003 randomised
Lowry-Webster Anxiety and Cluster Universal Secondary 10–13 CDI Yes 0 12

et al.135 2001 depression randomised

Manassis et al.175 2010 Anxiety and Individually Targeted Primary 8–11 CDI Yes 0 12
McCarty et al.218 2011 Depression Individually Targeted Secondary 13 (0.38) MFQ, CDRS Yes 0 6, 12 18
randomised
McCarty et al.219 2013 Depression Individually Targeted Secondary 11–15 MFQ Yes 0 6, 12
randomised
McLaughlin236 2011 Depression Individually Targeted M 10–15 CES-D, BDI No 0

randomised
Mendelson et al.210 Depression Cluster Universal Primary 9–11 SMFQ No 0

2010 randomised
Merry et al.197 2004 Depression Individually Universal Secondary 13–15 RADS, BDI Yes 0 6, 12 18
randomised
continued
179
180
APPENDIX 2
Age (SD) In Post

Noël et al.220 2013 Depression Individually Targeted Secondary 13–15 CES-D No 0
randomised
Pattison and Lynd- Depression Individually Universal Primary 9–12 CDI Yes 0 8
Stevenson155 2001 randomised
Peden et al.234 2000 Depression Individually Targeted University 18–24 CES-D, BDI No 0 6 18
randomised
Peng et al.170 2015 Anxiety and Cluster Targeted Secondary 14.2 Mental Health Yes 0
depression randomised (2.34) Test-depression
Perry et al.136 2017 Depression Cluster Universal Secondary 16–17 MDI Yes 0 6 18
randomised
Pophillat et al.156 2016 Anxiety and Cluster Universal Primary 6–8 CDI Yes 0
Poppelaars et al.221 Depression Cluster Targeted Secondary 11–16 RADS Yes 0 3 6, 12

2016 randomised
Pössel et al.198 2004 Depression Cluster Universal Secondary 13–14 CES-D Yes 0 3 6
randomised
Pössel et al.200 2013 Depression Cluster Universal Secondary 14–16 CDI Yes 0 4 8, 12
randomised
Pössel et al.199 2011 Depression Cluster Universal Secondary 12–13 Self-reported Yes 0 6, 12
randomised questionnaire –
depression
Puskar et al.222 2003 Depression Individually Targeted Secondary 14–18 RADS Yes 0 6, 12
randomised
Quayle et al.211 2001 Depression Individually Universal Primary 11–12 CDI Yes 0 6
randomised
Raes et al.201 2014 Depression Cluster Universal Secondary 13–20 DASS-depression Yes 0 6
randomised
Reynolds et al.233 2011 Depression Cluster Universal University 17.9 DASS-depression No 0 6

randomised (0.53)
DOI: 10.3310/phr09080
Age (SD) In Post

202
Rivet-Duval et al. Depression Individually Universal Secondary 12–16 RADS Yes 0 6
2011 randomised
Roberts et al.138 2003 Depression Cluster Universal Secondary 11–13 CDI Yes 0 6 18 30
randomised
Roberts et al.139 2010 Anxiety and Cluster Universal Secondary 11–13 CDI Yes 0 6 18
Rohde et al.223 2014 Depression Individually Targeted Secondary 13–19 CES-D Yes 0 6, 12 18, 24
randomised
Rooney et al.157 2006 Depression Cluster Universal Primary 8–9 CDI Yes 0 9 18
randomised
Rose et al.203 2014 Depression Cluster Universal Secondary 9–14 CDI, RADS Yes 0 6, 12
randomised
Sawyer et al.204 2010 Depression Cluster Universal Secondary 13.1 CES-D Yes 24
randomised (0.50)
Seligman et al.186 1999 Anxiety and Individually Targeted University 19 (NR) BDI Yes 0 3 36
Seligman et al.187 2007 Anxiety and Individually Targeted University 19 (NR) BDI Yes 0 1, 3

Shatté205 1997 Depression Individually Universal Secondary 12–14 CDI Yes 0 4 8, 12

randomised
Sheffield et al.141 2006 Depression Cluster Universal Secondary 13–15 CDI, CES-D Yes 0 6, 12
randomised
Sheffield et al.141 2006 Depression Cluster Targeted Secondary 13–15 CDI, CES-D Yes 0 6, 12
randomised
Simpson179 2008 Anxiety and Individually Targeted Primary 7–11 CDI Yes 0
Siu180 2007 Anxiety and Individually Targeted Primary 7–10 RCDS Yes 0
continued
181
182
APPENDIX 2
Age (SD) In Post

212
Soffer 2003 Depression Individually Universal Primary 10–11 RCDS Yes 0 1
randomised
Spence et al.206 2003 Depression Cluster Universal Secondary 12–14 BDI Yes 0 12 24 36,
randomised 48
Stallard et al.142 2013 Depression Cluster Universal Secondary 12–16 RCADS- Y-12 6, 12
Stallard et al.142 2013 Depression Cluster Targeted Secondary 12–16 RCADS- No 6, 12

Stallard et al.159 2014 Anxiety Cluster Universal Primary 9–10 RCADS- Y-12 12 24
Stice et al.237 2006 Depression Individually Targeted M 15–22 BDI No 0 1 6

randomised
Stice et al.224 2008 Depression Individually Targeted Secondary 14–19 BDI Yes 0 6, 12 24
randomised
Stoppelbein225 2003 Depression Cluster Targeted Secondary 15 (NR) CDI No 0 6

randomised
Tak et al.207 2016 Depression Cluster Universal Secondary 12–14 CDI Yes 0 6, 12 18, 24
randomised
Takagaki et al.235 2016 Depression Individually Targeted University 18–19 BDI Yes 0
randomised
Tokolahi et al.181 2018 Anxiety and Cluster Targeted Primary 7–12 CDI Yes 0
Tomba et al.143 2010 Anxiety and Cluster Universal Secondary 11.41 Kellner’s Yes 0 6
Topper et al.173 2017 Anxiety and Individually Targeted Secondary 15–22 CDI Yes 0 3 12
Velásquez et al.189 Anxiety and Individually Universal M NR Modified SDQ- No 0

2015 depression randomised depression
DOI: 10.3310/phr09080
Age (SD) In Post

Wijnhoven et al.226 Depression Individually Targeted Secondary 11–15 CDI, CES-D Yes 0 1 6
2014 randomised
Wong et al.144 2014 Anxiety and Cluster Universal Secondary 14–16 PHQ-9 Yes 0
Woods and Jose227 Depression Individually Targeted Secondary 14 (NR) CDI Yes 0 2 12
2011 randomised
Young et al.228 2006 Depression Individually Targeted Secondary 11–16 CES-D Yes 0 3 6
randomised
Young et al.229 2010 Depression Individually Targeted Secondary 13–17 CES-D, CDRS Yes 0 6, 12 18
randomised
Young et al.230 2016 Depression Individually Targeted Secondary 13.42 CES-D Yes 0 6
randomised (1.23)

Yu238 2002 Depression Individually Targeted M 8–15 CDI No 0 3 6
randomised
BDI, Beck Depression Inventory; CDI, Children’s Depression Inventory; CDRS, Children’s Depression Rating Scale; CES-D, Center for Epidemiologic Studies Depression Scale;
DASS, Depression, Anxiety and Stress Scale; DSRS, Depression Self-Rating Scale; HADS, Hospital Anxiety and Depression Scale; MDI, Major Depression Inventory; MFQ, Mood and
Feelings Questionnaire; NR, not reported; PHQ-9, Patient Health Questionnaire-9 items; RADS, Reynolds Adolescent Depression Scale; RCDS, Reynolds Child Depression Scale;
SMFQ, Short Mood and Feelings Questionnaire; YSR, Achenbach Youth Self Report; Zung, Zung self-rating scale (anxiety and depression).
Age is reported as a range, in years. If the range was not reported, we extracted the mean (SD) where available.
183
APPENDIX 2
TABLE 24 Studies not included in the anxiety or depression NMA, but which were eligible for inclusion in review
Not included in Not included in

Study Reason anxiety NMA depression NMA
Arnarson and Craighead213 2009 Data not available – ✗

Barrett et al.121 2005 Data not useable ✗ ✗
Bonhauser et al.122 2005 Not connected to network ✗ ✗
Britton et al.123 2014 Data not available ✗ –
a
Burckhardt et al.124 2015 Data not available ✗ ✗
a
Burckhardt et al.191 2016 Data not available – ✗
Cowell et al.231 2009 Not connected to network – ✗
Fung et al.216 2016 Data not available – ✗
Gaete et al.164 2016 Post-intervention time point not reported ✗ ✗
Liddle and Macmillan188 2010 Mixed age group (8–14 years) ✗ ✗
McLaughlin236 2011 Mixed age group (10–15 years) – ✗
Mendelson et al.210 2010 Data not available – ✗
Noël et al.220 2013 Data not available – ✗
Owen and Lanning169 1982 Baseline measures not reported ✗ –
Peden et al.234 2000 Data not available – ✗
Reynolds et al.233 2011 Not connected to network – ✗
Stallard et al.142 2013 Study used in universal analysis only – ✗
Stice et al.237 2006 Mixed age group (15–22 years) – ✗
Stoppelbein225 2004 Data not available – ✗
Velásquez et al.189 2015 Mixed age group (ages not reported) ✗ ✗
Yu238 2000 Mixed age group (8–15 years) – ✗
a Data were provided by author but analyses had been completed.
TABLE 25 Studies not reporting a primary review outcome: anxiety and depression
Age
Study Target Study design Population Setting (years) Outcome
Anticich et al.339 Anxiety Cluster Universal Primary 4–7 Preschool Anxiety Scale
2013 randomised
Dadds and Anxiety Cluster Universal Primary 3–7 Anxiety Disorders

Roth303 2008 randomised Interview Schedule-
Parent Version
Eather et al.340 Anxiety and Cluster Universal Secondary 15–16 SDQ-total

Haden et al.341 Anxiety and Individually Universal Primary 10–11 CBCL-parent rated
Khalsa et al.239 Anxiety and Cluster Universal Secondary 15–19 Behaviour Assessment
2012 depression randomised System for Children
Pahl and Anxiety Cluster Universal Primary 4–6 Preschool Anxiety scale
Barrett242 2010 randomised
Roberts et al.240 Anxiety and Cluster Universal Primary 9–12 SDQ-total

184

DOI: 10.3310/phr09080
TABLE 26 Study characteristics for included studies: process and delivery
Intervention Format
Age Sessions Intensity
Study Type Setting (years) Country Control 1 2 3 (n) (minutes) Delivered by 1 2
Ahlen et al.145 Universal Primary 8–11 HIC Usual CBT 10 600 Teacher Face to Group
2018 curriculum face
Anticich Universal Primary 4–7 HIC Waiting list Psychosupport CBT 10 NR Teacher Face to Group
et al.339 2013 face
Araya et al.118 Universal Secondary 14.5 MIC Usual CBT 11 660 Psychologist Face to Group
Attwood Universal Primary 10–12 HIC Attention CBT 6 270 Researcher Multimedia/ Group/
et al.146 2012 control computer individual
based
Aune and Universal Secondary 10–15 HIC No intervention CBT 3 135 Psychologist Face to Group
Stiles119 2009 face
Baker and Universal Secondary 16–18 HIC CBT self-help CBT 8 360 Teacher Face to Group
Butler120 1984 face
Barrett and Universal Primary 10–12 HIC Usual CBT CBT 10 750 Teachers or Face to Group
Turner147 curriculum Psychologist face
2001
Barrett Universal Secondary 9–16 HIC No intervention CBT 10 525 Psychologist Face to Group

et al.121 2005 face
Barry et al.190 Universal Secondary 15–16 HIC Usual CBT 4 Not clear ‘Coach’ Face to Group
Bonhauser Universal Secondary 15.3 MIC Exercise Exercise 120 10,800 Teacher Face to Group
et al.122 2005 face
Bouchard Universal Primary 9–12 HIC Waiting list CBT 10 750 Psychologist Face to Group
et al.148 2013 face
Britton et al.123 Universal Secondary 11.79 HIC Attention Mindfulness/ 30 225 Teacher Face to Group
2014 control relaxation face
Burckhardt Universal Secondary 14–16 HIC Attention Mindfulness/ 6 360 NA Multimedia/ Group
et al.124 2015 control relaxation computer
based
continued
185
186
APPENDIX 2
TABLE 26 Study characteristics for included studies: process and delivery (continued )
Intervention Format
Burckhardt Universal Secondary 15–18 HIC Usual Third wave 16 480 Psychologist Face to Group
et al.191 2016 curriculum face
Calear et al.125 Universal Secondary 12–17 HIC Waiting list CBT 5 150 Teacher Multimedia/ Group
2009 computer
based
Calear et al.126 Universal Secondary 12–18 HIC Waiting list CBT CBT 6 210 Teacher or MHP Multimedia/ Group
2016 supported computer
based
Calear et al.127 Universal Secondary 13–17 HIC Waiting list CBT 6 210 Teacher Multimedia/ Group
2016 computer
based
Cardemil Universal Primary 10–12 HIC Usual CBT 12 1080 Psychologist Face to Group
Chaplin Universal Secondary 11–14 HIC No intervention CBT CBT 12 1080 Teacher and Face to Group
et al.192 2006 researchers face
Clarke et al.193 Universal Secondary 14–16 HIC Usual Psychoeducation 3 150 Teacher Face to NA
Clarke et al.193 Universal Secondary 14–16 HIC Usual Behavioural 5 250 Teacher Face to NA
1993 curriculum therapy face
Collins et al.149 Universal Primary 9–10 HIC Usual CBT 10 NR Teacher or Face to Group
2014 curriculum school counsellor face
Dadds and Universal Primary 3–7 HIC No intervention CBT 6 NR Psychologist Face to Group
Roth303 2008 face
Eather et al.340 Universal Secondary 15–16 HIC Waiting list Exercise 16 960 Fitness instructor Face to Group
2016 face
Essau et al.150 Universal Primary 9–12 HIC Waiting list CBT 10 600 Psychologist Face to Group
2012 face
Gallegos151 Universal Primary 9–11 MIC Usual CBT 10 600 Teacher Face to Group
DOI: 10.3310/phr09080
Intervention Format
Gillham209 Universal Primary 10–12 HIC No intervention CBT 12 1440 Psychologist Face to Group
1995 face
Gillham Universal Secondary 11–13 HIC No intervention CBT 8 720 Researchers and Face to Group
et al.128 2006 psychologist face
Gillham Universal Secondary 11–14 HIC No intervention Attention CBT 12 1080 Teachers, school Face to Group
et al.194 2007 control + counsellors and face
psychosupport psychologists
Gucht et al.129 Universal Secondary 14–21 HIC Usual Third wave 4 480 Teacher Face to Group
Haden et al.341 Universal Primary 10–11 HIC Usual Mindfulness/ 36 3240 Teacher Face to Group
2014 curriculum relaxation face
Hiebert Universal Secondary 13–14 HIC Attention Mindfulness/ 11 660 Teacher and Face to Group
et al.130 1989 control relaxation school counsellor face
Hodas131 2016 Universal Secondary 12–14 HIC Waiting list CBT 7 455 Psychologist Face to Group
face
Horowitz Universal Secondary 14–15 HIC Usual IPT CBT 8 720 Psychologist Face to Group
Johnson Universal Secondary 13.63 HIC Usual Third wave 9 495 Psychologist Face to Group

Johnson Universal Secondary 13.44 HIC Usual Third wave Third wave 9 450 Psychologist Face to Group
Johnstone Universal Primary 9–10 HIC Usual CBT 10 600 Teacher Face to Group
Khalsa et al.239 Universal Secondary 15–19 HIC Usual Mindfulness/ 27.5 825 Yoga trainer Face to Group
2012 curriculum relaxation face
Kindt et al.196 Universal Secondary 11–16 HIC Usual CBT 16 NR Teacher Face to Group
Lock and Universal Secondary NR HIC No intervention CBT 10 750 Teacher Face to Group
Barrett134 face
2003
continued
187
188
APPENDIX 2
Intervention Format
Lowry-Webster Universal Secondary 10–13 HIC Waiting list CBT 10 600 Teacher Face to Group
et al.135 2001 face
Mendelson Universal Primary 9–11 HIC Waiting list Mindfulness/ 48 2160 Yoga trainer Face to Group
et al.210 2010 relaxation face
Merry et al.197 Universal Secondary 13–15 HIC Attention CBT + IPT 11 NR Teacher Face to Group
2004 control face
Miller et al.153 Universal Primary 7–12 HIC Waiting list CBT NR NR Teacher Face to Group
2010 face
Miller et al.154 Universal Primary 7–13 HIC Waiting list CBT 9 NR Teacher and Face to Group
2011 school counsellor face
Miller et al.154 Universal Primary 7–13 HIC Attention CBT 9 540 Teacher and Face to Group
2011 control school counsellor face
Pahl and Universal Primary 4–6 HIC Waiting list CBT 9 270 Psychologist Face to Group
Barrett242 face
2010
Pattison and Universal Primary 9–12 HIC No intervention Attention CBT CBT 10 1200 Child MHPs Face to Group
Lynd- control face
Stevenson155
2001
Perry et al.136 Universal Secondary 16–17 HIC Attention CBT 7 175 NA Multimedia/ Group
2017 control computer
based
Pophillat Universal Primary 6–8 HIC Usual CBT 10 NR Teacher Face to Group
Pössel et al.198 Universal Secondary 13–14 HIC Usual CBT 10 900 Psychologist or Face to Group
2004 curriculum graduate face
students
Pössel et al.199 Universal Secondary 12–13 HIC Usual CBT 10 900 Psychologist or Face to Group
2011 curriculum graduate face
students
DOI: 10.3310/phr09080
Intervention Format
Pössel et al.200 Universal Secondary 14–16 HIC Usual Attention CBT 10 900 Psychologist or Face to Group
2013 curriculum control graduate face
students
Potek137 2012 Universal Secondary 14–17 HIC Waiting list Mindfulness/ 6 270 Psychologist Face to Group
relaxation face
Quayle et al.211 Universal Primary 11–12 HIC Waiting list CBT 8 640 Psychologist Face to Group
2001 face
Raes et al.201 Universal Secondary 13–20 HIC Usual Third wave 8 800 Psychologist Face to Group
Reynolds Universal University 17.9 HIC Usual Behavioural 14 1680 Psychologist Face to Group
et al.233 2011 curriculum therapy face
Rivet-Duval Universal Secondary 12–16 MIC Waiting list CBT + IPT 11 660 Teacher Face to Group
et al.202 2011 face
Roberts Universal Secondary 11–13 HIC Usual CBT 12 NR Psychologist Face to Group
Roberts Universal Secondary 11–13 HIC Usual CBT 20 1200 Teacher Face to Group
Roberts Universal Primary 9–12 HIC Usual CBT CBT 20 1200 Teacher Face to Group

Rodgers Universal Secondary 12–13 HIC Waiting list CBT 10 600 Psychologist Face to Group
et al.140 2015 face
Rooney Universal Primary 8–9 HIC No intervention CBT 8 480 Psychologist Face to Group
et al.157 2006 face
Rose et al.203 Universal Secondary 9–14 HIC Waiting list CBT + IPT CBT + IPT 11 495 Psychologist Face to Group
2014 face
Ruttledge Universal Primary 9–13 HIC Waiting list CBT 10 NR Teacher Face to Group
et al.158 2016 face
Sawyer Universal Secondary 13.1 HIC Usual CBT 30 900 Teacher Face to Group
continued
189
190
APPENDIX 2
Intervention Format
205
Shatté 1997 Universal Secondary 12–14 HIC No intervention Attention CBT 12 1440 Teachers and Face to Group
control psychologist face
Sheffield Universal Secondary 13–15 HIC No intervention CBT 8 380 Teachers and Face to Group
et al.141 2006 psychologist face
Soffer212 2003 Universal Primary 10–11 HIC No intervention Attention Behavioural 8 320 Psychologist Face to Group
control therapy face
Spence et al.206 Universal Secondary 12–14 HIC Usual CBT 8 380 Teacher Face to Group
Stallard et al.142 Universal Secondary 12–16 HIC Usual Attention CBT + IPT 9 495 Facilitator Face to Group
2013 curriculum control face
Stallard Universal Primary 9–10 HIC Usual CBT CBT 9 540 Teacher and Face to Group
et al.159 2014 curriculum facilitator face
Tak et al.207 Universal Secondary 12–14 HIC Usual CBT 16 800 Teacher and Face to Group
2016 curriculum psychologist face
Tomba et al.143 Universal Secondary 11.41 HIC CBT CBT 6 720 Psychologist Face to Group
2010 face
Velásquez Universal Primary/ NR MIC Waiting list Mindfulness/ 24 2880 Yoga trainer Face to Group
et al.189 2015 secondary relaxation face
Wong et al.144 Universal Secondary 14–16 HIC Usual CBT CBT 6 240 Teacher Multimedia/ Group
2014 curriculum computer
based
Arnarson and Indicated Secondary 14–15 HIC No intervention CBT + IPT 14 NR Psychologist Face to Group
Craighead213 face
2009
Balle and Selective Secondary 11–17 HIC Waiting list CBT 6 270 Psychologist Face to Group
Tortella- face
Feliu160 2010
Berry and Indicated Secondary 12–15 HIC Waiting list CBT 8 480 Psychologist Face to Group
Hunt161 2009 face
DOI: 10.3310/phr09080
Intervention Format
Clarke et al.214 Indicated Secondary 14–16 HIC No intervention CBT 15 675 School Face to Group
1995 psychologist face
Congleton215 Selective Secondary 12–14 HIC Waiting list CBT 8 480 Psychologist Face to Group
1995 face
Cooley- Indicated Primary 9–10 HIC Waiting list CBT 13 780 Psychologist Face to Group
Strickland face
et al.174 2011
Cova et al.162 Indicated Secondary 14–15 MIC No intervention CBT 11 990 Psychologist Face to Group
2011 face
Cowell et al.231 Selective Primary 10.4 HIC No intervention Psychosupport 6 NR Nurse Face to Group
2009 face
Cui et al.183 Indicated University 19.42 MIC Waiting list CBT Psychosupport 8 960 Psychologist Face to Group
2016 face
Dobson Indicated Secondary 13–18 HIC Attention CBT 15 675 Psychologist Face to Group
et al.163 2010 control face
Ellis et al.184 Indicated University 18–25 HIC No intervention CBT Psychosupport 3 300 NA Multimedia/ Individual
2011 computer
based

