A Randomized Placebo-Controlled Trial of a School-Based Depression Prevention Program
Abstract
Objective To conduct a placebo-controlled study of the effectiveness of a universal school-based depression prevention program.Method Three hundred ninety-two students age 13 to 15 from two schools were randomized to intervention (RAP-Kiwi) and placebo programs run by teachers. RAP-Kiwi was an 11-session manual-based program derived from cognitive-behavioral therapy. The placebo was similar but with cognitive components removed. Outcomes were self-rated depression scales, the Reynolds Adolescent Depression Scale (RADS), and the Beck Depression Inventory II (BDI-II). Follow-up was to 18 months. Analysis was done on an intent-to-treat basis.Results Immediately after the intervention, depression scores were reduced significantly more by RAP-Kiwi than by placebo, with a mean difference in change from baseline between groups of 1.5 on BDI-II (CI > 0.38, p =.01) and 2.24 on RADS (CI > 0.22, p =.04). Categorical analysis confirmed significant clinical benefit with an absolute risk reduction of 3% (95% CI, 1-11%, McNemar chi, p =.03), with the "number needed to treat" for short-term benefit of 33. Group differences in depression scores averaged across time to 18 months were significant on RADS but not on BDI-II. Retention rates were 91% at 6 months and 72% at 18 months.Conclusions The RAP-Kiwi program is a potentially effective public health measure. Confirmation of effectiveness measuring episodes of depressive illness and broader measures of adjustment is warranted.
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Successful adolescent psychopathology prevention programs have incurred high financial costs and relied on scarce resources such as teachers' classroom time or researchers for delivery.
“Furthermore, programs that have been successful in reducing psychopathology in adolescents have incurred high financial costs and relied on scarce resources, such as teachers’ classroom time or researchers for program delivery [15].”
From Feasibility and effectiveness of a web-based positive psychology program for youth mental health: Randomized controlled trial (2014) · cites this paper as [15]
Reported means in some trials, even those reporting statistical significance, suggest no clear advantage for the early intervention condition.
“Reported means in some trials, even those that reported statistical significance, suggest no clear advantage for the early intervention condition (e.g. Horowitz, Garber, Ciesla, Young, & Mufson, 2007; Merry, McDowell, Wild, Bir, & Cunliffe, 2004; Quayle, Dziurawiec, Roberts, Kane, & Ebsworthy, 2001).”
From A randomized controlled trial of strong minds: A school-based mental health program combining acceptance and commitment therapy and positive psychology (2016) · cites this paper as Merry et al., 2004
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Gillham, J. E., Reivich, K. J., Brunwasser, S. M., Freres, D. R., Chajon, N. D., Kash-MacDonald, V. M., Chaplin, T. M., Abenavoli, R. M., Matlin, S. L., Gallop, R., et al. (2012) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2012.706517 · Cited by 95 · see citing works
“In depression prevention studies that include more than one self-report measure, this kind of discrepancy is common (e.g., Horowitz, Garber, Ciesla, Young, & Mufson, 2007; Merry et al., 2004; Muñoz et al., 1995).”
Backgroundvan de Sande, M. C., Fekkes, M., Kocken, P., Diekstra, R. F. W., Reis, R., & Gravesteijn, C. (2019) · Psychology in the Schools · doi:10.1002/pits.22307 · Cited by 94 · see citing works
Stallard, P., Phillips, R., Montgomery, A., Spears, M., Anderson, R., Taylor, J., Araya, R., Lewis, G., Ukoumunne, O., Millings, A., et al. (2013) · Health Technology Assessment · doi:10.3310/hta17470 · Cited by 87 · see citing works
“Three studies have demonstrated a reduction in symptoms of depression relative to a control group post intervention, and all have demonstrated good reach (> 70% of the eligible population) and low attrition (< 10%),(16,24,25) although sustained effects at long-term follow-up (12 months) were not assessed in two of the…”
BackgroundRapee, R. M., Wignall, A., Sheffield, J., Kowalenko, N., Davis, A., McLoone, J., & Spence, S. H. (2006) · Prevention Science · doi:10.1007/s11121-006-0035-4 · Cited by 87 · see citing works
“…this stage seems to favor indicated programs and many authors have agreed that the cost savings found with indicated programs makes these the most cost-effective methods of program delivery for the prevention of adolescent depression (Andrews et al., 2002; Clarke et al., 1995; Merry et al., 2004).”
