Research paperThe effectiveness of simple psychological and physical activity interventions for high prevalence mental health problems in young people: A factorial randomised controlled trial
Introduction
The high prevalence and significant burden of disease associated with common mental health problems such as depression and anxiety in young people (Australian Bureau of Statistics, 2010, Gore et al., 2011) has ongoing adverse consequences such as poor social and vocational functioning (Brent and Birmaher, 2002, Judd et al., 1996, McGorry et al., 2007) and increased risks of self-harm and suicide-related behaviours (Hetrick et al., 2012). These outcomes do not solely occur in people with full-threshold or severe forms of disorder; considerable impairment in functioning is associated with what are often referred to as ‘sub-threshold’ mental health problems, which are equally, if not more, prevalent than the diagnosable disorders (Judd et al., 1997, Judd et al., 1996, Rivas-Vazquez et al., 2004). Effective interventions provided in the early stages of illness, including sub-threshold presentations and the first or early episodes of full threshold depression or anxiety, have the potential to rapidly improve the mental health and functioning of young people and prevent the negative impacts of persistent depression on interpersonal, education, employment and health outcomes (Hetrick et al., 2008).
Low-cost, low-intensity psychological interventions that focus on skill-building and increasing opportunities for positive reinforcement may be effective and acceptable alternatives for young people in comparison to more complex interventions such as cognitive behavioural therapy (Hetrick et al., 2015), and may promote intervention engagement (Rickwood et al., 2014, Rickwood et al., 2007, Tylee et al., 2007). While there is emerging evidence to suggest that problem solving therapy (Eskin et al., 2008, Lerner and Clum, 1990) and increased physical activity (Brown et al., 2013, Ekeland et al., 2004, Larun et al., 2006) may have benefits in reducing symptoms of mental distress, particularly depression, in younger populations, directly comparable evaluations in clinical samples are lacking. As the systematic reviews of physical activity interventions have included studies that were highly heterogeneous or recruited predominantly healthy individuals, evidence of the effect of physical activity for the treatment of depression in children and adolescents is limited. A notable exception is a recent study of preferred intensity circuit training added to treatment as usual in a clinical sample of adolescents with depression, finding improved depression outcomes in the intervention group at the 6-month follow-up assessment (Carter et al., 2015, Carter et al., 2016).
We conducted a fully crossed factorial randomised controlled trial of PST and behavioural activation of physical activity, each compared against appropriate control conditions of supportive counselling and lifestyle psychoeducation. This trial examined the effectiveness of these interventions separately, and in combination in reducing depression and anxiety symptoms in help-seeking young people (aged 15–25 years) attending youth mental health services.
Section snippets
Study design
In a 2×2 single-blind factorial RCT comparing the two active interventions to their matched control conditions, participants were randomised to one of four intervention combinations: (i) behavioural activation physical activity (‘physical activity’) and problem solving therapy (PST); (ii) physical activity and supportive counselling; (iii) psychoeducation and PST; and (iv) psychoeducation and supportive counselling (e.g., see Montgomery et al. (2003)) for a description of the design). All
Demographic characteristics and drop out
Of the 176 consenting participants who were randomised in the study, 106 (60.2%) completed all 6 intervention sessions, 17 (9.7%) completed fewer than 6 sessions due to symptom improvement, 16 (9.1%) did not commence the intervention, 2 (1.1%) met exclusion criteria that were not detected at baseline (IQ<70 and prior intervention) and were excluded from the analyses, 7 (4.0%) were withdrawn due to clinical reasons, and 28 (15.9%) dropped out of the trial (see CONSORT diagram Fig. 1 for the flow
Main findings
This RCT demonstrated that a physical activity intervention using a behavioural activation approach significantly reduced symptoms of depression in young people at post-intervention (six weeks), compared to a lifestyle psychoeducation intervention. There was a medium effect size for both self-report and clinician-rated variables. At post-intervention, the physical activity intervention group was in the ‘minimal depression’ range whilst the psychoeducation group was in the ‘mild’ range on the
Contributors
AGP, SEH, AFJ, AJM, ARY, PDMc and RP designed the study, developed the methodology, and wrote the manuscript. AJM and AGP conducted the analyses. FS, JS and SB collected the data and contributed to the manuscript. All authors have approved the final article.
Funding
This study was funded in part by: NHMRC Centre for Clinical Research Excellence Grant 264611; NHMRC Program Grant 566529; beyondblue, the National Depression Initiative funding LGC-000041; and University of Melbourne Early Career Researcher Grant 600801 awarded to Dr Alexandra Parker. The funding bodies have had no role in the study design or the decision to submit the manuscript for publication.
Conflict of interest
None.
Acknowledgements
We gratefully acknowledge the clinical and management staff of headspace Sunshine and Glenroy for supporting the project, especially Alison McRoberts, Scott Ward, Kim Wood, Nick Prendergast, Carsten Schley, and Chris Brunner; Professors Ian Hickie, Daniel Lubman, and Nicholas Allen for their contributions to the research design; Dr Sarah Bendall and Carsten Schley for providing additional clinical supervision; Antonetti Scaffidi for data collection; and Michaela Willet and Dr Magenta Simmons
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