Fitzgerald Indicated Secondary 15–18 HIC Attention BM 4 NR Researcher Multimedia/ Group
et al.114 2016 control computer
based
Fung et al.216 Indicated Secondary 12–14 HIC Waiting list Third wave 12 720 Psychologist Face to Group
2016 face
Gaete et al.164 Indicated Secondary 13–18 MIC Usual CBT 8 360 Psychologist Face to Group
Gillham Indicated Secondary 10–15 HIC No intervention CBT CBT 10 900 Teacher and Face to Group
et al.165 2012 school counsellor face
Hiebert Indicated Secondary 15–17 HIC Waiting list Mindfulness/ BIO 8 320 Psychologist Face to Individual
et al.130 1989 relaxation face
continued
191
192
APPENDIX 2
Intervention Format
185
Higgins Indicated University 17–19 HIC No intervention CBT 2 240 Psychologist Face to Group
2007 face
Hunt et al.166 Indicated Secondary 11–13 HIC No intervention CBT 10 500 Teacher and Face to Group
2009 school counsellor face
Jaycox et al.232 Indicated Primary 10–13 HIC Waiting list CBT 12 1080 Psychologist Face to Group
1994 face
Jordans Selective Secondary 11–14 LIC Waiting list Mixed 15 900 Researcher Face to Group
et al.167 2010 face
Kiselica Indicated Secondary 14–15 HIC Psychoeducation CBT 8 480 Counsellors Face to Group
et al.168 1994 face
Liddle and Selective Primary/ 8–14 HIC Waiting list CBT 10 NR Psychologist Face to Group
Macmillan188 secondary face
2010
Livheim Indicated Secondary 12–17 HIC Psychosupport Third wave 8 NR Psychologist Face to Group
et al.217 2015 face
Manassis Indicated Primary 8–11 HIC Attention CBT 12 720 Psychologist Face to Group
et al.175 2010 control face
McCarty Indicated Secondary 13 HIC Usual CBT 12 NR Not clear Face to Group
McCarty Indicated Secondary 11–15 HIC Psychosupport CBT 12 600 Therapists Face to Group
et al.219 2013 face
McLaughlin236 Indicated Primary/ 10–15 HIC Psychosupport CBT 10 500 Psychologist Face to Group
2011 secondary face
McLoone Indicated Primary 7–10 HIC Waiting list CBT CBT 10 600 School Face to Group
et al.176 2012 counsellors face
Mifsud and Indicated Primary 8–11 HIC Waiting list CBT 8 480 School Face to Group
Rapee177 2005 counsellors face
Miller et al.178 Indicated Primary 7–12 HIC Attention CBT 9 540 Teacher and Face to Group
2011 control school counsellor face
DOI: 10.3310/phr09080
Intervention Format
Noël et al.220 Indicated Secondary 13–15 HIC Waiting list CBT 12 Students Face to Group
2013 face
Owen and Indicated Secondary 15–16 HIC Waiting list Mindfulness/ CBT CBT 6 180 Counsellors Face to Group
Lanning169 relaxation face
1982
Peden et al.234 Indicated University 18–24 HIC No intervention CBT NR NR NA Face to Group
2000 face
Peng et al.170 Selective Secondary 14.2 MIC No intervention Exercise 24 NR NR Face to Group
2015 face
Poppelaars Indicated Secondary 11–16 HIC Waiting list CBT CBT CBT 8 480 Psychologist Face to Individual
et al.221 2016 face
Puskar et al.222 Indicated Secondary 14–18 HIC No intervention CBT 10 450 Nurse Face to Group
2003 face
Rice171 2009 Indicated Secondary 10–18 HIC Attention CBT Mindfulness/ 16 560 Psychologist Face to Group
control relaxation face
Rohde et al.223 Indicated Secondary 13–19 HIC Psychoeducation CBT CBT 6 360 Psychologist or Face to Group
2014 self-help face
Scholten Indicated Secondary 11–15 HIC Attention Biofeedback 6 360 Researcher Multimedia/ Individual

based
Schoneveld Indicated Primary 8–13 HIC Attention Biofeedback 5 300 Researcher Multimedia/ Group
based
Schoneveld Indicated Primary 7–12 HIC CBT Biofeedback 6 360 Master’s Multimedia/ Group
et al.116 2018 students and computer
psychologist based
Seligman Selective University 19 HIC No intervention CBT 8 960 Psychologist Face to Group/
et al.186 1999 face individual
Seligman Selective University 19 HIC No intervention CBT 8 960 Psychologist Face to Group
et al.187 2007 face/
multimedia
continued
193
194
APPENDIX 2
Intervention Format
Sheffield Indicated Secondary 13–15 HIC No intervention CBT CBT CBT 8 380 Teachers Face to Group
et al.141 2006 or school face
counsellor
or both
Simpson179 Indicated Primary 7–11 HIC Attention CBT 12 1080 NR Face to Group
2008 control face
Siu180 2007 Indicated Primary 7–10 HIC Waiting list CBT 8 NR Counsellors Face to Group
face
Sportel et al.117 Indicated Secondary 12–15 HIC No intervention BM CBT 20 900 NA Multimedia/ Individual
2013 computer
based
Stallard et al.142 Indicated Secondary 12–16 HIC Usual Usual CBT + IPT 9 495 Facilitator Face to Group
2013 curriculum curriculum face
Stice et al.237 Indicated Secondary/ 15–22 HIC Waiting list CBT 4 240 Psychologist Face to Group
2006 university face
Stice et al.224 Indicated Secondary 14–19 HIC No intervention CBT self-help Psychosupport CBT 6 360 Self-help or Face to Group
2008 psychologist face
Stoppelbein225 Indicated Secondary 15 HIC Attention CBT 10 500 Psychologist Face to Group
2003 control face
Takagaki Indicated University 18–19 HIC No intervention Behavioural 5 300 Psychologist Face to Group
et al.235 2016 therapy face
Tokolahi Selective Primary 7–12 HIC Waiting list Occupational 8 480 Occupational Face to Group
et al.181 2018 therapy therapist face
Topper et al.173 Selective Secondary 15–22 HIC Waiting list CBT 6 540 Psychologist Face to Group
2017 face
van Starrenburg Indicated Primary 7–13 HIC Waiting list CBT 12 720 Psychologist Face to Group
et al.182 2017 face
individual
individual
individual
Group/
Group/
Group/
Group
Group
Group
2
Format
Face to
Face to
Face to
Face to
Face to
Face to
face
face
face
face
face
face
1
(minutes) Delivered by
social worker
Psychologist/
Psychologist
Psychologist
counsellors
Therapist
Teacher
School
Intensity
1200
400
900
900
720
450
Sessions
10
10
11
10
(n)
8
3
2
Intervention
CBT
CBT
CBT
CBT
IPT
IPT
1
No intervention
Psychosupport
Psychosupport
Psychosupport
Waiting list
curriculum
(years) Country Control
Usual
MIC
11–15 HIC
11–16 HIC
13–17 HIC
HIC
HIC
13.42
8–15
Age
14
Indicated Secondary
Indicated Secondary
Indicated Secondary
Indicated Secondary
Indicated Secondary
secondary
NA, not applicable; NR, not reported.
Indicated Primary/
Setting
Type
Young et al.228
Young et al.229
Young et al.230
et al.226 2014
Jose227 2011
Woods and
Yu238 2002
Wijnhoven
Study
2006
2010
2016
195
APPENDIX 2
Risk-of-bias assessments for studies reporting anxiety or

depression outcome
Risk-of-bias judgements were made for 137 studies included in the review of studies to prevent
anxiety and/or depression. Each study was assessed using the Cochrane Risk of Bias tool, version 1.0,79
which rates the risk of bias as low, unclear or high. For ‘other bias’, we considered cluster trials only,
and examined bias arising from the timing of identification and recruitment of participants (recruitment
bias). We also considered unit-of-analysis errors (not accounting for clustering) and possibility of
contamination across clusters.
196

DOI: 10.3310/phr09080
TABLE 27 Risk-of-bias assessment for all studies reporting an anxiety and/or depression outcome
Risk of bias
Random Blinding of Blinding of

sequence Allocation participants and outcome Selective Incomplete Other bias
Study Population Setting generation concealment personnel assessment reporting outcome data (cluster RCTs)
Ahlen et al.145 2018 Universal Primary Low Low High High Lowa High High
Anticich et al.339 Universal Primary Unclear Unclear High High Unclear Low Unclear
2013
Araya et al.118 2013 Universal Secondary Low Unclear High High Lowb Low Unclear
Arnarson and Indicated Secondary Unclear Unclear High High Unclear High NA
Craighead213 2009
Attwood et al.146 Universal Primary Unclear Unclear Unclear Unclear Unclear High NA
2012
Aune and Stiles119 Universal Secondary Unclear Unclear High High Unclear Unclear High
2009
Baker and Butler120 Universal Secondary Unclear Unclear High High Unclear Unclear High
1984
Balle and Tortella- Selective Secondary Unclear Unclear High High Unclear Low NA
Feliu160 2010

Barrett and Universal Primary Unclear Unclear High High High High High
Turner147 2001
Barrett et al.121 Universal Secondary Unclear Unclear High High Unclear High Unclear
2005
Barry et al.190 2017 Universal Secondary Unclear Unclear High High Unclear Low NA
161
Berry and Hunt Indicated Secondary Low Unclear High High Unclear Low Low
2009
Bonhauser et al.122 Universal Secondary Unclear Unclear High High High Low High
2005
Bouchard et al.148 Universal Primary Unclear Unclear High High Unclear Low Unclear
2013
continued
197
198
APPENDIX 2
TABLE 27 Risk-of-bias assessment for all studies reporting an anxiety and/or depression outcome (continued )
Risk of bias

Britton et al.123 Universal Secondary Low High High High Unclear Low NA
2014
Burckhardt et al.124 Universal Secondary Low Unclear Unclear Unclear Unclearb High Low
2015
Burckhardt et al.191 Universal Secondary Unclear Unclear High High High High High
2016
Calear et al.125 2009 Universal Secondary Low Low High High Lowb Low Low
b
Calear et al.126 2016 Universal Secondary Low Low High High Unclear Low Low
Calear et al.127 2016 Universal Secondary Unclear Unclear High High Lowb Low Unclear
208
Cardemil et al. Universal Primary Unclear Unclear High High Unclear High NA
2007
Chaplin et al.192 Universal Secondary Low Unclear High High Unclear High NA
2006
Clarke et al.193 1993 Universal Secondary Unclear Unclear High High High Low High
Clarke et al.193 1993 Universal Secondary Unclear Unclear High High High High High
214
Clarke et al. 1995 Indicated Secondary Unclear Unclear High High Unclear High NA
149
Collins et al. 2014 Universal Primary Unclear Unclear High High Unclear High High
a
Congleton215 1995 Selective Secondary Unclear Unclear High High Low High NA
Cooley-Strickland Indicated Primary Unclear Unclear High High High Unclear High
et al.174 2011
Cova et al.162 2011 Indicated Secondary Unclear Unclear High High Unclear Unclear NA
Cowell et al.231 2009 Selective Primary Unclear Unclear High High Unclear Unclear High
183
Cui et al. 2016 Indicated University Unclear Unclear High High Unclear Low High
303
Dadds and Roth Universal Primary Unclear Unclear High High Unclear High High
2008
DOI: 10.3310/phr09080
Risk of bias

Dobson et al.163 Indicated Secondary Low Unclear Low Low Lowb Unclear NA
2010
Eather et al.340 2016 Universal Secondary Low Low High High Unclearb Unclear High
Ellis et al.184 2011 Indicated University Unclear Unclear High High Unclear Unclear NA
Essau et al.150 2012 Universal Primary Unclear Unclear High High Unclear High Unclear
114 b
Fitzgerald et al. Indicated Secondary Unclear Unclear Low Low Low Unclear NA
2016
Fung et al.216 2016 Indicated Secondary Unclear High High High Unclear Low NA
164 b b
Gaete et al. 2016 Indicated Secondary Low Low High High Low Unclear NA
a
Gallegos151 2008 Universal Primary Unclear Unclear High High Low Unclear High
Gillham209 1995 Universal Primary Unclear Unclear High High Lowa Unclear NA
Gillham et al.128 Universal Secondary Unclear Unclear High High Unclear Unclear NA
2006
Gillham et al.194 Universal Secondary Low Unclear High High Unclear Unclear NA
2007

Gillham et al.165 Indicated Secondary Low Unclear High High Lowb Unclear NA
2012
Gucht et al.129 2017 Universal Secondary Low Unclear High High Unclear High High
Haden et al.341 2014 Universal Primary Unclear High High High Unclear Low NA
Hiebert et al.130 Indicated Secondary Unclear Unclear High High Unclear Unclear NA
1989
Hiebert et al.130 Universal Secondary Unclear Unclear High High Unclear Unclear NA
1989
Higgins185 2007 Indicated University Unclear Unclear High High Unclear High NA
a
Hodas131 2016 Universal Secondary Unclear Unclear High High Low High NA
continued
199
200
APPENDIX 2
Risk of bias

Horowitz et al.195 Universal Secondary Low High High High Unclear Low NA
2007
Hunt et al.166 2009 Indicated Secondary Unclear Unclear High High Unclear Low NA
Jaycox et al.232 1994 Indicated Primary Unclear Unclear High High Unclear High NA
132
Johnson et al. Universal Secondary Low Unclear High High Unclear Low NA
2016
Johnson et al.133 Universal Secondary Low Unclear High High Lowb Low NA
2017
Johnstone et al.152 Universal Primary Unclear Unclear High High Unclear Low Low
2014
Jordans et al.167 Selective Secondary Low Low High High Lowb Low Low
2010
Khalsa et al.239 2012 Universal Secondary Unclear Unclear High High Unclear High High
196 b
Kindt et al. 2014 Universal Secondary Low Low High High Low High Low
Kiselica et al.168 Indicated Secondary Unclear Unclear High High Unclear Unclear NA
1994
Liddle and Selective Primary/ Unclear Unclear High High Unclear Unclear NA
Macmillan188 2010 secondary
Livheim et al.217 Indicated Secondary Low Unclear High High High Unclear NA
2015
Lock and Barrett134 Universal Secondary Unclear Unclear High High Unclear High High
2003
Lowry-Webster Universal Secondary Unclear Unclear High High High High High
et al.135 2001
Manassis et al.175 Indicated Primary Low Unclear Low Low Lowb Low NA
2010
DOI: 10.3310/phr09080
Risk of bias

McCarty et al.218 Indicated Secondary Unclear Unclear High High Lowb Unclear NA
2011
McCarty et al.219 Indicated Secondary Low Low Unclear Unclear Unclear Unclear NA
2013
McLaughlin236 2011 Indicated Primary/ Low High Low Low Lowa Unclear NA
secondary
McLoone et al.176 Indicated Primary Low Unclear High High High Unclear High
2012
Mendelson et al.210 Universal Primary Unclear Unclear High High Unclear High High
2010
Merry et al.197 2004 Universal Secondary Low Low Low Low Unclear High NA
Mifsud and Rapee177 Indicated Primary Unclear Unclear High High High High High
2005
Miller et al.153 2010 Universal Primary Unclear Unclear High High Unclear Low High
Miller et al.154 2011 Universal Primary Unclear Unclear High High Unclear Unclear High

Miller et al.178 2011 Indicated Primary Unclear Unclear High High Unclear Low High
154
Miller et al. 2011 Universal Primary Unclear Unclear High High Unclear Low Low
Noël et al.220 2013 Indicated Secondary Low Unclear High High Unclear Low NA
Owen and Indicated Secondary Unclear Unclear High High Unclear Low NA
Lanning169 1982
Pahl and Barrett242 Universal Primary Unclear Unclear High High Unclear High High
2010
Pattison and Lynd- Universal Primary Unclear Unclear High High Unclear Low NA
Stevenson155 2001
Peden et al.234 2000 Indicated University Unclear Unclear High High Unclear Unclear NA
170
Peng et al. 2015 Selective Secondary Unclear Unclear High High Unclear Low Unclear
continued
201
202
APPENDIX 2
Risk of bias

Perry et al.136 2017 Universal Secondary Unclear Low Low Low Lowb Low Low
Pophillat et al.156 Universal Primary Unclear Unclear High High Unclear High Low
2016
Poppelaars et al.221 Indicated Secondary Unclear Low High High Lowb Low Low
2016
Pössel et al.198 2004 Universal Secondary Unclear Unclear High High Unclear High Unclear
Pössel et al.199 2011 Universal Secondary Unclear Unclear High High High High Unclear
Pössel et al.200 2013 Universal Secondary Unclear Unclear High High Unclear High Unclear
137
Potek 2012 Universal Secondary Unclear Unclear High High Unclear Low NA
222
Puskar et al. 2003 Indicated Secondary Low Unclear High High Unclear High NA
Quayle et al.211 Universal Primary Unclear Unclear High High Unclear High NA
2001
Raes et al.201 2014 Universal Secondary Low Low High High Unclear Low Unclear
Reynolds et al.233 Universal University Unclear Unclear Unclear Unclear Unclear Low Low
2011
Rice171 2009 Indicated Secondary Unclear Unclear Unclear Unclear Lowa High NA
Rivet-Duval et al.202 Universal Secondary Unclear High High High Unclear Low NA
2011
Roberts et al.138 Universal Secondary Unclear Unclear High High Unclear Low Unclear
2003
Roberts et al.139 Universal Secondary Unclear Unclear High High Unclear High Unclear
2010
Roberts et al.240 Universal Primary Unclear Unclear High High Unclear Low Unclear
2018
DOI: 10.3310/phr09080
Risk of bias

Rodgers et al.140 Universal Secondary Unclear Unclear High High High Unclear NA
2015
Rohde et al.223 2014 Indicated Secondary Low Unclear High High Unclear Low NA
157
Rooney et al. Universal Primary Unclear Unclear High High Unclear Unclear Unclear
2006
Rose et al.203 2014 Universal Secondary Unclear Unclear Unclear Unclear Unclear Low Unclear
158
Ruttledge et al. Universal Primary Low Unclear High High Unclear Low Unclear
2016
Sawyer et al.204 Universal Secondary Unclear Low High High Unclear Unclear Low
2010
Scholten et al.172 Indicated Secondary Low Unclear Unclear Unclear Lowb Low NA
2016
Schoneveld et al.115 Indicated Primary Low Low Unclear Unclear Lowb Low NA
2016
Schoneveld et al.116 Indicated Primary Low Low Low Low Lowb Low NA
2018

Seligman et al.186 Selective University Unclear Unclear High High Unclear Unclear NA
1999
Seligman et al.187 Selective University Unclear Unclear High High Unclear Unclear NA
2007
Shatté205 1997 Universal Secondary Unclear Unclear High High Unclear Low NA
Sheffield et al.141 Universal Secondary Low Low High High Unclear Low High
2006
Sheffield et al.141 Indicated Secondary Low Low High High Unclear Low High
2006
Simpson179 2008 Indicated Primary Unclear Unclear Low Low Unclear Low NA
Siu180 2007 Indicated Primary Unclear Unclear High High Unclear Low NA
continued
203
204
APPENDIX 2
Risk of bias

Soffer212 2003 Universal Primary Unclear Unclear High High Lowa Unclear NA
Spence et al.206 Universal Secondary Unclear Unclear High High Unclear High Unclear
2003
Sportel et al.117 Indicated Secondary Low Low High High Lowb High Unclear
2013
Stallard et al.142 Universal Secondary Low Low High High Lowb High Low
2013b
Stallard et al.142 Indicated Secondary Low Low High High Lowb High Low
2013b
Stallard et al.159 Universal Primary Low Low High High Lowb Low Low
2014b
Stice et al.237 2006 Indicated Secondary/ Unclear Unclear High High Unclear Low NA
university
Stice et al.224 2008 Indicated Secondary Low Unclear High High Lowb Low NA
225 a
Stoppelbein 2003 Indicated Secondary Unclear Unclear Unclear Unclear Low High Low
b
Tak et al.207 2016 Universal Secondary Unclear Low High High Low Unclear Low
Takagaki et al.235 Indicated University Low Low High High Lowb Low NA
2016
Tokolahi et al.181 Selective Primary Low Low High High Lowb Low Low
2018
Tomba et al.143 2010 Universal Secondary Unclear Unclear Unclear Unclear Unclear Low High
b
Topper et al.173 Selective Secondary Unclear Low High High Low Low NA
2017
van Starrenburg Indicated Primary Unclear Unclear High High Unclearb Low NA
et al.182 2017
DOI: 10.3310/phr09080
Risk of bias

Velásquez et al.189 Universal Primary/ Unclear Unclear High High Unclear Low Unclear
2015 secondary
Wijnhoven et al.226 Indicated Secondary Low Low High High Unclear Low NA
2014
Wong et al.144 2014 Universal Secondary Low Unclear High High Lowb High Unclear
Woods and Jose227 Indicated Secondary Low Unclear High High Unclear High NA
2011
Young et al.228 2006 Indicated Secondary Low Unclear Unclear Unclear Unclear Low NA
Young et al.229 2010 Indicated Secondary Low Unclear Unclear Unclear Lowb Low NA

Young et al.230 2016 Indicated Secondary Low Unclear Unclear Unclear Unclear Low NA
238
Yu 2002 Indicated Primary/ Unclear Unclear High High Unclear Unclear NA
secondary
NA, not applicable.
a Thesis.
b Trial registration or protocol located and viewed.
Notes
Risk-of-bias assessments for studies reporting a conduct disorder outcome are reported in Figure 16. Where ‘NA’ is given in ‘other bias’, the trial was individually randomised.
205
APPENDIX 2
Studies reporting facilitator fidelity and integrity measures
TABLE 28 Author-reported facilitator fidelity and/or integrity for studies reporting an anxiety or depression outcome
Study Facilitator fidelity/integrity