BackgroundKilbourne, A. M., Smith, S. N., Choi, S. Y., Koschmann, E., Liebrecht, C., Rusch, A., Abelson, J. L., Eisenberg, D., Himle, J. A., Fitzgerald, K. D., et al. (2018) · Implementation Science · doi:10.1186/s13012-018-0808-8 · Cited by 85 · see citing works
Dray, J., Bowman, J., Campbell, E. M., Freund, M., Hodder, R. K., Wolfenden, L., Richards, J., Leane, C., Green, S., Lecathelinais, C., et al. (2017) · Journal of Adolescence · doi:10.1016/j.adolescence.2017.03.009 · Cited by 83 · see citing works
“…al., 2008) or no differential effects (Araya et al., 2013; Buttigieg et al., 2015; Chaplin et al., 2006; Horowitz et al., 2007; Kindt et al., 2014; Merry et al., 2004; Roberts et al., 2010; Sawyer et al., 2010; Tak, Lichtwarck-Aschoff, Gillham, Van Zundert, & Engels, 2016; Tomba et al., 2010;…”
BackgroundPrevention of depression in childhood and adolescence
Mendelson, T., & Tandon, S. D. (2016) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2015.11.005 · Cited by 77 · see citing works
Aseltine, R. H., Schilling, E. A., James, A., Glanovsky, J. L., & Jacobs, D. G. (2009) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/chi.0b013e318195bce8 · Cited by 75 · see citing works
Reducing Anxiety to Prevent Depression
Flannery-Schroeder, E. C. (2006) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2006.07.006 · Cited by 72 · see citing works
Jack Tizard Lecture: Cognitive Behaviour Therapies for Children: Passing Fashion or Here to Stay?
GRAHAM, P. J. (2005) · Child and Adolescent Mental Health · doi:10.1111/j.1475-3588.2005.00119.x · Cited by 74 · see citing works
The effectiveness of a school-based adolescent depression education program
Swartz, K. L., Kastelic, E. A., Hess, S. G., Cox, T. S., Gonzales, L. C., Mink, S. P., & Raymond DePaulo, J. (2010) · Health Education & Behavior · doi:10.1177/1090198107303313 · Cited by 70 · see citing works
Collaborative for Academic, Social and Emotional Learning (CASEL)
Durlak, J. A., Dymnicki, A. B., Taylor, R. D., Weissberg, R. P., Schellinger, K. B., Dubois, D., Lipsey, M., Greenberg, M., & O’brien, M. U. (2012) · Springer eBooks · doi:10.1007/springerreference_69828 · Cited by 69 · see citing works
Wong, N., Kady, L., Mewton, L. R., Sunderland, M., & Andrews, G. (2014) · Internet Interventions · doi:10.1016/j.invent.2014.05.004 · Cited by 68 · see citing works
Prevention of depression: The state of the science at the beginning of the 21st Century
Barrera, A. Z., Torres, L. D., & Muñoz, R. F. (2007) · International Review of Psychiatry · doi:10.1080/09540260701797894 · Cited by 65 · see citing works
Kidger, J., Donovan, J., Biddle, L., Campbell, R., & Gunnell, D. (2009) · BMC Public Health · doi:10.1186/1471-2458-9-403 · Cited by 75 · see citing works
“The first group aims to prevent or reduce emotional disorders such as depression and anxiety, by developing coping skills commonly used within psychiatry [ 11-13 ].”
BackgroundWhittaker, R., Stasiak, K., McDowell, H., Doherty, I., Shepherd, M., Chua, S., Dorey, E., Parag, V., Ameratunga, S., Rodgers, A., et al. (2017) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12753 · Cited by 64 · see citing works
“It should be noted that the depression scores in both arms of the study dropped on all measures, and that the magnitude of effect was similar to the intervention arm of a previous study done by our group (Merry et al., 2004).”
ResultHetrick, S., Cox, G., & Merry, S. (2015) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph120504758 · Cited by 62 · see citing works
“It is salutary that its effectiveness was not shown in a real world trial [64].”
