Elsevier

Journal of Affective Disorders

Volume 196, 15 May 2016, Pages 200-209
Journal of Affective Disorders

Research paper
The effectiveness of simple psychological and physical activity interventions for high prevalence mental health problems in young people: A factorial randomised controlled trial

https://doi.org/10.1016/j.jad.2016.02.043Get rights and content

Highlights

  • Largest trial of a physical activity intervention in a clinical sample of young people, including a high proportion of males.

  • Intervention resulted in a clinically meaningful improvement in depression symptoms in young people.

  • Potential for integration into routine clinical care as an adjunctive intervention for depression in young people.

Abstract

Background

The prevalence and burden of disease of depression and anxiety disorders in young people necessitates effective early intervention strategies. The aim of this study was to evaluate the effectiveness of low-intensity interventions (problem solving therapy (PST) and physical activity promotion) in young people (15–25 years) with mild-moderate depression and/or anxiety.

Method

A 2×2 factorial randomised controlled trial (RCT) with factors of PST versus supportive counselling (control) and behavioural activation physical activity versus lifestyle psychoeducation (control). Help-seeking participants (n=176) were randomised to receive up to 6 manualised intervention sessions. Primary outcomes were post-intervention depressive symptoms (Beck Depression Inventory-II (BDI-II), anxiety symptoms (Beck Anxiety Inventory), and Montgomery-Åsberg Depression Rating Scale (MADRS)). Trial registration ACTRN12608000550303.

Results

Depression symptoms were significantly reduced in the physical activity group compared to psychoeducation (BDI-II: d=0.41 (95% CI: 0.07–0.76); MADRS: d=0.48 (95% CI: 0.13–0.82), but not post-intervention anxiety symptoms. PST was not superior to supportive counselling, nor were any interactions between interventions significant.

Limitations

As self reported levels of physical activity did not significantly differ between baseline and end-point in those randomised to the physical activity intervention, it is unclear as to whether some form of physical activity not measured in the trial may have led to the difference in depression symptoms.

Conclusions

PST was not superior to supportive counselling in reducing depression and anxiety symptoms in young people. Participants who received the physical activity intervention reported the greatest reduction in depression symptoms, however further research is required to establish the mechanism of action and to determine its effectiveness as an adjunct intervention in routine clinical practice.

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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      No studies reported including people identifying as gender diverse or non-binary. Twelve of the studies consisted of University or College students (Caldwell et al., 2016; Call et al., 2014; Falsafi, 2016; Gallego et al., 2014; Kim et al., 2013; Kim et al., 2004; Mailey et al., 2010; McEntee, 1996; Papp et al., 2019; Robert-Mccomb et al., 2015; Sabourin et al., 2016; Smits et al., 2008); six studies comprised of school children/young people (Bao, 2014; Khalsa, 2012; Melnyk et al., 2013; Melnyk et al., 2009; Norris et al., 1992); three studies included individuals from the general community population (Kanojia et al., 2013; Maurer et al., 2020; Smits et al., 2008); one study included only individuals who were overweight (Jelalian et al., 2011); and one study included individuals who were seeking support for anxiety (Parker et al., 2016). Eighteen studies included non-clinical samples (i.e. not presumed or measured to be experiencing clinical levels of anxiety or other mental health problems) and four studies included clinical samples: in two studies participants scored over a threshold for anxiety on a clinical tool (Call et al., 2014; Parker et al., 2016); in one study participants were receiving counseling (Mailey et al., 2010); and in one study, participants had a diagnosis of depression or anxiety disorder (Falsafi, 2016).

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