145
Ahlen et al. 2018 Teachers received regular e-mails and visits to check schedule adherence. Most
teachers (n = 17) completed all 10 sessions, two completed eight sessions and one
completed six of the 10 scheduled sessions. Sessions were not recorded satisfactorily
Aune and Stiles119 2009 Adherence and competence were rated as very good to excellent (adherence:
mean = 5.33, competence: mean = 5.67)
Barrett and Turner147 2001 88–92% concordance reported
Barrett et al.121 2005 88.8–95.6% concordance between session and manual content was reported
Burckhardt et al.191 2016 Sessions were audio-recorded. Adherence to acceptance and commitment therapy
was scored on a four-point Likert scale where 1 = minimal and 4 = very high
adherence. The mean across all session components was 3.0
Clarke et al.193 1993 Mean compliance for evaluated sessions was 86.2% (range 61–100%) compliance
214
Clarke et al. 1995 Sessions were audio-recorded. Adherence averaged 93.9% compliance (SD 5.2%,
range 77.8–100% protocol compliance)
Collins et al.149 2014 Authors reported a high level of fidelity to intervention content by lesson and
facilitator groups. Mean fidelity rating across all sessions: 6.31 (on a seven-point
scale)
Dadds and Roth303 2008 Across all sessions, mean adherence to the manual/ intended intervention was 96%
(range 83–100%)
Dobson et al.163 2010 Adherence to intervention protocol was assessed by audio-tape. The first author
listened to randomly selected tapes and tried to identify the intervention.
Identification was 100% accurate. The authors stated that this suggests ‘strong
adherence to treatment protocols’
Essau et al.150 2012 Adherence to the intervention content ranged from 78[%] to 97%
151
Gallegos 2008 Compliance with the programme manual was reported by classroom. The mean
compliance across all classrooms was 2.07 (four-point scale, 1 = extremely well and
4 = not at all)
Gillham et al.194 2007 Sessions were audio-taped and integrity scores rated on a seven-point scale
(7 = excellent coverage). Integrity score for degree of items covered: PRP mean 4.9
(SD 0.48); PEP mean 4.4 (SD 0.36). Integrity score for percentage of items covered
satisfactorily: PRP 80% (SD 7.5%); PEP 68% (SD 5.7%)
Gillham et al.165 2012 PRP sessions were audio-taped:

On average, group leaders covered 68% of the integrity items to some degree
(rated ≥ 2) and 47% of the items satisfactorily (rated ≥ 4)
Hunt et al.166 2009 Facilitators were asked to rate their compliance to intervention content and aims.
A total of 49.0% complied ‘extremely well’ and 44.8% ‘moderately well’. Sessions
were also audio-recorded; however, only 40% of schools provided usable audio-tapes.
Of these, only half (55%) were rated as complying moderately or extremely well to
the intervention content and activities
Johnson et al.133 2017 An average proficiency score of 5 out of 6 was given for facilitator adherence and
competence
Johnstone et al.152 2014 Implementation integrity was recorded by 88.46% of teachers in a logbook.
The average content covered was mean 95.6% (SD 5.31%)
Kindt et al.196 2014 A total of 16 out of 28 teachers filled out adherence reports for OVK. On average,
80.5% of lessons were taught (95.3% of the first eight and 65.5% of the last
eight lessons)
206

TABLE 28 Author-reported facilitator fidelity and/or integrity for studies reporting an anxiety or depression
outcome (continued )

219
McCarty et al. 2013 For the Positive Thoughts and Actions intervention, video-recordings were reviewed;
the mean facilitator adherence to core concepts of the intervention was 92%, (range
73–100%). For the control intervention, audio-recorded interviews were reviewed;
the mean facilitator adherence was 92% (range 80–96%)
Miller et al.154 2011 Two sessions were audio-recorded. Adherence to intervention content and objectives
ranged from 96.4% (session 3) to 83.3% (session 6)
Miller et al.178 2011 Sessions were audio-recorded and rated by graduate students using a Likert scale.
Adherence to programme objectives ranged from 76.85% to 79.51%
Miller et al.154 2011 Sessions were audio-recorded and rated by graduate students using a Likert scale.
Adherence to programme objectives ranged from 76.85% to 79.51%
Pahl and Barrett242 2010 Facilitators completed logbooks. Mean adherence to the manual was 94%
(range 90–98%)
Pössel et al.200 2013 Facilitators recorded their adherence to the intervention manual after each session.
Adherence was 91.6% in the CBT intervention and 92.4% in the control intervention
Roberts et al.138 2003 Facilitators completed integrity checklists. The mean percentage of content covered
was 74.11%. Sessions were also audio-recorded. No difference between facilitator-
rated adherence and independent assessment of session recordings was reported
Roberts et al.139 2010 The mean percentage of teacher-reported intervention adherence in the SLS lessons
was 95.3% (range 87.3–98.3%). The mean percentage of teacher-reported content
adherence in the OTS lessons was 98.04% (range 97.5–100%). Independent
assessment agreed with teachers’ reporting (100% agreement)
Roberts et al.240 2018 Intervention content comprised 10 modules. Average module implementation
for SLS: teacher training-only arm, 9.16 (SD 2.02); teacher training + coaching,
9.24 (SD 1.74). Average module implementation for OTS: teacher training-only arm,
7.92 (SD 3.25); teacher training + coaching arm, 8.06 (SD 3.56)
Rodgers and Dunsmuir140 Random sessions were video-recorded. Protocol fidelity and integrity checks ‘showed
2015 concordance between session and manual content (89%)’
Rohde et al.223 2014 Sessions were recorded. Adherence and competence were rated on 10-point scales,
on which higher scores indicated higher adherence/competence. The mean adherence
was 7.0 (SD 0.7) and mean competence was 7.1 (SD 0.7)
Rose et al.203 2014 No deviations from the manualized programs were observed
Ruttledge et al.158 2016 All teachers returned the fidelity checklist confirming that they had delivered all
10 sessions of the programme in sequence and covered the key components
Sawyer et al.204 2010 Session materials were manualised, and teachers completed checklists on session
content completion. Checklists were returned by 36–44% of teachers across the
3 years. Teachers covered a mean of 70% of content and activities in Year 8 (range
17–100%), a mean of 70% in Year 9 (range 21–100%) and a mean of 74% in Year 10
(range 20–100%)
Sheffield et al.141 2006 The mean number of program elements completed each session was 85%
(universal)
Sheffield et al.141 2006 The mean number of program elements completed each session was > 92%
(indicated)
Soffer212 2003 Sessions were audio-taped and were evaluated by independent assessors, who
concluded that ‘All sessions met 100% adherence to the treatment manuals’
Spence et al.206 2003 All teachers reported 100% of the materials were completed in five sessions
(sessions 1, 2, 6, 7 and 8). Half of the teachers did not complete the remaining
sessions or only partially completed the content (sessions 3–5)
continued
207
APPENDIX 2
TABLE 28 Author-reported facilitator fidelity and/or integrity for studies reporting an anxiety or depression

142
Stallard et al. 2013 Of the 36 classroom-based CBT sessions observed to assess intervention fidelity,
31 covered all the core tasks, with at least 75% of core tasks being covered in the
remaining five sessions
Stallard et al.159 2014 One session from each school was audio-taped and evaluated independently. In the
health-led intervention, 100% of sessions delivered the core intervention tasks and
home activities. In the school-led intervention, 60% of the sessions implemented
all the core tasks and home activities and 32% delivered all core tasks, but not
home activities
Stice et al.224 2008 Adherence to intervention components and facilitator competence were evaluated.
Cognitive behavioural intervention: 96% of intervention components were delivered
and 94% of items were delivered with good competence. Supportive–expressive
intervention: 100% of components were fully adhered to and 94% of items were
delivered with good competence
Tak et al.207 2016 Facilitators completed a self-reported questionnaire for assessing fidelity:
Program fidelity was 80%
Takagaki et al.235 2016 Sessions were audio-recorded. A checklist was used to evaluate the facilitators’
adherence to intervention content and protocol:
. . . the therapist’s adherence to the protocol was 100%
Topper et al.173 2017 Sessions were audio-taped:

On average, 93% of the essential and required elements of the protocol were completed
per session
Young et al.230 2016 Sessions were audio-recorded and followed a manual. Sessions were rated by an
‘experienced clinician’; 98.5 % of techniques were delivered with fidelity. A total of
49% of techniques were satisfactorily delivered and 49.5% were rated superior
for delivery
OTS, optimistic thinking skills; OVK, Op Volle Kracht; PEP, Penn Enhancement Program; PRP, Penn Resilience Program;
SLS, social life skills.
Note
As reported by study authors (if available).
208

Appendix 3 Network meta-analysis

results
Model fit tables: by population, setting and outcome
Tables 29–46 report model fit statistics for each population, setting and time point analysis. Model fit
for depression (Tables 38–46) and anxiety outcomes (Tables 29–37) are reported in separate tables.
We assessed both fixed- and random-effects models on the basis of model fit. Component-level models
were fitted assuming consistency and random-effects only. Heterogeneity was evaluated by examining the
posterior median between-study SD (τ) and 95% CrIs from the random-effects model, and by comparing
model fit of the fixed- and random-effects models. Model fit was measured by the posterior mean of
residual deviance. In addition, we examined the DIC, which penalises model fit with model complexity.
Differences of ≥ 5 points for posterior mean residual deviance and DIC were considered meaningful,
with lower values preferred.101 Inconsistency was assessed by comparing the goodness of fit of a model,
assuming consistency with one allowing for inconsistency (i.e. a model that provides effect estimates
based on direct evidence only). A common between-study variance was also assumed for both the
consistency and inconsistency models.
209
210
APPENDIX 3
TABLE 29 Model fit statistics: universal population, secondary setting: anxiety
Residual
Population Setting Time point Model Data pointsa devianceb DIC PDc SD (τ) (95% CrI) Convergenced Chains
Intervention-level NMA
Universal Secondary Post intervention Fixed effect, consistency 45 92.9 112.8 27 – 40,000 3
Post intervention Random effects, consistency 49.5 102.0 35.4 0.11 (0.02 to 0.22) 100,000 3
Post intervention Random effects, inconsistency 49.9 102.2 35.2 0.15 (0.01 to 0.20) 30,000 3
Component-level NMA (random effects, consistency)
Universal Secondary Post intervention Interventione 45 49.3 101.7 35.3 0.11 (0.02 to 0.22) 20,000 2
Post intervention Additive component levelf 47.6 100.5 35.8 0.06 (0.00 to 0.21) 40,000 2
Post intervention Full interaction component level 48.2 102.6 37.7 0.09 (0.01 to 0.24) 200,000 2
BGR, Brooks–Gelman–Rubin.
a Number of data points (equivalent to total number of study arms).
b Posterior mean residual deviance.
c Effective number of parameters in model parameters.
d Convergence: number of iterations before convergence occurred, on X chains, observed using BGR diagnostic tool in OpenBUGS.
e Intervention = main effects or intervention-level NMA model.
f Additive component model (components nested within the intervention).
Note
Intervention-level, additive-component and full interaction-component models fitted assuming random effects and consistency.
Priors:
l between-study SD: uniform(0,5)
l treatment effect: normal(0,1000).
TABLE 30 Regression coefficients estimated from additive and full interaction component models: universal,
secondary, anxiety
Component model Intervention Regression coefficient 95% CrI
Additive CBT + psychoeducation –0.39 –0.78 to 0.01
CBT + mindfulness 0.57 0.08 to 1.03
CBT + relaxation 0.07 –0.21 to 0.38

Full interaction CBT + relaxation –31.58 –144.30 to 90.75
CBT + psychoeducation –0.39 –0.83 to 0.06
CBT + psychoeducation + relaxation –0.30 –0.84 to 0.27
CBT + psychoeducation + mindfulness + relaxation –31.41 –144.10 to 90.93

Additive and full interaction component models were fitted assuming consistency and random effects.
211
212
APPENDIX 3
TABLE 31 Model fit statistics: universal population, primary setting: anxiety
Residual
Universal Primary Post intervention Fixed effect, consistency 34 43.0 145.7 19 – 20,000 3
Random effects, consistency 37.4 145.8 24.6 0.10 (0.01 to 0.26) 100,000 3
Random effects, inconsistency 39.7 148.4 25.0 0.08 (0.00 to 0.26) 200,000 3

Universal Primary Post intervention Interventione 34 37.6 145.7 24.6 0.09 (0.00 to 0.26) 20,000 2
f
Additive component level 36.0 147.5 27.8 0.13 (0.01 to 0.34) 20,000 2
Full interaction component level 36.0 148.6 28.9 0.15 (0.01 to 0.36) 20,000 2
Note
Priors:
primary, anxiety
Full interaction CBT + psychoeducation 0.11 –0.53 to 0.74

CBT + relaxation –0.24 –0.97 to 0.49

213
214
APPENDIX 3
TABLE 33 Model fit statistics: targeted population, secondary setting: anxiety
Residual
Targeted Secondary Post intervention Fixed effect, consistency 36 38.0 104.4 23 – 50,000 3
Targeted Secondary Post intervention Interventione 36 36.01 105.4 26 0.06 (0.00 to 0.22) 20,000 2
f
Note
Priors:
TABLE 34 Regression coefficients estimated from additive and full interaction component models: targeted,
secondary, anxiety
Additive CBT + psychoeducation 0.12 –0.53 to 0.74
Full interaction CBT + psychoeducation 0.88 –193.90 to 196.50

CBT + psychoeducation + relaxation 0.08 –0.57 to 0.69

215
216
APPENDIX 3
TABLE 35 Model fit statistics: targeted population, primary setting: anxiety
Residual
Targeted Primary Post intervention Fixed effects, consistency 25 53.3 83.8 15 – 100,000 3
Targeted Primary Post intervention Interventione 25 23.9 62.3 22.2 0.42 (0.21 to 0.89) 20,000 2
f
f Additive component model (nested within the intervention).
Note
Priors:
primary, anxiety
CBT + behavioural 0.06 –2.54 to 2.63

Full interaction CBT + behavioural + relaxation –0.32 –3.75 to 3.24
CBT + psychoeducation + behavioural 0.05 –2.46 to 2.64

217
218
APPENDIX 3
TABLE 37 Model fit statistics: targeted population, tertiary/university setting: anxiety
Data Residual
Population Setting Time point Model pointsa devianceb DIC PDc SD (τ) (95% CrI) Chains Convergenced
Targeted Tertiary/ Post Fixed effect, consistency 10 16.9 39.9 7.0 – 2 10,000
university intervention
Post Random effects, 10.7 36.6 9.9 0.43 (0.05 to 2.24) 2 100,000
intervention consistency
Post Random effects, 9.8 35.1 9.4 0.21 (0.01 to 2.68) 2 50,000
intervention inconsistency
Note
Priors:
DOI: 10.3310/phr09080
TABLE 38 Model fit statistics: universal population, secondary setting: depression
Residual
Population Setting Time point Model Data pointsa devianceb DIC PDc SD (τ) (95% CrI) Chains Convergenced
Universal Secondary Post intervention Fixed effect, consistency 76 139.7 212.4 43.0 – 3 30,000
Post intervention Random effects, consistency 78.3 172.3 64.3 0.15 (0.10 to 0.22) 3 100,000
Post intervention Random effects, inconsistency 80.0 175.1 65.5 0.15 (0.09 to 0.23) 3 100,000

Universal Secondary Post intervention Interventione 76 78.3 172.3 64.3 0.15 (0.10 to 0.22) 2 20,000
Post intervention Additive component levelf 77.2 173.9 67 0.14 (0.08 to 0.22) 2 20,000
Post intervention Full interaction component level 77.6 176.5 69.2 0.15 (0.10 to 0.23) 2 20,000

Note
Priors:
219
APPENDIX 3
secondary, depression
Additive Cognitive + psychoeducation 0.12 –0.05 to 0.29
Cognitive + behavioural 0.56 –0.21 to 1.34
Cognitive + mindfulness –0.03 –0.40 to 0.34

Cognitive + relaxation 0.01 –0.17 to 0.20
Third wave + psychoeducation –0.45 –0.87 to –0.04
Third wave + (mindfulness + relaxation) –0.30 –0.77 to 0.17
Full interaction Cognitive + behavioural 0.00 0.00 to 0.00
Cognitive + behavioural + relaxation –0.08 –0.36 to 0.19
Cognitive + psychoeducation –0.53 –1.31 to 0.25
Cognitive + psychoeducation + behavioural + 0.05 –0.17 to 0.28

relaxation
Cognitive + psychoeducation + behavioural + 0.01 –0.42 to 0.44

Third wave + psychoeducation 0.16 –0.26 to 0.58
Third wave + mindfulness + relaxation –0.30 –0.81 to 0.21

220

DOI: 10.3310/phr09080
TABLE 40 Model fit statistics: universal population, primary setting: depression
Residual
Universal Primary Post intervention Fixed effect, consistency 29 66.4 127.3 17.0 – 3 30,000
Post intervention Random effects, consistency 28.9 98.7 26 0.32 (0.18 to 0.59) 3 100,000

Universal Primary Post intervention Interventione 29 28.8 98.6 26 0.33 (0.18 to 0.60) 2 20,000
Post intervention Additive component levelf 28.8 99.5 26.9 0.37 (0.20 to 0.70) 2 20,000

e Intervention = main effects or intervention-level NMA model..
Note
Priors:
221
APPENDIX 3
primary, depression
Full interaction CBT + psychoeducation –0.35 –1.40 to 0.69


222

DOI: 10.3310/phr09080
TABLE 42 Model fit statistics: targeted population, secondary setting: depression
Residual
Targeted Secondary Post intervention Fixed effect, consistency 55 144.1 252.4 34.0 – 3 30,000
Post intervention Random effects, consistency 57.6 183.2 51.4 0.38 (0.25 to 0.58) 3 100,000

Targeted Secondary Post intervention Interventione 55 57.5 183.1 51.4 0.38 (0.25 to 0.58) 2 20,000
Post intervention Additive component levelf 58.0 184.3 52.0 0.35 (0.21 to 0.58) 2 20,000

e Intervention = main effects or intervention-level model.
Note
Priors:
223
APPENDIX 3
secondary, depression
Additive CBT + cognitive –0.20 –1.02 to 0.62
CBT + psychoeducation 0.37 –0.09 to 0.84
CBT+ behavioural –0.10 –0.61 to 0.40

Full interaction Cognitive + behavioural –0.11 –0.71 to 0.53
Cognitive + behavioural + relaxation –0.16 –0.95 to 0.64
Cognitive + psychoeducation 0.55 –0.28 to 1.38
Cognitive + psychoeducation + 0.11 –0.51 to 0.73

behavioural
Cognitive + psychoeducation + 0.50 –0.27 to 1.29

224

DOI: 10.3310/phr09080
TABLE 44 Model fit statistics: targeted population, primary setting: depression
Residual
Targeted Primary Post intervention Fixed effect, consistency 10 15.5 41.2 8.0 – 10,000 3
Post intervention Random effects, consistency 10.3 38.1 10.5 0.60 (0.08 to 3.80) 60,000 3
Post intervention Random effects, inconsistency 10.3 38 10 0.60 (0.07 to 3.79) 100,000 3

Targeted Primary Post intervention Interventione 10 10.3 38.1 10.1 0.62 (0.07 to 3.74) 20,000 2
Post intervention Additive component levelf 10.0 37.8 10.4 2.48 (0.12 to 4.87) 50,000 2
Post intervention Full interaction component level 9.9 37.7 9.9 2.43 (0.12 to 4.87) 40,000 2

Note
Priors:
225
APPENDIX 3
primary, depression
CBT + behavioural –0.21 –9.10 to 8.59

Full interaction Cognitive + behavioural + relaxation –16.39 –99.72 to 96.58
Cognitive + psychoeducation + behavioural –0.28 –9.10 to 8.41
Cognitive + psychoeducation + –17.12 –100.40 to 95.73

226

DOI: 10.3310/phr09080
TABLE 46 Model fit statistics: targeted population, tertiary/university setting, depression
Population Setting Time point Model Data pointsa Residual devianceb DIC PDc SD (τ) (95% CrI) Convergenced
Targeted Tertiary/university Post intervention Fixed effect, consistency 12 22.4 51.0 9.0 – 30,000
Post intervention Random effects, consistency 12.5 44.0 12.0 0.51 (0.12 to 2.50) 70,000
Post intervention Random effects, inconsistency 11.8 43.0 11.6 0.26 (0.02 to 2.48) 150,000