BackgroundSelf-citationSwartz, K., Musci, R. J., Beaudry, M. B., Heley, K. M., Miller, L., Alfes, C., Townsend, L. D., Thornicroft, G., & Wilcox, H. C. (2017) · American Journal of Public Health · doi:10.2105/ajph.2017.304088 · Cited by 63 · see citing works
Emotional well-being of children and adolescents
Choi, A. (2018) · OECD education working papers · doi:10.1787/41576fb2-en · Cited by 71 · see citing works
Attempting to prevent depression in youth: a systematic review of the evidence
Merry, S., & Spence, S. H. (2007) · Early Intervention in Psychiatry · doi:10.1111/j.1751-7893.2007.00030.x · Cited by 59 · see citing works
“The purpose of this review was to update the information on prevention and early intervention programmes for depression in adolescents, building on the Cochrane report and meta-analysis reported by Merry et al. (2004).13”
MethodSelf-citationWright, B., Tindall, L., Littlewood, E., Allgar, V. L., Abeles, P., Trépel, D., & Ali, S. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-012834 · Cited by 59 · see citing works
Prevention of depression in youth: A qualitative review and future suggestions
Sutton, J. M. (2007) · Clinical Psychology Review · doi:10.1016/j.cpr.2007.01.014 · Cited by 55 · see citing works
McCarty, C. A., Violette, H. D., Duong, M. T., Cruz, R. A., & McCauley, E. (2013) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2013.782817 · Cited by 58 · see citing works
Religiosity and Behavioral Health Outcomes of Adolescents Living in Disaster-Vulnerable Areas
Rose, T., Shields, J. J., Tueller, S., & Larson, S. L. (2014) · Journal of Religion and Health · doi:10.1007/s10943-014-9828-0 · Cited by 57 · see citing works
Brunwasser, S. M., & Garber, J. (2015) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2015.1020541 · Cited by 57 · see citing works
“RAP also has been evaluated in two nonrandomized controlled trials (Harnett & Dadds, 2004; Shochet et al., 2001) and an RCT with only a placebo comparison condition (Merry et al., 2004).”
MethodMackay, B., Shochet, I. M., & Orr, J. A. (2017) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-017-3263-5 · Cited by 57 · see citing works
“RAP-A is based on integral elements of CBT and Interpersonal Psychotherapy (IPT), both of which have developed a solid evidence base for the treatment of depression in young people (Clarke et al. 2001; Garber 2006; Garber et al. 2009a; Horowitz et al. 2007; Merry et al. 2004; RivetDuval et al. 2011).”
MethodCheek, C., Bridgman, H., Fleming, T., Cummings, E., Ellis, L., Lucassen, M. F., Shepherd, M., & Skinner, T. (2014) · JMIR Serious Games · doi:10.2196/games.3183 · Cited by 51 · see citing works
“Early intervention with cognitive behavior therapy (CBT) for young people with depression has been shown to be effective in reducing mental health symptoms [6-9].”
A survey of adolescents’ knowledge about depression
Hess, S. G., Cox, T. S., Gonzales, L. C., Kastelic, E. A., Mink, S. P., Rose, L. E., & Swartz, K. (2004) · Archives of Psychiatric Nursing · doi:10.1016/j.apnu.2004.09.005 · Cited by 54 · see citing works
“With regards to depression, however, we have ound no publication to date, describing a schoolased depression education program, although here are several reports of school based depression revention programs (Burns & Hickie, 2002; erry et al., 2004; Shochet et al., 2001; Oria, ureton, & Canham, 2001).”