Note
Priors:
227
Appendix 4 Full network meta-analysis

and standard pairwise meta-analyses
T he following tables report the random-effects consistency results for all populations and settings
and are presented alongside the pairwise meta-analyses, if data were available.
Pairwise meta-analyses were conducted for all intervention and control comparisons for which direct
head-to-head evidence was available. The method of estimation is similar to the NMA, except that
the consistency assumption is removed, such that intervention effects for separate comparisons
are unrelated and separate intervention effects can be estimated. Estimates are reported for the
immediate post-intervention main time point only and are from a random-effects model that assumes
that the heterogeneity parameter is common across intervention comparisons. This better reflects
the assumption made in the NMA and, therefore, allows a fair comparison of the intervention effect
estimates obtained from both approaches. Vague prior distributions were used for all parameters, and
convergence is reported in the model fit tables above (Tables 29–46).
Intervention effect estimates are reported as standardised mean differences and interventions labelled
numerically. Intervention comparisons are interpreted as the ‘higher’ number relative to the ‘lower’ number,
that is smd[1,5] is the relative intervention effect of 5 over 1. For example, smd[1,5] –0.15, (95% CrI –0.34
to 0.04) would be interpreted as intervention 5 is reducing anxiety, compared with intervention 1.
Analysis-specific intervention numbers are provided as footnotes to each table and differ across analyses.
TABLE 47 Results from network and pairwise meta-analyses: universal population, secondary setting, anxiety outcome
NMA Pairwise
a
Intervention comparison SMD 95% CrI SMD 95% CrI
smd[1,2] –0.05 –0.28 to 0.18 NA
smd[1,3] –0.07 –0.34 to 0.19 NA
smd[1,4] –0.15 –0.51 to 0.15 NA
smd[1,5] –0.15 –0.34 to 0.04 –0.15 –0.33 to 0.02
smd[1,6] 0.03 –0.14 to 0.20 0.04 –0.10 to 0.19
smd[1,7] –0.65 –1.14 to –0.19 NA
smd[2,3] –0.02 –0.25 to 0.21 NA
smd[2,4] –0.10 –0.43 to 0.17 NA
smd[2,5] –0.09 –0.24 to 0.03 –0.07 –0.19 to 0.04
smd[2,6] 0.08 –0.20 to 0.37 NA
smd[2,7] –0.60 –1.05 to –0.17 –1.08 –1.76 to –0.39
smd[3,4] –0.08 –0.44 to 0.23 NA
smd[3,5] –0.07 –0.27 to 0.11 –0.07 –0.25 to 0.10

continued
229
APPENDIX 4
TABLE 47 Results from network and pairwise meta-analyses: universal population, secondary setting, anxiety
NMA Pairwise
a
smd[3,6] 0.10 –0.21 to 0.42 NA
smd[3,7] –0.58 –1.07 to –0.12 NA
smd[4,5] 0.01 –0.24 to 0.30 –0.06 –0.32 to 0.19
smd[4,6] 0.18 –0.17 to 0.59 NA
smd[4,7] –0.50 –0.90 to –0.10 –0.29 –0.75 to 0.16
smd[5,6] 0.18 –0.07 to 0.44 NA
smd[5,7] –0.51 –0.94 to –0.08 NA
smd[6,7] –0.68 –1.20 to –0.19 NA

NA, not available.
a 1 = usual curriculum, 2 = waiting list, 3 = no intervention, 4 = attention control, 5 = CBT and 6 = third wave,
7 = mindfulness/relaxation.
Note
‘NA’ denotes that there was no direct head-to-head RCT for that comparison.
TABLE 48 Results from network and pairwise meta-analyses: universal population, primary setting, anxiety outcome
NMA Pairwise
Intervention comparisona SMD 95% CrI SMD 95% CrI
smd[1,2] 0.02 –0.20 to 0.22 NA
smd[1,3] 0.23 –0.15 to 0.60 NA
smd[1,4] –0.17 –0.51 to 0.17 NA
smd[1,5] –0.07 –0.23 to 0.05 –0.08 –0.24 to 0.04
smd[2,3] 0.20 –0.18 to 0.58 NA
smd[2,4] –0.19 –0.54 to 0.16 NA
smd[2,5] –0.10 –0.26 to 0.06 –0.09 –0.25 to 0.05
smd[3,4] –0.39 –0.83 to 0.04 –0.38 –0.97 to 0.22
smd[3,5] –0.30 –0.65 to 0.05 –0.31 –0.65 to 0.03
smd[4,5] 0.09 –0.22 to 0.40 0.11 –0.27 to 0.47

NA, not available.
a 1 = usual curriculum, 2 = waiting list, 3 = no intervention, 4 = attention control and 5 = CBT.
Note
230

TABLE 49 Results from network and pairwise meta-analyses: targeted population, secondary setting, anxiety outcome
NMA Pairwise
smd[1,2] 0.30 0.09 to 0.53 NA

smd[1,3] –0.09 –0.39 to 0.22 NA
smd[1,4] 1.08 0.52 to 1.64 NA
smd[1,5] 0.03 –0.11 to 0.16 0.03 –0.10 to 0.16
smd[1,6] –0.18 –0.55 to 0.21 NA
smd[1,7] 0.03 –0.42 to 0.48 NA
smd[1,8] –0.17 –0.45 to 0.11 –0.21 –0.54 to 0.15
smd[1,9] –0.47 –0.86 to –0.09 –0.47 –0.87 to –0.08
smd[2,3] –0.40 –0.71 to –0.09 NA
smd[2,4] 0.77 0.20 to 1.34 NA
smd[2,5] –0.28 –0.45 to –0.11 –0.27 –0.46 to –0.10
smd[2,6] –0.48 –0.86 to –0.11 –0.58 –1.17 to 0.01
smd[2,7] –0.28 –0.71 to 0.15 –0.24 –0.82 to 0.33
smd[2,8] –0.48 –0.79 to –0.17 NA
smd[2,9] –0.77 –1.22 to –0.34 NA
smd[3,4] 1.17 0.56 to 1.78 NA
smd[3,5] 0.12 –0.17 to 0.40 –0.03 –0.43 to 0.38
smd[3,6] –0.08 –0.38 to 0.20 –0.03 –0.36 to 0.30
smd[3,7] 0.12 –0.31 to 0.55 –0.10 –0.75 to 0.58
smd[3,8] –0.08 –0.36 to 0.20 –0.01 –0.36 to 0.34
smd[3,9] –0.38 –0.87 to 0.11 NA
smd[4,5] –1.05 –1.60 to –0.50 –1.05 –1.59 to –0.52
smd[4,6] –1.25 –1.91 to –0.60 NA
smd[4,7] –1.05 –1.75 to –0.36 NA
smd[4,8] –1.25 –1.86 to –0.64 NA
smd[4,9] –1.55 –2.23 to –0.87 NA
smd[5,6] –0.20 –0.56 to 0.16 NA
smd[5,7] 0.00 –0.43 to 0.43 NA
smd[5,8] –0.20 –0.46 to 0.07 NA
smd[5,9] –0.50 –0.91 to –0.09 NA
smd[6,7] 0.20 –0.24 to 0.65 NA
smd[6,8] 0.00 –0.37 to 0.38 NA
smd[6,9] –0.30 –0.84 to 0.25 NA
smd[7,8] –0.20 –0.67 to 0.27 NA
smd[7,9] –0.50 –1.09 to 0.09 NA
smd[8,9] –0.30 –0.78 to 0.17 NA
NA, not available.
a 1 = no intervention, 2 = waiting list, 3 = attention control, 4 = psychosupport, 5 = CBT, 6 = biofeedback,
7 = mindfulness/relaxation, 8 = CBM and 9 = exercise.
Note
231
APPENDIX 4
TABLE 50 Results from network and pairwise meta-analyses: targeted population, primary setting, anxiety outcome
NMA Pairwise
smd[1,2] –0.35 –1.05 to 0.33 NA
smd[1,3] –0.38 –0.84 to 0.07 –0.35 –0.79 to 0.09

smd[1,4] 0.11 –0.91 to 1.14 0.11 –0.93 to 1.16
smd[1,5] –0.38 –1.50 to 0.72 NA
smd[2,3] –0.03 –0.54 to 0.49 –0.03 –0.55 to 0.50
smd[2,4] 0.47 –0.77 to 1.71 NA
smd[2,5] –0.03 –1.16 to 1.11 NA
smd[3,4] 0.50 –0.62 to 1.62 NA
smd[3,5] 0.00 –1.01 to 1.01 0.00 –1.04 to 1.03
smd[4,5] –0.50 –2.01 to 1.01 NA

NA, not available.
a 1 = waiting list, 2 = attention control, 3 = CBT, 4 = occupational therapy and 5 = biofeedback.
Note
TABLE 51 Results from network and pairwise meta-analyses: universal population, secondary setting, depression
outcome
NMA Pairwise
a
smd[1,2] 0.00 –0.19 to 0.19 NA
smd[1,3] 0.02 –0.16 to 0.20 NA
smd[1,4] 0.07 –0.12 to 0.26 0.31 –0.05 to 0.69
smd[1,5] –0.04 –0.16 to 0.07 –0.05 –0.17 to 0.06
smd[1,6] –0.03 –0.21 to 0.14 –0.02 –0.19 to 0.14
smd[1,7] –0.19 –0.46 to 0.08 NA
smd[1,8] –0.03 –0.36 to 0.29 –0.10 –0.47 to 0.26
smd[1,9] –0.13 –0.49 to 0.22 –0.13 –0.49 to 0.22
smd[1,10] –0.02 –0.40 to 0.37 –0.02 –0.40 to 0.37
smd[2,3] 0.02 –0.18 to 0.23 NA
smd[2,4] 0.07 –0.14 to 0.28 NA
smd[2,5] –0.04 –0.20 to 0.11 –0.02 –0.18 to 0.13
smd[2,6] –0.04 –0.30 to 0.22 NA
smd[2,7] –0.19 –0.41 to 0.04 –0.21 –0.46 to 0.05
smd[2,8] –0.03 –0.39 to 0.33 NA
smd[2,9] –0.14 –0.54 to 0.26 NA
smd[2,10] –0.02 –0.45 to 0.41 NA
232

TABLE 51 Results from network and pairwise meta-analyses: universal population, secondary setting, depression
NMA Pairwise
a
smd[3,4] 0.05 –0.15 to 0.24 –0.03 –0.30 to 0.23
smd[3,5] –0.06 –0.21 to 0.08 –0.05 –0.20 to 0.10
smd[3,6] –0.06 –0.31 to 0.19 NA
smd[3,7] –0.21 –0.49 to 0.07 NA
smd[3,8] –0.05 –0.41 to 0.30 NA
smd[3,9] –0.16 –0.55 to 0.24 NA
smd[3,10] –0.04 –0.47 to 0.38 NA
smd[4,5] –0.11 –0.27 to 0.05 –0.22 –0.56 to 0.12
smd[4,6] –0.11 –0.36 to 0.15 NA
smd[4,7] –0.25 –0.51 to 0.00 –0.18 –0.55 to 0.18
smd[4,8] –0.10 –0.46 to 0.26 NA
smd[4,9] –0.20 –0.60 to 0.19 NA
smd[4,10] –0.09 –0.51 to 0.34 NA
smd[5,6] 0.00 –0.20 to 0.21 NA
smd[5,7] –0.14 –0.39 to 0.10 NA
smd[5,8] 0.01 –0.32 to 0.33 NA
smd[5,9] –0.09 –0.46 to 0.28 NA
smd[5,10] 0.02 –0.38 to 0.43 NA
smd[6,7] –0.15 –0.47 to 0.17 NA
smd[6,8] 0.00 –0.37 to 0.37 NA
smd[6,9] –0.10 –0.49 to 0.29 NA
smd[6,10] 0.02 –0.40 to 0.44 NA
smd[7,8] 0.15 –0.25 to 0.56 NA
smd[7,9] 0.05 –0.39 to 0.49 NA
smd[7,10] 0.17 –0.30 to 0.64 NA
smd[8,9] –0.10 –0.58 to 0.37 NA
smd[8,10] 0.02 –0.49 to 0.52 NA
smd[9,10] 0.12 –0.40 to 0.64 NA

NA, not available.
a 1 = usual curriculum, 2 = waiting list, 3 = no intervention, 4 = attention control, 5 = CBT and 6 = third wave,
7 = IPT + CBT, 8 = IPT, 9 = psychoeducation and 10 = behavioural therapy.
Note
233
APPENDIX 4
TABLE 52 Results from network and pairwise meta-analyses: universal population, primary setting, depression outcome
NMA Pairwise
smd[1,2] –0.09 –0.77 to 0.54 NA
smd[1,3] 0.13 –0.40 to 0.65 NA

smd[1,4] –0.07 –0.79 to 0.62 NA
smd[1,5] –0.13 –0.44 to 0.17 –0.11 –0.37 to 0.16
smd[1,6] –0.10 –1.04 to 0.80 NA
smd[2,3] 0.22 –0.48 to 0.96 NA
smd[2,4] 0.02 –0.83 to 0.88 NA
smd[2,5] –0.04 –0.60 to 0.56 –0.06 –0.56 to 0.49
smd[2,6] –0.01 –1.05 to 1.04 NA
smd[3,4] –0.20 –0.79 to 0.37 –0.15 –0.71 to 0.39

smd[3,5] –0.26 –0.69 to 0.17 –0.29 –0.66 to 0.08
smd[3,6] –0.23 –1.03 to 0.55 –0.12 –0.88 to 0.64
smd[4,5] –0.06 –0.68 to 0.59 NA
smd[4,6] –0.03 –0.84 to 0.78 NA
smd[5,6] 0.03 –0.85 to 0.88 NA

NA, not available.
a 1 = usual curriculum, 2 = waiting list, 3 = no intervention, 4 = attention control, 5 = CBT and 6 = behavioural therapy.
Note
TABLE 53 Results from network and pairwise meta-analyses: targeted population, secondary setting, depression outcome
NMA Pairwise
smd[1,2] 0.22 –0.27 to 0.70 NA
smd[1,3] 0.04 –0.72 to 0.82 NA
smd[1,4] –0.81 –1.81 to 0.18 NA
smd[1,5] 0.02 –0.62 to 0.66 NA
smd[1,6] –0.22 –0.58 to 0.13 –0.16 –0.47 to 0.15
smd[1,7] –0.68 –1.83 to 0.47 NA
smd[1,8] –0.65 –1.50 to 0.16 NA
smd[1,9] –0.90 –2.20 to 0.40 NA
smd[1,10] –0.28 –1.13 to 0.58 –0.28 –1.12 to 0.57
smd[1,11] 0.12 –0.50 to 0.72 NA
smd[2,3] –0.18 –0.92 to 0.59 NA
smd[2,4] –1.03 –2.01 to –0.04 NA
smd[2,5] –0.20 –0.82 to 0.43 NA
234

TABLE 53 Results from network and pairwise meta-analyses: targeted population, secondary setting, depression
NMA Pairwise
a
smd[2,6] –0.44 –0.77 to –0.11 –0.40 –0.71 to –0.08
smd[2,7] –0.90 –2.03 to 0.25 NA
smd[2,8] –0.87 –1.70 to –0.06 NA
smd[2,9] –1.12 –2.40 to 0.17 NA
smd[2,10] –0.50 –1.48 to 0.49 NA
smd[2,11] –0.10 –0.70 to 0.49 NA
smd[3,4] –0.85 –2.02 to 0.28 NA
smd[3,5] –0.02 –0.90 to 0.83 NA
smd[3,6] –0.26 –0.95 to 0.41 –0.25 –0.94 to 0.40
smd[3,7] –0.72 –2.01 to 0.56 NA
smd[3,8] –0.69 –1.73 to 0.30 NA
smd[3,9] –0.94 –2.37 to 0.46 NA
smd[3,10] –0.32 –1.47 to 0.81 NA
smd[3,11] 0.08 –0.78 to 0.90 NA
smd[4,5] 0.83 –0.24 to 1.91 NA
smd[4,6] 0.59 –0.34 to 1.52 0.59 –0.34 to 1.52
smd[4,7] 0.14 –1.30 to 1.57 NA
smd[4,8] 0.16 –1.05 to 1.35 NA
smd[4,9] –0.09 –0.92 to 0.75 –0.09 –0.91 to 0.74
smd[4,10] 0.53 –0.77 to 1.85 NA
smd[4,11] 0.93 –0.13 to 1.98 NA
smd[5,6] –0.24 –0.78 to 0.30 –0.22 –0.71 to 0.26
smd[5,7] –0.70 –1.65 to 0.26 –0.70 –1.65 to 0.25
smd[5,8] –0.67 –1.21 to –0.16 –0.67 –1.20 to –0.16
smd[5,9] –0.92 –2.28 to 0.43 NA
smd[5,10] –0.30 –1.36 to 0.76 NA
smd[5,11] 0.09 –0.56 to 0.75 0.26 –0.55 to 1.08
smd[6,7] –0.46 –1.55 to 0.64 NA
smd[6,8] –0.43 –1.19 to 0.31 NA
smd[6,9] –0.68 –1.93 to 0.57 NA
smd[6,10] –0.06 –0.98 to 0.86 NA
smd[6,11] 0.33 –0.16 to 0.83 0.22 –0.59 to 1.02
smd[7,8] 0.02 –1.08 to 1.11 NA

continued
235
APPENDIX 4
TABLE 53 Results from network and pairwise meta-analyses: targeted population, secondary setting, depression
NMA Pairwise
a
smd[7,9] –0.22 –1.88 to 1.43 NA
smd[7,10] 0.40 –1.03 to 1.83 NA
smd[7,11] 0.79 –0.37 to 1.95 NA
smd[8,9] –0.25 –1.70 to 1.22 NA
smd[8,10] 0.37 –0.80 to 1.57 NA
smd[8,11] 0.77 –0.06 to 1.62 NA
smd[9,10] 0.62 –0.92 to 2.18 NA
smd[9,11] 1.02 –0.33 to 2.36 NA
smd[10,11] 0.40 –0.65 to 1.44 NA

NA, not available.
a 1 = no intervention, 2 = waiting list, 3 = usual curriculum, 4 = attention control, 5 = psychosupport, 6 = CBT, 7 = third
wave, 8 = IPT, 9 = CBM, 10 = exercise and 11 = psychoeducation.
Note
TABLE 54 Results from network and pairwise meta-analyses: targeted population, primary setting, depression outcome
NMA Pairwise
a
smd[1,2] –0.72 –3.56 to 2.10 NA
smd[1,3] –0.48 –2.49 to 1.50 –0.48 –2.48 to 1.47

smd[1,4] –0.10 –2.94 to 2.71 –0.10 –2.87 to 2.69
smd[2,3] 0.25 –1.76 to 2.21 0.25 –1.73 to 2.21
smd[2,4] 0.62 –3.39 to 4.60 NA
smd[3,4] 0.38 –3.06 to 3.84 NA

NA, not available.
a 1 = waiting list, 2 = attention control, 3 = CBT and 4 = occupational therapy.
Note
236

Appendix 5 Further time points:

results from the intervention-level network
meta-analysis
TABLE 55 Results from the intervention-level network meta-analysis: further time points for anxiety outcome
Follow-up (months)
6–12 13–24 ≥ 25
Population
and setting Intervention Reference SMD 95% CrI SMD 95% CrI SMD 95% CrI
Universal, CBT Usual –0.11 –0.34 to 0.11 –0.01 –2.84 to 2.81 –0.23 –0.55 to 0.08
secondary curriculum
Third wave Usual –0.05 –0.32 to 0.22 – – – –

curriculum
CBT + IPT Usual –0.02 –0.42 to 0.36 – – – –
curriculum
Universal, CBT Usual –0.11 –0.35 to 0.11 0.00 –0.68 to 0.71 –0.12 –0.26 to 0.02
primary curriculum
Targeted, CBT No 0.05 –0.12 to 0.20 –0.26 –0.52 to –0.01a –0.39 –0.65 to –0.14a
secondary intervention
CBM No –0.14 –0.53 to 0.24 – – – –
intervention
Targeted, CBT Waiting list –0.17 –1.37 to 1.06 – – – –
primary
Biofeedback Waiting list –0.28 –2.49 to 1.93 – – – –
a Single study.
237
APPENDIX 5
TABLE 56 Results from the intervention-level network meta-analysis: further time points for depression outcome
Follow-up (months)
6–12 13–24 ≥ 25
Population
and setting Intervention Reference SMD 95% CrI SMD 95% CrI SMD 95% CrI
Universal, CBT Usual –0.02 –0.10 to 0.06 –0.04 –0.20 to 0.14 –0.14 –2.89 to 2.63
secondary curriculum
Third wave Usual –0.13 –0.27 to 0.01 – – – –

curriculum
CBT + IPT Usual –0.10 –0.26 to 0.05 –0.10 –0.57 to 0.39 – –

curriculum
IPT Usual 0.11 –0.13 to 0.35 – – – –

curriculum
Universal, CBT Usual –0.15 –0.43 to 0.09 –0.03 –0.62 to 0.55 –0.27 –0.42 to –0.13a
primary curriculum
Targeted, CBT No –0.04 –0.51 to 0.41 –0.18 –2.56 to 2.16 –0.27 –1.05 to 0.50a
secondary intervention
IPT No –0.49 –1.49 to 0.48 0.09 –3.81 to 3.93 – –

intervention
Targeted, CBT Waiting list –0.34 –0.72 to 0.05b –0.50 –0.96 to 0.05a – –
primary
a Single study.
b Fixed effect.
238

Appendix 6 Exploring heterogeneity and

publication bias
Comparison-adjusted funnel plots to explore potential small study effects
A funnel plot is a graph of the study-level treatment effect estimates plotted against their SE. In a standard
funnel plot, the vertical axis (SE) is reported in reverse, so that studies with smaller SEs are seen at the
top of the plot (typically larger studies). Comparison-adjusted funnel plots follow this convention, but
are modified to allow for multiple treatments and multiple comparisons from NMA. In the following
graphs, we plot active treatments versus inactive control only. The x-axis reports the difference of each
study’s estimate (yiXY) from the direct summary effect for each comparison (yiXY − µXY), and the y-axis
reports the SE of yiXY. The red line represents the null hypothesis that the comparison-specific pooled
effect estimates do not differ from the study-specific effect sizes. In the absence of small-study effects,
all points should be symmetrical around the null.
Following Chaimani et al.,98 the comparisons included in these funnel plots are for a control compared
with an active intervention. Specific interventions are listed after each graph.
Meta regression, subgroup analysis and risk-of-bias sensitivity analysis
Facilitator delivering intervention: metaregression

Interventions were categorised as being delivered by a teacher or a MHP. There was considerable variation
in the classification of ‘MHP’ and it should therefore be regarded as a simplification. Here, MHP includes
school counsellors, qualified psychotherapists, and graduate and post-doctoral psychology students
(which included general psychology, educational psychology or counselling psychology, if specified).
In most studies, MHPs were external to the educational setting; however, this was not always the case.
0
Standard error of effect size
Comparison
1 vs. 5
4 vs. 7
1 vs. 6
2 vs. 5
2 vs. 7
3 vs. 5
4 vs. 5
–0.4 –0.2 0.0 0.2 0.4

Effect size centred at comparison-specif ic pooled effect (YiXY – µXY)
FIGURE 17 Comparison-adjusted funnel plot: universal population, secondary setting – anxiety. 1 = usual curriculum,
2 = waiting list, 3 = no intervention, 4 = attention control, 5 = CBT, 6 = third wave and 7 = mindfulness/relaxation.
239
APPENDIX 6
Standard error of effect size Comparison

1 vs. 5
2 vs. 5
3 vs. 4
3 vs. 5
4 vs. 5
–0.4 –0.2 0.0 0.2 0.4

FIGURE 18 Comparison-adjusted funnel plot: universal population, primary setting – anxiety. 1 = usual curriculum,
2 = waiting list, 3 = no intervention, 4 = attention control and 5 = CBT.
Comparison
1 vs. 4
3 vs. 4
1 vs. 6
3 vs. 5
1 vs. 8
3 vs. 6
2 vs. 4
3 vs. 7
2 vs. 5
2 vs. 7
–0.4 –0.2 0.0 0.2 0.4

FIGURE 19 Comparison-adjusted funnel plot: targeted population, secondary setting – anxiety. 1 = no intervention, 2 = waiting
list, 3 = attention control, 4 = CBT, 5 = mindfulness/relaxation, 6 = bias modification, 7 = biofeedback and 8 = exercise.
0
Comparison
1 vs. 3
1 vs. 4
2 vs. 3
–1.0 –0.5 0.0 0.5

FIGURE 20 Comparison-adjusted funnel plot: targeted population, primary setting – anxiety. 1 = waiting list,
2 = attention control, 3 = CBT and 4 = occupational therapy.
240

Standard error of effect size Comparison

1 vs. 5
3 vs. 5
1 vs. 6
4 vs. 5
1 vs. 7
1 vs. 9
2 vs. 5
2 vs. 8
–0.4 –0.2 0.0 0.2 0.4

FIGURE 21 Comparison-adjusted funnel plot: universal population, secondary setting – depression. 1 = usual curriculum,
2 = waiting list, 3 = no intervention, 4 = attention control, 5 = CBT, 6 = third wave, 7 = IPT, 8 = IPT + CBT and
9 = behavioural therapy.
0
Comparison
1 vs. 5
2 vs. 5
3 vs. 4
3 vs. 5
3 vs. 6
–0.5 0.0 0.5

FIGURE 22 Comparison-adjusted funnel plot: universal population, primary setting – depression. 1 = usual curriculum,
2 = waiting list, 3 = no intervention, 4 = attention control, 5 = CBT and 6 = behavioural therapy.
241
APPENDIX 6

Comparison
1 vs. 6
1 vs. 9
2 vs. 6
3 vs. 6
4 vs. 10
4 vs. 6
–0.5 0.0 0.5

FIGURE 23 Comparison-adjusted funnel plot: targeted population, secondary setting – depression. 1 = no intervention,
2 = waiting list, 3 = usual curriculum, 4 = attention control, 6 = CBT, 9 = exercise and 10 = cognitive bias modification.
0
Comparison
1 vs. 3
1 vs. 4
2 vs. 3
–0.4 –0.2 0.0 0.2 0.4

FIGURE 24 Comparison-adjusted funnel plot: targeted population, primary setting – depression. 1 = waiting list,
2 = attention control, 3 = CBT and 4 = occupational therapy.
Metaregression analyses
Facilitator metaregression
Meta-regression and subgroup analyses were performed in OpenBUGS following the Evidence Synthesis
Technical Support Unit code available from the NICE Decision Support Unit website and described in Dias
et al.102,103 Interventions that varied by person of delivery were CBT, third-wave and mindfulness/relaxation
interventions. To explore whether or not intervention effects were modified by person delivering
the intervention (teacher or MHP), we fitted a metaregression model for intervention–teacher (0) and
intervention–MHP (1). This enables us to estimate the intervention effect at each value of the covariate,
for each intervention, including multiarm trials that compared the effect of both facilitators. When there
were two or more interventions that were delivered by a teacher or MHP, a random-effects NMA model
was fitted and we assumed a hierarchical model for the regression coefficient across interventions (CBT,
third wave and mindfulness/relaxation), whereby the regression coefficients were assumed to come from
242

a normal distribution with mean (m.beta) and precision (tau.beta). The between-studies SD was assumed
to be common for each value of the covariate. We estimated a between-intervention SD (sd.beta) for the
covariate regression coefficients. Vague priors were specified.
When only a single intervention varied by person delivering it, a fixed covariate effect (as for mode
of delivery) was fitted.
TABLE 57 Results from metaregression of intervention facilitator: universal population, secondary setting: anxiety
Intervention-facilitator SMD 95% CrI Number of studies
CBT – teacher –0.13 –0.32 to 0.06 9
CBT – MHP –0.17 –0.42 to 0.03 6
Third wave – teacher –0.10 –0.38 to 0.19 1
Third wave – MHP 0.10 –0.10 to 0.29 2
Mindfulness/relaxation – teacher –0.48 –1.02 to 0.08 1
Mindfulness/relaxation – MHP –0.95 –1.68 to –0.27 1

Intervention Regression coefficient 95% CrI
CBT –0.4 –0.23 to 0.10
Third wave 0.20 –0.15 to 0.53
Mindfulness/relaxation –0.48 –1.39 to 0.22
Parameter Posterior mean 95% CrI
m.beta –0.11 –1.29 to 0.94
sd.beta 0.58 0.04 to 1.83
Posterior median between-study SD 0.10 (95% CrI 0.01 to 0.22)
TABLE 58 Results from metaregression of intervention facilitator: universal population, primary setting: anxiety
CBT – teacher –0.05 –0.21 to 0.08 6
CBT – MHP –0.18 –0.42 to 0.00 4
CBT –0.14 –0.33 to 0.03
243
APPENDIX 6
TABLE 59 Results from metaregression of intervention facilitator: targeted population, secondary setting: anxiety
CBT – other 0.01 –0.18 to 0.20 2
CBT – MHP 0.00 –0.22 to 0.22 7
Biofeedback – other –0.04 –0.59 to 0.53 1
Biofeedback – MHP –0.27 –0.88 to 0.32 1
CBT –0.01 –0.23 to 0.20

Biofeedback –0.20 –0.96 to 0.39
m.beta –0.08 –1.62 to 1.29
sd.beta 0.57 0.00 to 1.89
TABLE 60 Results from metaregression of intervention facilitator: universal population, secondary setting: depression
CBT – teacher –0.07 –0.21 to 0.08 10
CBT – MHP –0.01 –0.15 to 0.14 8
Third wave – teacher –0.07 –0.37 to 0.23 1
Third wave – MHP –0.02 –0.22 to 0.17 3
CBT + IPT – teacher –0.21 –0.53 to 0.11 2
CBT + IPT – MHP –0.07 –0.43 to 0.31 1

CBT 0.06 –0.10 to 0.22
Third wave 0.05 –0.29 to 0.36
CBT + IPT 0.13 –0.20 to 0.55
m.beta 0.08 –0.53 to 0.72
sd.beta 0.18 0.01 to 1.48
244

TABLE 61 Results from metaregression of intervention facilitator: universal population, primary setting: depression
CBT – teacher –0.19 –0.52 to 0.14 4
CBT – MHP 0.08 –0.46 to 0.57 5
CBT 0.27 –0.30 to 0.80
TABLE 62 Results from metaregression of intervention facilitator: targeted population, secondary setting: depression
Intervention-faciliator SMD 95% CrI Number of studies
CBT – other –0.10 –0.49 to 0.27 14
CBT – MHP –0.30 –0.67 to 0.06 2
CBT –0.20 –0.52 to 0.13
Mode of delivery metaregression

Interventions were categorised as being delivered face to face or via computer/internet (multimedia).
Across all networks, the only intervention that varied by mode of delivery was CBT. To explore whether
or not intervention effects were modified by mode of delivery, we fitted a metaregression model for
CBT-face to face (covariate = 0) and CBT-multimedia (covariate = 1). This enabled us to estimate the
intervention effect for both CBT-face to face and CBT-multimedia. A random-effects NMA model
was fitted, but the regression coefficient for the covariate was assumed a fixed effect across studies.
The between-studies SD was assumed to be common for CBT-face to face and CBT-multimedia.
Results are reported for universal secondary settings only, as there were insufficient data available for
meaningful analysis in other populations/settings.
TABLE 63 Results from metaregression of intervention mode of delivery: universal population, secondary school
setting: depression
Intervention-facilitator SMD 95% CrI
CBT – face to face –0.03 –0.14 to 0.09
CBT – multimedia –0.15 –0.38 to 0.07

CBT –0.12 –0.34 to 0.10
245
APPENDIX 6
TABLE 64 Results from metaregression of intervention mode of delivery: universal population, secondary school
setting: anxiety
Intervention-facilitator SMD 95% CrI
CBT – face to face –0.14 –0.36 to 0.07
CBT – multimedia –0.16 –0.42 to 0.10

CBT –0.02 –0.27 to 0.23
Subgroup analysis: examining whether or not intervention effect is modified by the

intended focus of the intervention
For each population, setting and outcome combination, intervention estimates are compared across
three subgroups: (1) interventions that aimed to prevent symptoms of anxiety (2) interventions that
aimed to prevent only symptoms of depression and (3) interventions that aimed to prevent both
symptoms of anxiety and symptoms of depression. The interest here is whether or not interventions
designed specifically to prevent one clinical disorder might still affect the other. An intervention on the
prevention of anxiety may also report the effect on depressive symptoms, for example.
TABLE 65 Results from subgroup analysis by focus of the intervention
Focusa Comparisonb Studiesc (n) SMDd 95% CrI SDe 95% CrI
Universal, secondary: self-reported depression
Anxiety CBT vs. no intervention 4 0.05 –0.13 to 0.22 0.04 0.00 to 0.33
Depression CBT vs. no intervention 18 –0.14 –0.36 to 0.06 0.18 0.10 to 0.30
Anxiety + depression CBT vs. no intervention 10 0.05 –0.33 to 0.47 0.13 0.01 to 0.32
Universal, secondary: self-reported anxiety
Anxiety CBT vs. no intervention 7 –0.12 –0.96 to 0.72 0.35 0.02 to 1.43
Depression CBT vs. no intervention 4 0.00 –5.26 to 5.25 1.66 0.12 to 4.74
Anxiety + depression CBT vs. no intervention 10 –0.05 –0.91 to 0.38 0.16 0.03 to 0.37
Universal, primary: self-reported depression
Anxiety CBT vs. usual curriculum 2 0.18 –0.06 to 0.41 Fixed-effects analysis
Depression CBT vs. usual curriculum 6 –0.57 –1.51 to 0.37 0.34 0.03 to 0.96
Anxiety + depression CBT vs. usual curriculum 4 –0.16 –0.42 to 0.13 0.17 0 to 0.78
Universal, primary: self-reported anxiety

Anxiety CBT vs. usual curriculum 9 –0.37 –0.64 to –0.12 0.08 0.00 to 0.32
Depression CBT vs. no intervention 2 –0.31 –0.61 to 0.00 Fixed-effects analysis
Anxiety + depression CBT vs. usual curriculum 4 0.04 –0.16 to 0.27 0.07 0.00 to 0.61
Targeted, secondary: self-reported depression
Anxiety CBT vs. waiting list 2 –0.21 –0.49 to 0.08 Fixed-effects analysis
Depression CBT vs. waiting list 17 –0.33 –0.86 to 0.20 0.38 0.24 to 0.62
Anxiety + depression CBT vs. waiting list 3 –0.67 –3.65 to 2.33 0.78 0.00 to 4.56
246

TABLE 65 Results from subgroup analysis by focus of the intervention (continued )
Focusa Comparisonb Studiesc (n) SMDd 95% CrI SDe 95% CrI
Targeted, secondary: self-reported anxiety
Anxiety CBT vs. no intervention 8 0.13 –0.95 to 1.18 0.33 0.03 to 1.34
Depression CBT vs. no intervention 3 0.00 –0.15 to 0.16 0.08 0.00 to 0.26
Targeted, primary: self-reported anxiety
Anxiety CBT vs. waiting list 7 –0.16 –0.41 to 0.09 0.14 0.00 to 0.48
a Focus: anxiety = focus of intervention was prevention of anxiety, depression = focus of intervention was prevention
of depression, anxiety + depression = focus of intervention was prevention of both anxiety and depression.
b Comparison: when feasible, the intervention effect estimate has been reported for the same intervention vs. control
comparison for each subgroup to allow for meaningful comparison.
c Studies: number of studies per subgroup.
d SMD for each subgroup (and 95% CrI).
e SD: between-study variation in effect for each subgroup (unless fixed-effects analysis).
Sensitivity analyses
TABLE 66 Sensitivity analysis for intracluster correlation coefficient
ICC = 0.01 ICC = 0.06
Intervention SMD 95% CrI SMD 95% CrI
Universal, secondary, depression (19/34 trials)
CBT –0.04 –0.16 to 0.07 –0.04 –0.16 to 0.08

Third wave –0.04 –0.21 to 0.14 –0.03 –0.20 to 0.14
IPT + CBT –0.18 –0.46 to 0.09 –0.18 –0.45 to 0.08
IPT –0.03 –0.37 to 0.30 –0.03 –0.34 to 0.29
Behavioural therapy –0.02 –0.40 to 0.37 –0.02 –0.41 to 0.38
Universal, primary, depression (7/12 trials)
CBT –0.13 –0.44 to 0.18 –0.13 –0.44 to 0.17
Targeted, secondary, depression (5/24 trials)

CBT –0.21 –0.58 to 0.14 –0.21 –0.58 to 0.14
Third wave –0.68 –1.83 to 0.47 –0.68 –1.84 to 0.48
IPT –0.65 –1.50 to 0.16 –0.65 –1.50 to 0.17
CBM –0.89 –2.20 to 0.41 –0.89 –2.21 to 0.41
Exercise –0.28 –1.11 to 0.55 –0.28 –1.11 to 0.55
Targeted, primary, depression (1/5 trials)
CBT –0.47 –2.46 to 1.54 –0.48 –2.48 to 1.50

Occupational therapy –0.1 –2.92 to 2.76 –0.1 –2.90 to 2.72
continued
247
APPENDIX 6
TABLE 66 Sensitivity analysis for intracluster correlation coefficient (continued )
ICC = 0.01 ICC = 0.06
Universal, secondary, anxiety (12/21 trials)
CBT –0.15 –0.34 to 0.04 –0.15 –0.34 to 0.04

Third wave 0.03 –0.15 to 0.21 0.04 –0.13 to 0.20
Mindfulness/relaxation –0.66 –1.16 to –0.19 –0.64 –1.12 to –0.19
Universal, primary, anxiety (11/15 trials)
CBT –0.08 –0.24 to 0.04 –0.07 –0.23 to 0.06
Targeted, secondary, anxiety (5/15 trials)
CBT 0.03 –0.10 to 0.16 0.03 –0.11 to 0.17
Biofeedback –0.17 –0.55 to 0.21 –0.17 –0.55 to 0.21

Mindfulness/relaxation 0.04 –0.41 to 0.49 0.03 –0.41 to 0.48
CBM –0.17 –0.44 to 0.10 –0.17 –0.45 to 0.13
Exercise –0.47 –0.83 to –0.12 –0.47 –0.89 to –0.04
Targeted, primary, anxiety (2/11 trials)
CBT –0.39 –0.85 to 1.14 –0.38 –0.85 to 0.07
Occupational therapy 0.11 –0.93 to 0.72 0.11 –0.93 to 1.15
TABLE 67 Sensitivity analysis for change from baseline standard deviation
C = 0.6 C = 0.8
Universal, secondary, depression (34 trials)
CBT –0.04 –0.15 to 0.07 –0.04 –0.16 to 0.07
Third wave –0.03 –0.2 to 0.13 –0.03 –0.21 to 0.14
IPT + CBT –0.18 –0.44 to 0.08 –0.18 –0.45 to 0.08

IPT –0.03 –0.34 to 0.28 –0.03 –0.36 to 0.29
Universal, primary, depression (12 trials)
CBT –0.13 –0.44 to 0.17 0.13 –0.44 to 0.18
Behavioural therapy –0.08 –1.04 to 0.84 0.12 –1.03 to 0.77
Targeted, secondary, depression (24 trials)
CBT –0.21 –0.57 to 0.13 –0.22 –0.59 to 0.13

Third wave –0.67 –1.83 to 0.48 –0.68 –1.83 to 0.45
IPT –0.63 –1.47 to 0.18 –0.71 –1.56 to 0.13
CBM –0.89 –2.2 to 0.40 –0.91 –2.22 to 0.39
Exercise –0.28 1.12 to 0.56 –0.28 –1.13 to 0.58
248

TABLE 67 Sensitivity analysis for change from baseline standard deviation (continued )
C = 0.6 C = 0.8
Targeted, primary, depression (5 trials)
CBT –0.47 –2.46 to 1.45 –0.48 –2.55 to 1.57

Occupational therapy –0.10 –2.85 to 2.64 –0.10 –3.00 to 2.77
Universal, secondary, anxiety (21 trials)
CBT –0.19 –0.41 to 0.01 –0.21 –0.45 to 0.00
Third wave 0.03 –0.15 to 0.21 0.03 –0.18 to 0.25
Mindfulness/relaxation –0.69 –1.22 to –0.18 –0.77 –1.29 to –0.28
Universal, primary, anxiety (15 trials)
CBT –0.06 –0.21 to 0.06 –0.08 –0.24 to 0.04

Targeted, secondary, anxiety (15 trials)
CBT 0.03 –0.11 to 0.17 0.03 –0.10 to 0.17
Mindfulness/relaxation 0.02 –0.48 to 0.12 0.04 –0.36 to 0.44
CBM –0.17 –0.42 to 0.11 –0.17 –0.42 to 0.11
Exercise –0.47 –0.89 to –0.05 –0.47 –0.83 to –0.11
Targeted, primary, anxiety (11 trials)

CBT –0.38 –0.83 to 0.06 –0.39 –0.86 to 0.07
Occupational therapy 0.11 –0.88 to 1.10 0.11 –0.95 to 1.17

C, correlation coefficient.
249
Appendix 7 Additional outcomes

Suicidal ideation, behaviour and self-harm outcomes
TABLE 68 Studies reporting that participants with suicidal behaviours or thoughts were excluded
Study Population Setting Quotation/details

218
McCarty et al. 2011 Indicated Secondary Suicidal ideation was an exclusion criterion
181
Tokolahi et al. 2018 Selective Primary Reporting parasuicidal and/or suicidal thoughts or
behaviours was an exclusion criterion
Young et al.230 2016 Indicated Secondary Reporting significant suicidal ideation or non-suicidal
self-injury (n = 11) was an exclusion criterion
Kindt et al.196 2014 Universal Secondary The question on suicide was removed from the
Child Depression Inventory. The authors reported
that this was ‘to optimize collaboration with school
officials and parents’
McCarty et al.219 2013 Indicated Secondary Current suicidal ideation was an exclusion criterion
Peden et al.234 2000 Indicated University Current suicidal ideation was an exclusion criterion
223
Rohde et al. 2014 Indicated Secondary Current/acute suicidal ideation was an exclusion
criterion
Young et al.229 2010 Indicated Secondary Suicidal ideation or self-harm behaviours were
exclusion criteria
Livheim et al.217 2015 Indicated Secondary Suicidality was an exclusion criterion
Cowell et al.231 2009 Selective Primary Suicidal ideation was an exclusion criterion
226
Wijnhoven et al. 2014 Indicated Secondary Suicidal ideation was an exclusion criterion
186
Seligman et al. 1999 Selective University Students who were considered at current suicide risk
were excluded
251
APPENDIX 7
TABLE 69 Studies reporting that schools requested suicidal behaviour or thought questions be excluded
Study Population Setting Quotation/details
Hodas et al.131 2016 Universal Secondary The question on suicidal ideation was removed from the Child
Depression Inventory
Johnstone et al.152 2014 Universal Primary The question on suicidal ideation was removed from the
Child Depression Inventory. The authors note this was because
school officials expressed concern about its appropriateness for
primary-aged children
Pophillat et al.156 2016 Universal Primary The question on suicidal ideation was removed from the Child
Depression Inventory. The authors note this was removed
‘in accordance with the Western Australia Department of
Education’s standards’
Soffer et al.212 2003 Universal Primary The author reported not using the Children’s Depression
Inventory at all, as the Board of Education ‘did not approve . . .
due to its explicit assessment of suicidality’
Tak et al.207 2016 Universal Secondary The question on suicidal ideation was removed ‘due to ethical
considerations’ (scale used: Child Depression Inventory)
Chaplin et al.192 2006 Universal Secondary The question on suicidal ideation was removed ‘at the request of
school administrators’ (scale used: Child Depression Inventory)
Gillham et al.165 2012 Indicated Secondary Questions on suicidal ideation were removed ‘at the request of
school administrators’ (scales used: Child Depression Inventory
and Reynolds Adolescent Depression Scale)
Horowitz et al.195 2007 Universal Secondary Question on suicidal ideation was removed ‘because of concerns of
the participating schools’ (scale used: Child Depression Inventory)
Pössel et al.200 2013 Universal Secondary Question on suicidal ideation was removed ‘at the request of
the school, as is common in school-based research’ (scale used:
Child Depression Inventory)
Socioeconomic status, biological sex and ethnicity
TABLE 70 Socioeconomic status, sex and ethnicity as extracted from authors’ reports: universal interventions
Trial Setting Sex Ethnicity Socioeconomic Status
Ahlen et al.145 2018 Primary Mixed NC Median of household income

US$6000–7000/month
Anticich et al.339 Primary Mixed Study conducted in Australia. . . . working to middle class
2013 Catholic preschools and primary
schools in the greater
metropolitan area of Brisbane.
Participants described as ‘white’
Araya et al.118 2013 Secondary Mixed NC ‘Socially deprived’. Author
reported School Social
Deprivation Index, mean (SD)
0.85 (0.1) 0.85 (0.1)
Attwood et al.146 Primary Boys NC NC
2012
Aune and Stiles119 Secondary Mixed Study conducted in Norway: NC
2009 . . . less than 3% non-Caucasian
Baker and Butler120 Secondary Mixed Caucasian NC
1984
252

TABLE 70 Socioeconomic status, sex and ethnicity as extracted from authors’ reports: universal interventions (continued )
Barrett and Primary Mixed . . . predominantly from Anglo- 75.35% dual-parent and 11.55%
Turner147 2001 Saxon families with English as single-parent families
their primary language . . . varying levels of socio-
economic advantage . . .
Barrett et al.121 Secondary Mixed The majority of children . . . diverse levels of socio-economic
2005 were white, Anglo-Saxon, status . . . working to middle class
Catholic or Protestant Christian
Barry et al.190 2017 Secondary Boys The majority of participants NR
stated that they were ‘white,
white Irish or any other white
background’
Bonhauser et al.122 Secondary Mixed No information provided. Study . . . a low socioeconomic area . . .
2005 was conducted in Santiago, Chile The percentage of the
population living below the
poverty level . . . is 15%
Bouchard et al.148 Primary Mixed NC Schools were representative of
2013 ‘low-, average-, high-, and very
high-income neighbourhoods’
Britton et al.123 Secondary Mixed NC an independent Quaker school
2014
Burckhardt et al.124 Secondary Mixed NC . . . schools were among the
2015 highest . . . socioeconomic status
compared to other schools
in Australia
Burckhardt et al.191 Secondary Mixed NC 76% of the students were in the
2016 top quartile of socio-economic
advantage
Calear et al.125 Secondary Mixed 94% of participants stated that . . . a mix of public, private,
2009 English was their first language. coeducational, single-sex,
Other languages were Chinese, metropolitan, and rural schools
Hindi, Arabic and Indonesian from six Australian states
Calear et al.126 Secondary Mixed 88% reported that English NC
2016 was their first language.
Other languages reported
were Chinese, Vietnamese, Indian
and Arabic
Calear et al.127 Secondary Mixed 97% of participants reported NC
2016 English as their first language
Cardemil et al.208 Primary Mixed School 1: 77.2% Latino, 11.7% School 1: 95.3% of students from
2007 African American, 7.8% Caucasian low-income households
and 2.8% Asian
School 2: 89.8% of students from
School 2: 98.9% African low-income families
American, 0.6% Asian, 0.2%
Latino and 0.2% Caucasian
Chaplin et al.192 Secondary Girls Mostly white (88.7%), with Median family annual income
2006 4.1% African American, 1.5% was ≥ US$100,000
Latino, 1% Asian American
and 4.6% more than one race
or ethnicity
continued
253
APPENDIX 7
Clarke et al.193 Secondary Mixed 90% of enrolled students . . . schools were located in
1993a identified as White predominantly middle-class
neighborhoods
Clarke et al.193 Secondary Mixed 90% of enrolled students . . . schools were located in
1993b identified as White predominantly middle-class
neighborhoods
Collins et al.149 Primary Mixed Participants were described as 6.9% of students were eligible
2014 98% British white for free school meals
. . . schools were located in
relatively affluent suburbs
Dadds and Roth303 Primary Mixed 86.8% of participants were The majority of participants
2008 described as white, Anglo-Saxon are described as ‘working to
middle class’
Eather et al.340 Secondary Mixed NC NC
2016
Essau et al.150 2012 Primary Mixed The majority were of German 72% of parents reported having
origin (95%). Others identified a high school or equivalent
Southern and Eastern European educational level
backgrounds. A total of 63%
identified as catholic and 10.9%
as protestant
Gallegos151 2008 Primary Mixed The study was conducted in the The author described most
metropolitan area of Monterrey, people living in the local area as
Northern Mexico. No further being of a medium SES, ‘ranked
information is given as number 6’ [Instituto Nacional
de Estadística Geografía e
Informática (INEGI; National
Institute of Statistics, Geography,
and Information)]
Gillham209 1995 Primary Mixed NC NC
Gillham et al.128 Secondary Mixed Most students stated that they Suburban Philadelphia
2006 were from Caucasian backgrounds.
Two students were of African A total of 47% had household
American descent, one of Asian incomes of > US$100,000, 34%
descent, and one student defined of US$60,000–99,999. 19% of
their ethnicity as ‘other’ < US$60,000
Gillham et al.194 Secondary Mixed The majority of students School 1: 39% reported income
2007 were of Caucasian descent, of > US$100,000; 72% of
< 10% African American descent, > US$60,000. In schools 2 and 3,
< 2% Latino descent and 84% and 66%, respectively,
< 3% Asian descent reported family income of
< US$60,000
Gucht et al.129 2017 Secondary Mixed The study was conducted NC
in a Dutch-speaking region
of Belgium
Haden et al.341 Primary Mixed Study was conducted in New York Most participants had a household
2014 Most participants were . . . White income in the US$10,000–75,000
or > US$125,000 range
Hiebert et al.130 Secondary Mixed The study was conducted in NC
1989 a large suburban area in
Western Canada
254

Hodas131 2016 Secondary Girls School 1: 72% of students were School 1: affluent households
Caucasian ‘. . . who are able to afford the
nearly US$27,000 annual tuition’
School 2: 45% of students were
African American and 43% were School 2: economically diverse
Caucasian
Horowitz et al.195 Secondary Mixed 79% Caucasian, 13% African Students came from working to
2007 American, 2% Latino, 1% Asian middle class communities
American, 1% Native American,
3% mixed heritage
Johnson et al.132 Secondary Mixed NC 16.2% low SES, 39% medium
2016 SES, 44.8% high SES
Johnson et al.133 Secondary Mixed NC . . . a broad range of
2017 socioeconomic (SES)
demographics
Johnstone et al.152 Primary Mixed NC Schools were in the ‘poorest
2014 (bottom 30%) in the Western
Australian Department of
Education and Training School
Database’
Khalsa et al.239 Secondary Mixed Students attending the school A total of 17% of students were
2012 were described as ‘90% white’ described as from a low-income
population
Kindt et al.196 2014 Secondary Mixed The authors report that Schools were eligible for the
approximately 50% of study if ≥ 30% of their students
participants were classed as came from low-income areas
being an ‘ethnic minority’
Lock and Barrett134 Secondary Mixed NC The schools were described as
2003 being ‘socio-economically
diverse’
Lowry-Webster Secondary Mixed NC No details on SES were given.
et al.135 2001 The study was conducted in
catholic schools in the Brisbane
metropolitan area
Mendelson et al.210 Primary Mixed A total of 83.5% of students self- No details on SES were given.
2010 identified as African American, Study was conducted in
4.1% as Latino, 4.1% as white, Baltimore City public schools
and 7.2% as ‘mixed race’
Merry et al.197 Secondary Mixed Children attending the school School 1 was in a lower
2004 were predominantly from Maori socioeconomic urban area;
and Pakeha backgrounds school 2 was in a middle-class
rural district
Miller et al.153 2010 Primary Mixed . . . a population that spoke . . . an unemployment rate of
English in 88% of homes . . . 5.5% . . .
Miller et al.154 2011 Primary Mixed 36% Canadian aboriginal – First NC
Nations, Native American, Metis,
and Inuit
Miller et al.154 2011 Primary Mixed 18% spoke a language other NC
than English in the home
continued
255
APPENDIX 7
Pahl and Barrett242 Primary Mixed NC A total of 19% of families had an

2010 annual income of < US$40,000,
38.7% between US$40,001 and
$80,000, and 28% between
US$80,001 and US$100,000
Pattison and Lynd- Primary Mixed NC The study is described as being
Stevenson155 2001 based in ‘a rural town south of
Adelaide’
Perry et al.136 2017 Secondary Mixed Roughly 43% spoke a language Participants were from selective
other than English at home and partially selective state/
public funded schools in
metropolitan Sydney, Australia
Pophillat et al.156 Primary Mixed NC ‘. . . a very low socioeconomic
2016 status area in Perth,’ Western
Australia
Pössel et al.198 Secondary Mixed NC NC
2004
Pössel et al.199 Secondary Mixed NC . . . a wide range of social classes
2011 is likely to be represented . . .
economically different regions of
the area are represented
Pössel et al.200 Secondary Mixed The sample was 72.8% Participants were working to
2013 Caucasian, 14.7% African middle class. A total of 29% of
American, 5.4% Latino, 1.4% the students were eligible for
Asian/Pacific Islander, 0.8% free or subsidised school meals
Native American, 4.4% mixed
heritage, and 0.6% ‘other’
Potek et al.137 2012 Secondary Mixed Total sample was 77.4% white; NC
16.1% black; 3.2% Latino and
3.2% East Asian
Quayle et al.211 Primary Girls NC The study was conducted in a
2001 private girls’ school in a high
socioeconomic suburb of Perth,
Western Australia
Raes et al.201 2014 Secondary Mixed NC NC
Reynolds et al.233 University Mixed Participants were 57.7% white, NC
2011 12.7% African American, 11.3%
Hispanic, 8.5% Asian or Pacific
Islander, 5.6% Asian Indian and
4.2% self-identified as ‘other’
Rivet-Duval et al.202 Secondary Mixed A total of 97.5% of participants Household income: 10%
2011 were Mauritian and were ‘. . . < Rs5000, 19% between Rs5000
representative of the ethnic and Rs15,000, 33% between
(primarily Creole, Hindu and Rs15,000 and Rs25,000 and 38%
Muslim) and religious (primarily > Rs25,000
Christian, Hindu and Muslim)
backgrounds of the Mauritian
population’
256

Roberts et al.138 Secondary Mixed Participants were 74% Australian, Mothers’ and fathers’ level of
2003 3% Australian Aboriginal, 5% UK education, respectively:
and Ireland, 3% European,
0.5% other non-English speaking l less than grade 10: 9%
and 15% not stated and 10%
l between grades 10 and 12:
52% and 39%
l grade 12: 18% and 17%
l vocational college: 20%
and 16%
l university: 5% and 6%
Roberts et al.139 Secondary Mixed Participants were 44% . . . schools were . . . sampled
2010 Australian, 4% other English from the lowest decile of
speaking, 7% other non-English socio-economic status based on
speaking and 44% not stated the Census Index of Relative
Socio-economic Status
Annual family income (Aus$):

14% < $20,000, 30%
$20,000–50,000; 13% > $50,000
and 43% not stated
Roberts et al.240 Primary Mixed Participants were 80.7% NC
2018 Australian, 1.7% Australian
Aboriginal, 9.2% other English-
speaking countries, 5% Asian,
1.9% European, and 1.5% other
non-English speaking countries
Rodgers and Secondary Mixed School 1: 68% white Irish, 18% . . . a socially disadvantaged
Dunsmuir140 2015 Irish travelling community and catchment area in a major city
14% foreign nationals in Ireland
School 2: 92% white Irish,

0% Irish travelling community
and 8% foreign nationals
School 3: 88% white Irish,

0% Irish travelling community
and 12% foreign nationals
Rooney et al.157 Primary Mixed NC The study was conducted in
2006 schools in ‘low socioeconomic
areas’
Rose et al.203 2014 Secondary Mixed Mixed Mixed
Ruttledge et al.158 Primary Mixed NC Mixed
2016
Sawyer et al.204 Secondary Mixed NC 81% of participants had
2010 at least one parent in full-time
employment
Shatté205 1997 Secondary Mixed NC NC
141
Sheffield et al. Secondary Mixed . . . a broad range of social and NC
2006 cultural backgrounds, consistent
with the Australian population . . .
Soffer212 2003 Primary Mixed Participants were 60% Caucasian, Average Hollingshead Index:
14% African American, 8% 35.37 (SD 11.67). Most parents
Hispanic American, 8% Asian reported occupations in the
American, 4% mixed ethnicity and middle-income range
6% other ethnicity
continued
257
APPENDIX 7
Spence et al.206 Secondary Mixed 90.1% of the students were Average SES score was 4.55
2003 born in Australia (SD 2.66). The authors describe
this as ‘typical of the SES
Other students reported a distribution of Australia’ and
‘variety of ethnic backgrounds ‘. . . indicative of lower middle SES’
typical of the Australian
population’
Stallard et al.142 Secondary Mixed . . . were representative of . . . schools were representative
2013 schools in the United Kingdom of schools in the United
for ethnicity Kingdom for deprivation
(eligibility for free school meals),
pupil absence rates, and
academic ability (examination
results and proportion of
children with identified special
educational needs)
Stallard et al.159 Primary Mixed Participants were 94% white ‘Family affluence’: 2% low;
2014 British, 6% ‘non-white’ 29% medium; 69% high.
Eligibility for free school meals
was lower than the national
average (12.4% vs. 18.2%)
Tak et al.207 2016 Secondary Mixed A total of 79% described as NC
Dutch, 21% ‘other’ and 16.9%
were from ethnic minorities. The
authors note this is lower than
the general population (20.3 %)
Tomba et al.143 Secondary Mixed NC NC
2010
Velásquez et al.189 Mixed Mixed Study was conducted in Bogotá, . . . a disadvantaged area
2015 (primary/ Colombia
secondary)
Wong et al.144 2014 Secondary Mixed NC NC
TABLE 71 Socioeconomic status, sex and ethnicity as extracted from authors’ reports: targeted interventions
Study Setting Sex Ethnicity SES
Arnarson and Secondary Mixed NC NC

Craighead213
2009
Balle and Secondary Mixed NC NC

Tortella-Feliu160
2010
Berry and Hunt161 Secondary Boys 74% of families were of an 54% of parents had not
2009 Anglo-Saxon, 17% were of completed tertiary education;
Middle Eastern and 9% were 76% were from lower to middle-
from an Asian ethnic background class backgrounds as classified
by annual income
Clarke et al.214 Secondary Mixed 92.5% of participants were Median parent education was
1995 ‘non-Hispanic white’ 1 to 2 years of college
Congleton215 Secondary Mixed 92% of participants were 25% of participants received

1995 described as ‘Caucasian’ subsidised or free school meals
258

TABLE 71 Socioeconomic status, sex and ethnicity as extracted from authors’ reports: targeted interventions (continued )
Cooley-Strickland Primary Mixed 92% African American, The schools in this study were in
et al.174 2011 8% ‘biracial’ disadvantaged areas. 90% of the
students in the schools received
subsidised or free school meals
Cova et al.162 Secondary Girls NC NC

2011
Cowell et al.231 Primary Mixed Not specifically referenced. 80% of families reported annual
2009 However, schools were selected incomes of < US$26,000
if the student body was ≥ 30%
from Latino ethnic backgrounds
Cui et al.183 2016 University Mixed NC NC

163
Dobson et al. Secondary Mixed NC NC
2010
Ellis et al.184 2011 University Mixed NC NC (participants were university

students)
Fitzgerald Secondary Mixed 93% white; 2% black; 2% Asian; Classified using ‘School
et al.114 2016 0% Irish Traveller; 1% other and disadvantage status’ (DEIS):
2% unknown non-DEIS 82%; DEIS 18%
Fung et al.216 Secondary Mixed 52.6% of students described No details on participants but
2016 themselves as self-identified school district in an ethnically
Latino and 47.4% as Asian diverse, low-income area
American
Gaete et al.164 Secondary Mixed NC The majority of participants

2016 were from ‘low socio-economic
families’
Gillham et al.165 Secondary Mixed Less than 1% Native American, Reported mothers’ and fathers’
2012 4% Asian, < 1% Pacific Islander/ education level. The majority
Native Hawaiian, 12% African had 'some college' education
American, 77% European and above (respectively): 79%
American, 3% Latino/a, 4% other and 69%
Hiebert et al.130 Secondary Mixed NC NC

1989
Higgins185 2007 University Mixed 95% of participants described NC

themselves as Caucasian, 2.6%
as Asian, 1.3% as African
American and 1.3% as other
Hunt et al.166 Secondary Mixed No information given. Schools NC

2009 were Catholic secondary schools
in Sydney
Jaycox et al.232 Primary Mixed Details provided for the Total family income (intervention
1994 intervention group: 80% group):
Caucasian, 17% African
American, 3% other l 16%, < US$20,000
l 44%, US$20,001–40,000
l 26%, US$40,001–60,000
l 7%, US$60,001–80,000
l 7%, > US$80,000
continued
259
APPENDIX 7
Jordans et al.167 Secondary Mixed l Caste/ethnicity (Nepal): 45% Details of family income not
2010 Brahmin/Chhetri/Thakuri provided. Nepal is classified as
l 25% Tharu a LIC
l 16% Terai caste
l 8% Dalit
l 7% other Jannajati
Kiselica et al.168 Secondary Mixed White Participants lived in an area

1994 described as ‘middle-class and
lower middle-class’
Liddle and Mixed Mixed NC (Scottish setting) NC

Macmillan188 (primary/
2010 secondary)
Livheim et al.217 Secondary Girls NC NC

2015
Manassis Primary Mixed Ethnicity as reported by families Our sample was [. . . ]

et al.175 2010 was 56.8% Caucasian, 12.8% economically diverse
Asian, 8.1% East Indian, 6.8%
Hispanic, 5.4% Filipino, 3.3%
black, and 6.8% mixed/other
McCarty Secondary Mixed Details provided for intervention Parental education was reported
et al.218 2011 group: for the intervention group: 64%
had a bachelor’s degree or
l 67% white higher
l 3% African American
l 6% Asian
l 6% Native American
l 19% other
3% of particpants described
themselves as Hispanic and 97%
as non-Hispanic
McCarty et al.219 Secondary Mixed Details provided for in l Parental education in

2013 intervention group: intervention group: 52% high
school diploma/some college;
l 63% white 23% bachelor’s degree;
l 5% African American 26% higher degree
l 15% Asian l Annual household income
l 8% Native American (intervention group): 38%,
l 2% Native Hawaiian/ < US$50,000; 26%,
Pacific Islander US$50,000–100,000; 36%,
l 8% other > US$100,000
7% of participants described
themselves as Hispanic and 93%
as non-Hispanic
McLaughlin236 Mixed Mixed 94% Caucasian, 2% Hispanic, Information not provided for
2011 (primary/ 2% African American, 2% Asian sample. 11% of students in the
secondary) and/or Pacific Islander, and < 1% school district were eligible for
American Indian subsidised or free school meals
McLoone Primary Mixed NC Reported for school-based

et al.176 2012 intervention group, mothers' and
fathers' occupational status
(respectively): 25% and 2%
unemployed, 32% and 15%
trade/clerical, 44% and 84%
professional
260

Mifsud and Primary Mixed Reported for the intervention Sample details not reported.
Rapee177 2005 group: 78% Australian, 17% Intervention was run in
other country, 5% Aboriginal areas with high levels of
socioeconomic disadvantage
Miller et al.178 Primary Mixed Ethnicity not reported. However, NC

2011 48% of the sample did not speak
English as their first language
with their families (18% spoke
Chinese, proportion of other
languages not reported)
Noël et al.220 Secondary Girls Reported for intervention group NC

2013 only: 80% African American,
15% non-Hispanic white and
5% Hispanic
Owen and Secondary Boys NR NR

Lanning169
1982
Peden et al.234 University Girls NC NC

2000
Peng et al.170 Secondary Mixed NC NC

2015
Poppelaars Secondary Girls Detail not reported. Authors NC

et al.221 2016 state that 94.7% of participants
had been born in the
Netherlands
Puskar et al.222 Secondary Mixed NC NC

2003
Rice171 2009 Secondary Mixed NC NC

Rohde et al.223 Secondary Mixed The participants are described Parental education 39% high
2014 as 6% Hispanic, 2% Asian school graduate or less, 26%
Americans, 1% African some college, 22% college
Americans, 72% Caucasian, 1% graduate and 13% graduate
Native American and 18% other degree
or mixed ethnic background
Scholten Secondary Mixed Authors state that 97.8% of ‘The majority’ of students in the
et al.172 2016 participants had been born in the sample were academically high
Netherlands achievers (‘high streamed
education tracks’)
Schoneveld Primary Mixed 89.7% of participants were 'of NC

et al.115 2016 Dutch descent'
Schoneveld Primary Mixed 91.4% of participants had been NC
et al.116 2018 born in the Netherlands
Seligman University Mixed NC NC

et al.186 1999
Seligman University Mixed NC NC

et al.187 2007
continued
261
APPENDIX 7
Sheffield et al.141 Secondary Mixed Sample specific details not NC

2006 provided. Authors state that
sample reflected the Australian
population for social and cultural
background
Simpson179 2008 Primary Mixed 56% ‘Caucasian’, 38% Asian/ Household annual income: 35.2%
South Asian descent and 6% > CAN$80,000 and 24.6%
were from other or mixed < CAN$35,000. Mothers’
ethnic backgrounds education: 68.5% some post-
secondary education, 14% did
not complete high school and
8.8% completed high school.
Fathers’ education: 40% some
post-secondary education, 19.3%
did not finish high school and 7%
finished high school
Siu180 2008 Primary Mixed NC NC
Sportel et al.117 Secondary Mixed NC NC

2013
Stallard et al.142 Secondary Mixed Information not explicitly Specific details not reported.
2013 provided. However, the schools However, schools are described
are described as ‘representative as 'representative of schools
of schools in the United in the United Kingdom for
Kingdom for ethnicity' deprivation pupil attendance and
academic ability’
Stice et al.237 Mixed Mixed 17% Asians, 6% blacks, 55% Parental education level: 20%
2007 (secondary/ ‘Caucasian’, 15% Hispanics, 7% high school graduate or less,
university) other/mixed ethnic background 20% some college, 34% college
graduate, 26% graduate degree
Stice et al.224 Secondary Mixed 2% Asian, 9% African American, Parental education level: 26%
2008 46% ‘Caucasian’, 33% Hispanic high school graduate or less,
and 10% other/mixed ethnic 17% some college, 35% college
heritage graduate, 18% graduate degree
Stoppelbein225 Secondary Mixed 88% ‘Caucasian’, 10% African SES: 18% lower, 22% lower
2003 American, 2% Asian American middle, 51% middle, 9% upper
middle
Takagaki University Mixed NC NC

et al.235 2016
Tokolahi et al.181 Primary Mixed 35% New Zealand English, 16% NC

2018 Maori, 18% Pacific, 10% Asian,
20% other
Topper et al.173 Secondary Mixed NC NC

2017
van Starrenburg et Primary Mixed 92.9% of participants and 90.8% Mothers’ education level:
al.182 2017 of their mothers were born in 55% completed a vocational
the Netherlands education, 25% had college or
higher education. 40% of the
families had a household income
considered ‘low to average’
Wijnhoven Secondary Girls 98% of the participants were NC

et al.226 2014 ‘of Dutch origin’
262

Woods and Secondary Mixed 45% of participants identified Schools were representative of a
Jose227 2011 themselves as Maori and 55% as range of SESs
Pacific
Young et al.228 Secondary Mixed 92.7% of participants identified [H]alf reported a gross
2006 as Hispanic household income of $25,000
or less
Young et al.229 Secondary Mixed 73.7% Hispanic, 39% African NC

2010 American
Young et al.230 Secondary Mixed 19.9% African American, 4.3% Participants reported a wide
2016 Asian and 8.1% other/mixed range of annual household
race. 38.2% Hispanic and incomes: 17.3% < US$25,000,
38.2% white ‘non-minority, 38.4% US$25,000–90,000, and
non-Hispanic’ 44.3% > US$90,000
Yu238 2002 Mixed Mixed NC Intervention group parental

(primary/ education level: (father and
secondary) mother, respectively) 5% and 4%
primary school, 9% and 6%
junior school, 29% and 34%
senior school, 28% and 45%
college, 28% and 11% more than
college. Intervention group
parental income level: 17%
< 1000 yuan; 25% 1001–2000
yuan; 24% 2001–3000 yuan;
17% 3001–4000 yuan; 17%
> 4001 yuan
NC, not clear; NR, not reported.
Intervention attendance and engagement
Table 72 reports student attendance figures, as reported by trial author.
TABLE 72 Attendance data for each study as reported by study author
Study Attendance
Ahlen et al.145 2018 Non-attendance ranged between 4.2% and 6.1% (at class level)
Araya et al.118 2013 80.5% of intervention group participants attended ≥ 6 sessions
Bonhauser et al.122 2005 Authors report that 87% of the sessions were completed
124
Burckhardt et al. 2015 8.0% of intervention group participants did not return any of their workbooks
from any of the sessions, 15.5% returned 1–2 workbooks, 20.8% returned
3–4 workbooks and 55.6% returned 5–6 session workbooks
Calear et al.125 2009 62% of the intervention group completed three or more sections (‘modules’) of
the intervention. 32.7% completed all sections. [mean number of sections
completed, 3.16 (SD 1.68)]
Calear et al.126 2016 School-based intervention: 78% completed 2 weeks, 43% completed at least
4 weeks and 36% completed all 6 weeks of the intervention. Health service
intervention: 87% completed 2 weeks, 65% completed at least 4 weeks and
50% completed all 6 weeks of the intervention
continued
263
APPENDIX 7
TABLE 72 Attendance data for each study as reported by study author (continued )
Study Attendance
Calear et al.127 2016 45% completed all 6 weeks of the intervention
Chaplin et al.192 2006 Single-sex PRP intervention: attendance mean = 7.03 sessions (SD 4.15).
Co-educational PRP intervention: attendance = mean 5.04 sessions (SD 3.56)
Clarke et al.214 1995 Average intervention group attendance = 72% (range 13% to 100%)
Congleton215 1995 Except for one participant, all attended at least six of the eight sessions; 69%
attended all eight sessions
Cooley-Strickland et al.174 2011 All participants attended at least 12 of the 13 sessions
Cova et al.162 2011 Universal intervention: 76.5% of the participants attended eight or more
sessions; 3.4% attended six or fewer sessions (mean = 8.86 sessions). Indicated
intervention: in the indicated modality of the programme, 43% attended six or
fewer sessions and 8.9% did not attend any session (mean = 6 sessions)
Cowell et al.231 2009 Participants in the north side intervention groups attended an average of eight
classes. Participants in the south side intervention group received an average of
4.72 classes (t = −2.47, df = 109, p = 0.02)
Cui et al.183 2016 Cognitive behavioural intervention: 56% of participants attended all eight
sessions and 85% attended at least six sessions. Supportive group intervention:
53% of participants attended all sessions and 82% attended at least six sessions
Eather et al.340 2016 Across all sessions the attendance was 94% for the intervention group
Essau et al.150 2012 21 children missed one session, 14 missed two sessions, and 6 missed three
sessions. All children missing as session had a 1 : 1 catch-up session before their
next group session. All these children received an individual session before
joining the next group session
Fung et al.216 2016 The average number of sessions attended was 10.28 out of 12 sessions
(85.63%)
Gaete et al.164 2016 An average of 55.5% participants attended each session (SD = 5.9; range,
45.0–66.4%)
Gillham et al.128 2006 Average number of sessions attended was 5.5 out of eight; 14% of participants
attended two or fewer sessions; 45% of participants attended seven or more
sessions
Gillham et al.194 2007 PRP intervention: average number of sessions attended was 6.71 (SD = 4.22);
16% did not attend any sessions. PEP intervention: average number of sessions
attended was 7.11 (SD = 4.43); 15% of participants did not attend any sessions
Gillham et al.165 2012 84% of students attended at least one session of the main intervention and
44% attended the booster session at 5 months
Johnson et al.132 2016 87% of participants attended six or more out of the eight sessions
133
Johnson et al. 2017 For the first two sessions, attendance was 40%. By the end of the intervention,
involvement was 9%
Johnstone et al.152 2014 The average number of sessions attended was 9.03 (SD 2.143)
239
Khalsa et al. 2012 73.4% of sessions were attended (SD 0.2%)
Livheim et al.217 2015 Acceptance and commitment intervention: attended an average of 5.8 out of
eight sessions
McCarty et al.218 2011 94% of parents received three or more sessions (out of four)
McCarty et al.219 2013 85% of parents participated in both home visit sessions, 38% attended both
parent workshop sessions, 22% attended one workshop and 40% did not attend
either workshop
264

Study Attendance
Mendelson et al.210 2010 Intervention attendance varied by school. School 1: 73.5% completed at least
75% of sessions and school 2: 40% of students attended 75% of sessions
Mifsud and Rapee177 2005 A mean of 7.38 of eight sessions were attended (SD 0.58) by students
Perry et al.136 2017 88% of participants completed at least four sessions
Poppelaars et al.221 2016 Participants completed an average of 6.77 (SD 1.17) out of eight lessons.
All participants received at least four sessions
Pössel et al.200 2013 Cognitive–behavioural prevention programme: participants attended a mean
of 8.5 (SD 2.3) sessions. Non-specific control: mean of 8.6 (SD 2.0) sessions
were attended
Puskar et al.222 2003 Students attended an average of nine sessions
Quayle et al. 211

2001 Most participants attended ‘three or four sessions.’ 8.3% of participants
attended seven sessions and 21% attended five or more sessions
Roberts et al.138 2003 Attendance ranged from 87% to 99% over the 12 sessions
139
Roberts et al. 2010 SLS intervention: 5.2% of students missed at least 25% of the sessions. OTS
intervention: 9% of students missed at least 25% of the sessions
Rohde et al.223 2014 Cognitive behavioural intervention: participants attended an average of 5.3
sessions (SD 0.9); 48% attended all six sessions. All students received at least
three sessions
Schoneveld et al.115 2016 80.9% of participants completed all game sessions. Mean = 4.71 sessions
(SD 0.69)
Seligman et al.186 1999 85% of participant attended the workshop

187
Seligman et al. 2007 84% of participant attended the workshop
Sheffield et al.141 2006 (universal) Mean number of sessions attended was > 90%
Sheffield et al.141 2006 (indicated) Mean attendance rate was 75% of the sessions
180
Siu 2008 Only eight students missed one session
Sportel et al. 117
2013 A small proportion of participants (n = 16) did not complete the intervention
Stallard et al.142 2013 Classroom-based CBT intervention: median sessions attended was 89%
(quartiles 67–100%); 80% of students attended at least 60% of planned
sessions. Attention control group: median sessions attended was 100%
(quartiles 88–100); 95% of students attended at least 60% of sessions
Stallard et al.159 2014 Classroom CBT intervention: 80% of participants attended at least 60% of the
sessions. Attention control group: 93% of participants attended at least 60% of
the sessions
Stice et al.224 2008 Cognitive–behavioural intervention: 44% of participants attended all sessions;
86% attended at least three of the six sessions. Supportive group intervention:
45% attended all sessions; 89% attended at least three of the six sessions
Tak et al.207 2016 Attendance data for main intervention not reported. However, 67.8% of
participants completed the booster session
Takagaki et al.235 2016 98.4% of participants completed all sessions
Topper et al.173 2017 Group intervention: mean number of sessions attended was 4.59 (SD 1.43).
Internet intervention: mean number of sessions attended was 3.96 (SD 1.65)
Velásquez et al.189 2015 21 participants were classified as low attenders and 47 were classified as high
attenders
Young et al.228 2006 Intervention participants attended a mean of 6.9 sessions (SD 1.0)
continued
265
APPENDIX 7
Study Attendance
Young et al.229 2010 IPT-AST intervention: participants attended an average of 5.22 group sessions
(SD 2.55). School counselling intervention: students attended an average of
3.76 sessions (SD 2.53)
Young et al.230 2016 IPT-AST intervention: mean number of sessions attended by participants was
6.80 (SD 1.85). Group counselling intervention mean sessions attended was
6.18 (SD 1.85)
CB, cognitive–behavioural; GC, group counselling; IPT-AST, Interpersonal Psychotherapy-Adolescent Skills Training;
IT, information technology; M, mean; ns, not significant; OTS, optimistic thinking skills; OVK, Op Volle Kracht;
PEP, Penn Enhancement Program; PRP, Penn Resilience Program; PTA, Positive Thoughts and Actions; SC, school counselling.
266

Appendix 8 Economic evaluation

Search carried out in the NHS Economic Evaluation Database
NHS Economic Evaluation Database (1968 to 2014) was searched on 22 May 2019.
Search strategy
1. MeSH DESCRIPTOR child, preschool

2. MeSH DESCRIPTOR child
3. MeSH DESCRIPTOR adolescent
4. MeSH DESCRIPTOR young adult
preadolesc* or pre-adolesc* or pubert* or pubescen* or prepube* or pre-pube* or teen* or (young
NEAR0 (adult* or people or patient* or men or women or man or woman or male* or female* or
survivor* or offender* or minorit*)) or youth* or student* or undergrad*)
6. (child* or adolesc* or paediatr* or pediatr*):so
7. #1 OR #2 OR #3 OR #4 OR #5 OR #6
8. MeSH DESCRIPTOR education
9. MeSH DESCRIPTOR schools
10. MeSH DESCRIPTOR schools, nursery
11. MeSH DESCRIPTOR school health services
12. MeSH DESCRIPTOR school nursing
13. MeSH DESCRIPTOR students
14. MeSH DESCRIPTOR universities
15. preschool or kindergarten or school* or college* or campus* or classroom* or curricul* or teacher*
or gatekeeper* or pupil*
16. MeSH DESCRIPTOR peer group
17. ((peer or peers) NEAR0 (education or group or relation* or support* or intervention* or leader*))
18. student* union
19. ((church or communit* or holiday* or religi* or spiritual* or youth or vacation) NEAR1 (camp or
club or group))
20. ((camp or club or group) NEAR1 (church or communit* or holiday* or religi* or spiritual* or youth
or vacation))
21. ((church or communit* or holiday* or religi* or spiritual* or youth or vacation) NEAR0 based)
22. #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19
OR #20 OR #21
23. MeSH DESCRIPTOR adaptation, psychological
24. MeSH DESCRIPTOR emotions
25. MeSH DESCRIPTOR mental health
26. MeSH DESCRIPTOR social adjustment
27. MeSH DESCRIPTOR stress, psychological EXPLODE ALL TREES
28. mental health or mental* ill* or psychiatric
29. wellbeing or well being
30. stress* or distress*
31. #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30
32. MeSH DESCRIPTOR depression
33. MeSH DESCRIPTOR depressive disorder
34. MeSH DESCRIPTOR mood disorders
35. (depress* or dysthymi* or affective disorder* or affective symptom* or mood* or mental):ti
267
APPENDIX 8
36. (depress* NEAR1 (adolescent* or child* or anaclitic* or episode* or disorder or scale* or score* or
symptom* or unipolar)) or ((adolescent* or child* or anaclitic* or episode* or disorder or scale* or
score* or symptom* or unipolar) NEAR1 depress*)
37. ((depress* or mood* or mental or psychological or wellbeing or well being or emotion*) NEAR1
(improve* or onset or prevent* or reduc*)) or ((improve* or onset or prevent* or reduc*) NEAR1
(depress* or mood* or mental or psychological or wellbeing or well being or emotion*)) 780
38. (Axis 1 or Axis I) NEAR0 disorder*
39. #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38
40. MeSH DESCRIPTOR anxiety disorders EXPLODE ALL TREES
41. MeSH DESCRIPTOR anxiety
42. anxi*:ti
43. (anxi* NEAR2 (adolescent* or child* or disorder* or general* or interpersonal or separation or
social*)) or ((adolescent* or child* or disorder* or general* or interpersonal or separation or
social*) NEAR2 anxi*)
compulsi* or GAD or stress disorder* or stress reaction* or acute stress or neurosis or neuroses
or neurotic or psychoneuro* or (school NEAR1 (refusal or avoid*)) or ((refusal or avoid*) NEAR1
school) or social avoidance or mutism)
45. (((anxi* or fear or fright) NEAR2 (perform* or athlet* or music* or act* or test* or exam*)) or math*
anxiety or ((perform* or athlet* or music* or act* or test* or exam*) NEAR2 (anxi* or fear
or fright)))
46. (public NEAR2 (speak* or speech)) or ((speak* or speech) NEAR2 public)
47. #40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46
48. MeSH DESCRIPTOR conduct disorder
49. MeSH DESCRIPTOR child behavior disorders
50. MeSH DESCRIPTOR juvenile delinqency
51. MeSH DESCRIPTOR social behavior
52. MeSH DESCRIPTOR social behavior disorders
53. ((behavi* or conduct or personalit*) NEAR1 (agressi* or nonagressi* or antisocial or anti social
or dyssocial or defiant or delinquen* or disturb* or disrupt* or disorder* or internalising or
internalizing or externalising or externalizing or problem*)) or ((agressi* or nonagressi* or
antisocial or anti social or dyssocial or defiant or delinquen* or disturb* or disrupt* or disorder*
or internalising or internalizing or externalising or externalizing or problem*) NEAR1 (behavi* or
conduct or personalit*))
54. ((conduct or behavi* or antisocial or anti social or dyssocial or emotional* or internalising or
internalizing or externalising or externalizing) NEAR2 (problem* or difficult* or psychopathol*)) or
((problem* or difficult* or psychopathol*) NEAR2 (conduct or behavi* or antisocial or anti social
or dyssocial or emotional* or internalising or internalizing or externalising or externalizing))
55. oppositional NEAR2 (defiant* or disorder*)
56. #48 OR #49 OR #50 OR #51 OR #52 OR #53 OR #54 OR #55
57. MeSH DESCRIPTOR preventive health services
58. MeSH DESCRIPTOR early intervention (education)
59. MeSH DESCRIPTOR health literacy
60. MeSH DESCRIPTOR patient education as topic
61. MeSH DESCRIPTOR health promotion
62. MeSH DESCRIPTOR primary prevention
63. MeSH DESCRIPTOR secondary prevention
64. prevent*:ti
65. prevention of
66. (prevent* NEAR1 (intervention or educat* or pilot or program* or project or protocol* or training
or universal or targeted or primary or secondary or selective or indicated or study or trial)) or
((intervention or educat* or pilot or program* or project or protocol* or training or universal or
targeted or primary or secondary or selective or indicated or study or trial) NEAR1 prevent*)
268

67. (early or brief) NEAR0 intervention*

68. ((universal or targeted) NEAR1 (program* or intervention*))
69. vulnerabl* or at risk or (risk NEAR1 reduc*) or (reduc* NEAR1 risk)
70. MeSH DESCRIPTOR risk
71. MeSH DESCRIPTOR risk factors
72. MeSH DESCRIPTOR accidents EXPLODE ALL TREES
73. MeSH DESCRIPTOR bereavement
74. MeSH DESCRIPTOR grief
75. MeSH DESCRIPTOR social problems
76. MeSH DESCRIPTOR bullying
77. MeSH DESCRIPTOR child of impaired parents
78. MeSH DESCRIPTOR child, orphaned
79. MeSH DESCRIPTOR crime victims
80. MeSH DESCRIPTOR disasters EXPLODE ALL TREES
81. MeSH DESCRIPTOR divorce
82. MeSH DESCRIPTOR life change events
83. MeSH DESCRIPTOR runaway behavior
84. MeSH DESCRIPTOR urban population
85. MeSH DESCRIPTOR rural population
86. MeSH DESCRIPTOR survivors
87. MeSH DESCRIPTOR violence
88. MeSH DESCRIPTOR warfare
89. MeSH DESCRIPTOR civil disorders EXPLODE ALL TREES
90. MeSH DESCRIPTOR crime EXPLODE ALL TREES
91. MeSH DESCRIPTOR human rights abuses EXPLODE ALL TREES
92. MeSH DESCRIPTOR parental death EXPLODE ALL TREES
93. MeSH DESCRIPTOR poverty
94. MeSH DESCRIPTOR social behavior disorders EXPLODE ALL TREES
95. MeSH DESCRIPTOR domestic violence
96. MeSH DESCRIPTOR child abuse EXPLODE ALL TREES
97. MeSH DESCRIPTOR ethnic violence EXPLODE ALL TREES
98. MeSH DESCRIPTOR physical abuse
99. MeSH DESCRIPTOR terrorism EXPLODE ALL TREES
100. MeSH DESCRIPTOR torture
101. MeSH DESCRIPTOR exposure to violence
102. MeSH DESCRIPTOR warfare and armed conflicts EXPLODE ALL TREES
103. MeSH DESCRIPTOR dissent and disputes
104. MeSH DESCRIPTOR family conflict
105. MeSH DESCRIPTOR psychosocial deprivation
106. #57 OR #58 OR #59 OR #60 OR #61 OR #62 OR #63 OR #64 OR #65 OR #66 OR #67 OR #68
OR #69 OR #70 OR #71 OR #72 OR #73 OR #74 OR #75 OR #76 OR #77 OR #78 OR #79 OR
#80 OR #81 OR #82 OR #83 OR #84 OR #85 OR #86 OR #87 OR #88 OR #89 OR #90 OR #91
OR #92 OR #93 OR #94 OR #95 OR #96 OR #97 OR #98 OR #99 OR #100 OR #101 OR #102
OR #103 OR #104 OR #105
107. MeSH DESCRIPTOR randomized controlled trial
108. MeSH DESCRIPTOR pragmatic clinical trial
109. randomised or randomized or randomisation or randomization
110. (RCT or (random* NEAR2 (administ* or allocat* or assign* or class* or cluster* or control* or
determine* or divide* or distribut* or expose* or fashion or number* or place* or recruit* or substitut*
or treat*)) or ((administ* or allocat* or assign* or class* or cluster* or control* or determine* or
divide* or distribut* or expose* or fashion or number* or place* or recruit* or substitut* or treat*)
NEAR2 random*))
111. at random
269
APPENDIX 8
112. placebo
113. trial
114. #107 OR #108 OR #109 OR #110 OR #111 OR #112 OR #113
115. treatment-as-usual or (treatment* NEAR1 usual) or (usual NEAR1 treatment*) or (standard
NEAR1 care) or (standard NEAR1 treatment) or (routine NEAR1 care) or (usual NEAR1
medication*) or (usual NEAR1 care) or TAU
116. waitlist* or wait-list* or waiting-list* or wait* list* or (waiting NEAR0 (condition or control))
or WLC
117. ((delay* NEAR2 (start or treatment*)) or ((start or treatment) NEAR2 delay*) or no intervention or
no treatment* or no-treatment or non treatment* or nontreatment* or non-treatment* or minim*
treatment* or untreated group* or untreated control* or without any treatment) and (control*
or group*)
118. (no intervention* or non intervention* or non-intervention* or without any intervention*) and
(control* or group*)
119. #115 OR #116 OR #117 OR #118
120. #114 OR #119
121. #7 AND #22 AND (#31 OR #39 OR #47 OR #56) AND #106 AND #120
122. (universal or indicated or targeted or at risk) and prevent* and (anxiety or depress* or conduct)
and (child* or adolesc* or school*)
123. (prevent* NEAR0 (program* or intervention)) and (anxiety or depress* or conduct) and (child* or
adolesc* or school*)
124. #122 OR #123
125. #120 AND #124
126. #121 OR #125
127. #126 IN NHSEED
Scoping search carried out in MEDLINE for economic decision models
As the original literature searches for the effectiveness analyses were conducted for RCTs only, we
conducted an additional scoping search to ascertain if we were likely to have missed publications
of model-based economic analyses. The following search strategy was implemented in MEDLINE.
No additional citations were located, and a full search was not conducted. The scoping search of
MEDLINE was 1946 to present, and the search was carried out on 17 June 2019.
Search strategy
1. decision model*.mp.
2. markov.mp.
3. Decision Trees/or decision tree*.mp.
4. economic model*.mp. or Models, Economic/
5. cohort model*.mp.
6. simulation model*.mp.
7. 1 or 2 or 3 or 4 or 5 or 6
8. depression.mp. or Depression/
9. Anxiety/or anxiety.mp. or Anxiety Disorders/
10. conduct disorder.mp. or Conduct Disorder/
11. 8 or 9 or 10
12. Child Psychiatry/or child*.mp. or Psychology, Child/or Child/
13. adolescent*.mp. or Adolescent Psychiatry/or Adolescent/
14. Young Adult/or young*.mp.
15. 12 or 13 or 14
16. 7 and 11 and 15
270

DOI: 10.3310/phr09080
Characteristics of studies contributing to the economic evaluation
TABLE 73 Studies describing cost-effectiveness analyses of school-based interventions
Study
Mihalopoulos et al.260 Anderson et al.261 Foster and Jones263,264

2012 2014 Foster250 2010 2006 and 2007 Lee et al.259 2017 Stallard et al.262 2015
Condition Depression Depression Conduct disorder Conduct disorder Depression Anxiety
Intervention Indicated Universal Indicated with a universal Indicated with a universal Universal and indicated Universal
type component component
Intervention ‘Representative’ RAP (CBT) Fast Track Fast Track ‘Hypothetical’ intervention FRIENDS (CBT)
intervention, CBT (multicomponent) (multicomponent) (group psychological)
based
Comparator No intervention Usual PSHE Usual provision Usual provision No intervention Usual school provision
Setting (school) Secondary Secondary Primary and secondary Primary and secondary Primary and secondary Primary
Age range 11–17 12–16 6–16 6–17 11–17 9–10

(years)

Type of CUA CEA, CUA CCA CEA CUA CUA, CEA
economic
analysis
Study type Model Trial Trial Trial Model Trial

Model type Markov N/A N/A N/A Markov N/A
Model time 5 years N/A N/A N/A 10 years N/A

horizon
Follow-up N/A 12 months 12–14 years 10 years N/A 6 months
period
Participants (n) N/A 3357 891 891 N/A 308

continued
271
272
APPENDIX 8
TABLE 73 Studies describing cost-effectiveness analyses of school-based interventions (continued )
Study

Cost of AU$47M total £41.96 per child US$58,000 per child US$58,283 per child £55.92 per child for
intervention school led, £52.55 for
health led
Perspective Health sector NHS and social Payer for intervention, Third-party payer Health and education Health sector (NHS) and
care criminal justice, education sector the education/social
services sector
Location Australia UK USA USA Australia UK
Resources Intervention, cost Inpatient stays, Outpatient visits, nights as Intervention only Intervention, ‘cost offsets’ Overnight hospital stays,
included ‘offsets’ defined as A&E attendances, an inpatient, number of (health care) A&E visits, outpatient
average annual outpatient admissions (for emotional/ appointments, GP for any
cost of treating visits, GP for any behavioural or any other reason, GP for worry/
depression, parental reason, GP for reason), medication, anxiety/happiness, GP
time and travel psychological repeating a grade, special nurse, school nurse,
problems, GP education, arrests, court counsellor, child mental
nurse, school appearances, police health service, child
nurse, counsellor, contacts, detention centre psychologist, social
community mental stays, jail stays worker, other
health service, professional, medication
child psychologist,
social worker,
other professional
Unit of N/A Year group School School N/A School

randomisation
Currency Australian dollars GBP US dollars US dollars Australian dollars GBP
Publication 2012 2014 2010 2006/7 2017 2015

year
Trial N/A ISRCTN19083628 NCT01653535 (follow-up) NCT01653535 (follow-up) N/A ISRCTN23563048

registration
DOI: 10.3310/phr09080
Study

Outcomes DALYs averted SMFQ, QALYs Range of antisocial Conduct disorder DALY QALYs
behaviour measures diagnosis averted
Source of N/A EQ-5D Self-reported, parent Diagnostic Interview N/A CHU-9D
outcomes reported, agency records Schedule of Children
Discount 3 N/A N/A 5 3 N/A

rate (%)
Cost year 2003 2014 Not stated 2004 2013 2013
Source of Literature CSRI Parent-completed Service Study records N/A CSRI parent interview
resource use Assessment for Children
and Adolescents,
adolescent self-reported,
review of agency records,
Life Changes assessment
Conclusions After school . . . the universal . . . the intervention Results indicate the School-based . . . find limited evidence
screening, screening provision of lacked both the breadth intervention is cost- psychological to support the universal
and the psychological classroom-based and depth of effects effective for the children interventions appear provision of specific
intervention CBT is unlikely on costly outcomes at highest risk to be cost-effective anxiety prevention

represent good value- to be either to demonstrate programmes in UK
for-money. Such an more effective cost-effectiveness or primary schools.
intervention needs or less costly even effectiveness Although we found no
to be seriously than usual evidence that the
considered in any school provision universal provision
national package of the FRIENDS
of preventive programme was cost-
health services effective over a 6-month
period, this conclusion
needs to be treated
with caution
A&E, accident and emergency; CEA, cost-effectiveness analysis; CSRI, Client Service Receipt Inventory; CUA, cost–utility analysis; EQ-5D, EuroQoL-5 Dimensions; GBP, Great British
pounds; ISRCTN, International Standard Randomised Controlled Trial Number; N/A, not applicable; NCT, National Clinical Trial; SMFQ, Short Mood and Feelings Questionnaire.
273
274
APPENDIX 8
TABLE 74 Economic evaluation: characteristics of CBT interventions with a psychoeducation component
Average
Number of session time Group
Study sessions (minutes) size (n) Parent sessions Facilitator (number) Manual Training Materials Other costs
Calear 6 35 30 Teacher or specialist (1) Yes No training Unclear
et al.126 2016
Calear 6 35 30 Teacher (1) Yes No training Unclear
et al.127 2016
Hodas131 10 50 4 2 Doctoral students/ No Unclear Worksheets

2016 1 psychologist and
2 undergraduates (2)
Rodgers and 10 60 11 Psychologist (1) Yes 1 day Workbooks

Dunsmuir140
2015
Lowry- 10 75 30 3 (low turnout) Teacher (1) Yes 1 day Workbooks 2 booster

Webster sessions
et al.135 2001
Wong et al.144 6.5 40 30 Teacher (1) Yes No training Worksheets

2014
Gillham 8 90 11 6 × 90 minutes Psychologist (2) Yes Developer, junior Unclear

et al.128 2006 staff were trained
(no details)
Lock and 12 75 30 3 (low turnout) Psychologist (1) Yes 1 day Workbooks

Barrett134
2003
Tomba 6 120 20 Psychologist (2) Yes Training on Handouts
et al.143 2010 recruitment
Horowitz 8 90 11 Psychologist and Yes Training workshops Workbooks

et al.195 2007 student (2) (no details)
Kindt et al.196 16 50 25 Teacher (1) Yes 4 days Workbooks Remote advice

2014
Pössel 10 90 16 Psychologist or Yes Participation Unclear

et al.198 2004 postgraduates (2)
DOI: 10.3310/phr09080
Average
Number of session time Group
Study sessions (minutes) size (n) Parent sessions Facilitator (number) Manual Training Materials Other costs
Pössel 10 90 27 Psychologist or Yes Participation, Unclear

et al.199 2011 postgrads (2) co-presenting
Tak et al.207 16 50 13 Psychologist (1) No 5 days Workbook 2-hour booster

2016
Aune and 3 45 30 1 day, nurses; Teacher (1) No 90 minutes, Booklet, website, Newspaper
Stiles119 2009 60 minutes, teachers handouts advertisement
parents; 90
minutes, carers
Barrett 10 50 25 4 × 2-hour Psychologist (1) Yes Training Workbook, booklet 2 booster
et al.121 2005 sessions (10 (unspecified sessions
participants) amount)
Barry et al.190 4 40 13 Unclear (0) No Unclear

2017

Pössel et al.200 10 90 8 Psychologist and Yes Participation
2013 postgraduate (2)
Sawyer et al.204 30 42 30 Teacher (1) Yes 1 day Workbook, poster,

2010 homework sheet,
CD, DVD
Sheffield 8 47 30 Teacher (1) Yes 1 day (6 hours) Workbook, notes,

et al.141 2006 poster, handouts
CD, compact disc; DVD, digital versatile disc.
275
276
APPENDIX 8
TABLE 75 Economic evaluation: characteristics of CBT + IPT interventions
Average
Number of session time Size of
Study sessions (minutes) group (n) Parent sessions Facilitator (number) Manual Training Materials Other costs
Merry et al.197 11 70 23 NA Teacher (1) Yes 2.5 days Workbook NA

2004
Rivet-Duval 11 60 10 NA Teacher (1) Yes 2 days (16 hours) Unclear NA

et al.202 2011 plus 0.5-day booster
Rose et al.203 20 45 9 NA Psychologist students (1) Yes 2 days (1 for each Workbook NA
2014 intervention)
NA, not applicable.
Cost data, assumptions and sources
TABLE 76 Unit costs associated with delivery of a school-based intervention (school funder perspective)
Cost type Unit cost (2018) Assumptions and sources
Average hourly rate for teachers l Secondary school = £37.88 Average salary342 for secondary school
in the UK l Primary school = £34.80 classroom teacher (2018) = £37,700
Average salary342 for primary school classroom

teacher (2018) = £34,700
Employer National Insurance contribution343

@ 13.8% over £8424
l Secondary school = £4040.09

l Primary school = £3626.09
Superannuation contribution = 16.4% (note that

the rate rose to 23.6% in 2019, but is covered
by a grant)344
l Secondary school = £6182.80

l Primary school = £5690.80
l Total annual cost of employing secondary
school teacher = £47,922.89
l Total annual cost of employing primary
school teacher = £44,016.89
l Working hours = 1265 per year345
Workbook (per student) £9 Costs for the workbooks varied between

approximately £4 and £12
Manual (per teacher) £25 Costs for the intervention manuals varied
between approximately £5 and £40
Cost of training one teacher l Secondary school = £520 l Two-day training course @ £410 (https://
l Primary school = £500 bounceforward.com/teach-resilience/)
l Training in mental health awareness @ £200
per teacher346
l CPD for teachers @ £280 + VAT
(https://cpdforteachers.com/)
l Estimate £225 + VAT = £270 per teacher
l Time of attendee = 1 day (6.5 hours)
¢ Secondary school = £246.22
¢ Primary school = £226.20
l One-day course cost, plus time of attendee:

¢ Secondary = £516.22
¢ Primary = £496.20
Average number of students l Secondary school = 948 students

per school347 l Primary school = 281 students
Average class size347 l Secondary school = 21.2 students

l Primary school = 27.1 students
CPD, continuing professional development; VAT, value-added tax.
277
Appendix 9 Comparison of findings with

previous systematic reviews
279
280
APPENDIX 9
TABLE 77 Characteristics of previous systematic reviews of anxiety and depression prevention
Studies Percentage
Summary Meta- Adjusted included in of studies
g j
Study Conditiona Populationb Settingc Interventiond Comparatore Designf effect analysish cluster?i review (n) included Summaryk
Wadell275 Anxiety, Universal All Psychological Not clear RCT NAl No NAl 6 83 Results presented by specific
2007 depression and targeted programme and p-value
and conduct
disorder
Horowitz and Depression Universal Not Not clear Control RCT Hedges’ g Not Not clear 30 43 Overall mean effect was 0.16
Garber285 and targeted clear clear
2006
Neil and Anxiety and Universal School Psychological, Not clear RCT Cohen’s d No Not clear 24 58 The effect sizes for controlled
Christensen111 depression targeted educational trials varied from small (0.18)
2007 and early to moderate (0.83)
intervention
Neil and Anxiety Universal School Psychological, Not clear RCT Cohen’s d NAl Not clear 27 52 l Adolescents: effect
Christensen112 targeted educational, size = 0.11–1.37,
2009 and early physical median = 0.32
intervention l Children: effect
size = 0.41–0.96,
median = 0.57
Calear and Depression Universal School Psychological, Waiting list, no RCT Cohen’s d NAl Not clear 42 71 Out of 42 trials, 23 (55%)
Christensen109 targeted educational intervention, significantly reduced
2010 and early usual curriculum, participants’ depressive
intervention attention control symptoms at post test or
follow-up, with effect sizes
ranging from 0.21 to 1.40.
The effect sizes of the
19 trials that did not obtain
significant results ranged
from –0.54 to 0.73
Stice et al.113 Depression Universal All Not clear Attention control, RCT, r Random Not clear 46 54 r = 0.15 (z = 4.96; p < 0.001)
2009 and targeted no intervention, quasi- effects
waiting list RCT
Fisak348 2011 Anxiety Universal All Psychological Not clear RCT, Hedges’ g Fixed Not clear 31 65 Anxiety: 0.18 (95% CI
and targeted pre–postm effects 0.13 to 0.23):
l Universal: 0.17 (no CI)

l Targeted: 0.26 (no CI)
DOI: 10.3310/phr09080
Studies Percentage
g j
Study Conditiona Populationb Settingc Interventiond Comparatore Designf effect analysish cluster?i review (n) included Summaryk
Teubert276 Anxiety Universal Not Not clear Waiting list, RCT Hedges’ g Random Not clear 59 42 l Anxiety: Hedges’
2011 and targeted clear attention control, effects g = 0.22; p < 0.001
placebo l Depression: Hedges’
g = 0.10; p < 0.01
Corrieri108 Anxiety and Universal School Psychological RCT Cohen’s d Not Not clear 24 71 l Depression: –0.12
2014 depression and targeted (> 100) clear (range –0.57 to 0.30)
l Anxiety: –0.29 (range
–0.67 to 0.19)
Ahlen et al.349 Anxiety and Universal Not Psychological, Not clear RCT Hedges’ g Random Yes 30 83 l Anxiety: 0.13 (95% CI
2015 depression clear educational effects 0.01 to 0.26)
l Depression: 0.11 (95% CI
0.03 to 0.20)
Brunwasser350 Depression Universal Not Psychological No intervention, RCT Hedges’ g Fixed Not clear 35 89 A review of each specific
2016 and targeted clear usual curriculum effects programme: only pools within
each programme for which
there were three or more
RCTs
Stockings Anxiety and Universal All Psychological, No intervention, RCT Cohen’s d Random Not clear 146 60 l Universal and depression:
et al.38 2016 depression and targeted educational, usual curriculum, effects –0.11 (95% CI –0.16
physical waiting list, to –0.05)
attention control l Universal and anxiety:
–0.16 (95% CI –0.27
to –0.06)

l Selective, depression: –0.23
(95% CI –0.36 to –0.09)
l Selective, anxiety: 0.10
(95% CI –0.10 to 0.30)
l Indicated, depression:
–0.33 (95% CI –0.46
to –0.20)
l Indicated, anxiety: –0.01
(95% CI –0.27 to 0.26)
Hetrick68 2016 Depression Universal All Psychological Usual curriculum, RCT SMD Random Yes 83 73 l All: –0.21 (95% CI –0.27
and targeted no intervention, effects to –0.15)
waiting list, l Universal: –0.11 (95% CI
attention control, –0.17 to –0.05)
other l Targeted: –0.32 (95% CI
–0.42 to –0.23)
continued
281
282
APPENDIX 9
TABLE 77 Characteristics of previous systematic reviews of anxiety and depression prevention (continued )
Studies Percentage
a b c d e f g j
Study Condition Population Setting Intervention Comparator Design effect analysish cluster?i review (n) included Summaryk
Lawrence Anxiety Targeted All Not clear Waiting list, RCT Hedges’ g Random Not clear 16 63 l Inactive: –0.43 (95%CI
et al.278 2017 active effects –0.73 to –0.12)
l Attention: –0.09 (95% CI
–0.28 to 0.10)
Waldron351 Anxiety Universal School Psychological Waiting list, no RCT Hedges’ g NAl NAl 8 100 NAl
2018 intervention,
attention control
Werner- Anxiety Universal School Psychological, No intervention, RCT Hedges’ g Random Not clear 81 81 l Depression: 0.23 (95% CI
Seidler et al.36 and and targeted educational usual curriculum, effects 0.19 to 0.28)
2017 depression waiting list, l Anxiety: 0.20 (95% CI
attention control 0.14 to 0.25)
Rasing et al.39 Anxiety Targeted All CBT No intervention, RCT Cohen’s d Random Not clear 36 81 l Depression: –0.25 (95% CI
2017 and usual curriculum, effects –0.38 to –0.12)
depression waiting list, l Anxiety: –0.19 (95% CI
attention control –0.36 to 0.03)
Moreno-Peral Anxiety Universal All Psychological, RCT SMD Random Not clear 9 77 Anxiety: –0.29 (95% CI
et al.110 2017 and targeted educational effects –0.47 to –0.10)
Bernaras Depression Universal School Psychological Not clear RCT NAl NAl NAl 9 89 NAl
et al.277 2019 and targeted
Johnstone Anxiety Universal School Psychological Waiting list, usual RCT Hedges’ g Random Not clear 14 100 l Anxiety: Hedges’ g = 0.09
et al.37 2018 and curriculum, effects (95% CI − 0.07 to 0.26)
depression placebo l Depression: Hedges’
g = 0.17 (95% CI
0.06 to 0.28)
NA, not applicable.
a Condition: which of anxiety, depression and conduct disorder the review considered.
b Population: if review included targeted and/or universal populations, or early intervention.
c Setting: whether review was restricted to school settings or wider.
d Intervention: which intervention review focused on – psychological, educational or physical.
e Comparator: which controls were included.
f Design: what types of study design were eligible for inclusion.
g Summary effect: if a meta-analysis was conducted, did the review use Cohen’s d, Hedges g, SMD or other?
h Meta-analysis: if a meta-analysis was conducted, was it fixed effects, random effects or not clear?
i Adjusted cluster.
j The percentage of studies from the listed review that were included in the NMA.
k Summary: a brief description of the results from the review.
l Narrative review.
m A non-randomised pre–post design.
TABLE 78 Lumping and splitting of control and interventions
Depression Anxiety
Universal Targeted Universal Targeted
Comparison SMD 95% CrI SMD 95% CrI SMD 95% CrI SMD 95% CrI
CBT vs. –0.08 –0.16 to –0.01 –0.25 –0.43 to –0.08 –0.07 –0.13 to –0.03 –0.19 –0.34 to –0.05
controla
SDb 0.17 0.12 to 0.23 0.38 0.28 to 0.54 0.06 0.01 to 0.14 0.29 0.18 to 0.43
Psychological –0.09 –0.15 to –0.02 –0.31 –0.48 to –0.14 –0.06 –0.12 to –0.02 NAd
interventionc
vs. control
SDb 0.17 0.12 to 0.23 0.39 0.28 to 0.55 0.06 0.00 to 0.15
NA, not applicable.
a The lumped ‘control’ condition varied depending on the population/setting/outcome, but could include usual
curriculum, no intervention, waiting list, attention control, psychosupport or psychoeducation comparators.
b SD: between-study heterogeneity.
c The lumped ‘psychological intervention’ comparator varied across the networks, but could include CBT, third wave,
IPT and CBT + IPT. We did not include behavioural therapy or CBM in the lumped psychological intervention comparator.
d There was only one psychological intervention in the targeted anxiety network (CBT) and so the two analyses
were equivalent.
283
EME
HS&DR
HTA
PGfAR
PHR
Part of the NIHR Journals Library
www.journalslibrary.nihr.ac.uk
This report presents independent research funded by the National Institute for Health Research (NIHR).
The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the
Department of Health and Social Care
Published by the NIHR Journals Library

Bookshelf NBK572522

Uploaded by

Copyright:

Available Formats

Bookshelf NBK572522

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Bookshelf NBK572522

Uploaded by

Copyright:

Available Formats

Journals Library

Public Health Research

School-based interventions to prevent

Deborah M Caldwell ,1* Sarah R Davies ,2

and Nicky J Welton1,4

of Murcia, Murcia, Spain

University College London, London, UK

Published July 2021

ISSN 2050-439X (Online)

Editorial contact: [email protected]

Criteria for inclusion in the Public Health Research journal

NIHR Journals Library Editors

Dr Tessa Crilly Director, Crystal Blue Consulting Ltd, UK

Dr Eugenia Cronin Senior Scientific Advisor, Wessex Institute, UK

Dr Peter Davidson Consultant Advisor, Wessex Institute, University of Southampton, UK

Professor Geoffrey Meads Emeritus Professor of Wellbeing Research, University of Winchester, UK

Dr Rob Riemsma Reviews Manager, Kleijnen Systematic Reviews Ltd, UK

Please visit the website for a list of editors: www.journalslibrary.nihr.ac.uk/about/editors

Editorial contact: [email protected]

NIHR Journals Library www.journalslibrary.nihr.ac.uk

School-based interventions to prevent anxiety, depression and

Deborah M Caldwell ,1* Sarah R Davies ,2 Joanna C Thorn ,1

*Corresponding author [email protected]

NIHR Journals Library www.journalslibrary.nihr.ac.uk

List of tables xiii

List of figures xvii

List of abbreviations xix

Plain English summary xxi

Scientific summary xxiii

Chapter 2 Methods for assessing effectiveness 9

Chapter 3 Intervention and component categorisation 19

Chapter 4 Effectiveness of educational setting-based interventions for

Chapter 5 Effectiveness of educational setting-based interventions for preventing

Chapter 6 Additional primary outcomes and secondary outcomes from studies

NIHR Journals Library www.journalslibrary.nihr.ac.uk

Parent-reported child anxiety, depression or internalising outcomes 76

Chapter 7 Effectiveness of educational setting-based interventions for preventing

Chapter 8 Economic evaluation 87

Chapter 9 Summary and interpretation of key findings 99

Chapter 10 Discussion 105

Implications for practice 112

Appendix 1 Methods for systematic review and network meta-analysis 141

Appendix 2 Results from systematic review 159

Appendix 3 Network meta-analysis results 209

Appendix 4 Full network meta-analysis and standard pairwise meta-analyses 229

Appendix 5 Further time points: results from the intervention-level network

Appendix 6 Exploring heterogeneity and publication bias 239

Appendix 7 Additional outcomes 251

Appendix 8 Economic evaluation 267

Appendix 9 Comparison of findings with previous systematic reviews 279

NIHR Journals Library www.journalslibrary.nihr.ac.uk

TABLE 2 Intervention-level classifications and component classifications by

TABLE 5 Risk-of-bias sensitivity analyses for self-reported anxiety 44

TABLE 6 Intervention-level classifications and component classifications by

TABLE 9 Risk-of-bias sensitivity analyses for self-reported depression 67

TABLE 10 Well-being and life satisfaction: population, setting and intervention

TABLE 11 Study-level summary for suicidal ideation and self-harm outcomes at

TABLE 12 Results from subgroup analysis by socioeconomic status 72

TABLE 13 Composite internalising outcomes at post intervention time point 72

TABLE 14 Author-reported satisfaction with the intervention 74