BackgroundMethodMa, L., Zhang, Y., Huang, C. X., & Cui, Z. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.03.051 · Cited by 57 · see citing works
Wolitzky-Taylor, K. B., Ruggiero, K., McCart, M., Smith, D. W., Hanson, R. F., Resnick, H. S., de Arellano, M. D., Saunders, B. E., & Kilpatrick, D. (2009) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374410903401146 · Cited by 49 · see citing works
Stallard, P. N., & Buck, R. (2013) · The British Journal of Psychiatry · doi:10.1192/bjp.bp.112.119172 · Cited by 53 · see citing works
Feuerborn, L. L., & Gueldner, B. A. (2019) · Mindfulness · doi:10.1007/s12671-019-01101-1 · Cited by 57 · see citing works
The Positive Impact of Social and Emotional Learning for Kindergarten to Eighth-Grade Students
Payton, J. W., Weissberg, R. P., Durlak, J. A., Dymnicki, A. B., Taylor, R. D., Schellinger, K. B., & Pachan, M. K. (2008) · Cited by 51 · see citing works
Randomized controlled trial of a friendship skills intervention on adolescent depressive symptoms.
Rose, K., Hawes, D. J., & Hunt, C. J. (2014) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0035827 · Cited by 51 · see citing works
Salazar de Pablo, G., De Micheli, A., Solmi, M., Oliver, D., Catalan, A., Verdino, V., Di Maggio, L., Bonoldi, I., Radua, J., Baccaredda Boy, O., et al. (2021) · Harvard Review of Psychiatry · doi:10.1097/hrp.0000000000000294 · Cited by 51 · see citing works
Tak, Y. R., Lichtwarck‐Aschoff, A., Gillham, J. E., Zundert, R. M. P. V., & Engels, R. C. M. E. (2015) · Research on Child and Adolescent Psychopathology · doi:10.1007/s10802-015-0080-1 · Cited by 49 · see citing works
“In contrast to these results, some universal prevention programs showed long-term benefits from 4 months up to 18 months follow-up (Lock and Barrett 2003; Merry et al. 2004; Pössel et al. 2004; Pössel et al. 2013; Pössel et al. 2008; Shochet et al. 2001).”
BackgroundMethodResultPerceived stigma and depression among black adolescents in outpatient treatment
Rose, T., Joe, S., & Lindsey, M. A. (2010) · Children and Youth Services Review · doi:10.1016/j.childyouth.2010.08.029 · Cited by 48 · see citing works
Impact of comorbidity in prevention of adolescent depressive symptoms.
Pössel, P., Seemann, S., & Hautzinger, M. (2008) · Journal of Counseling Psychology · doi:10.1037/0022-0167.55.1.106 · Cited by 47 · see citing works
“Although in some studies, no gender effect was found (Chaplin et al., 2006; Clarke et al., 1993, second study; Merry et al., 2004; Shochet et al., 2001), in other studies, boys (Clarke et al.”
BackgroundResultInfluentialShochet, I. M., & Ham, D. (2004) · International Journal of Mental Health Promotion · doi:10.1080/14623730.2004.9721935 · Cited by 47 · see citing works
“Merry et al (2004) concluded that, when delivered by teachers, RAP-Kiwi was effective in reducing depressive symptoms and was a potentially effective public health intervention.”
BackgroundMethodBramesfeld, A., Platt, L., & Schwartz, F. W. (2006) · Health Policy · doi:10.1016/j.healthpol.2005.11.012 · Cited by 43 · see citing works
Sinclair, R., Millar, L., Allender, S. E., Snowdon, W., Waqa, G., Jacka, F. N., Moodie, M., Petersen, S., & Swinburn, B. A. (2016) · PLoS ONE · doi:10.1371/journal.pone.0161709 · Cited by 46 · see citing works
Pössel, P., Adelson, J. L., & Hautzinger, M. (2011) · Behaviour Research and Therapy · doi:10.1016/j.brat.2011.09.010 · Cited by 41 · see citing works
“Although some of these studies reported no sex effects (Chaplin et al., 2006; Clarke et al., 1993 [second study reported]; Merry et al., 2004; Shochet et al., 2001), other studies differed as to whether boys (Clarke et al., 1993 [first study reported]; Shatté, 1996) or girls (Gillham, Hamilton,…”
BackgroundResultRice, F. J., Rawal, A., Riglin, L., Lewis, G., Lewis, G., & Dunsmuir, S. (2015) · Journal of Affective Disorders · doi:10.1016/j.jad.2015.07.019 · Cited by 40 · see citing works
Shochet, I. M., Saggers, B. R., Carrington, S. B., Orr, J. A., Wurfl, A. M., Duncan, B. M., & Smith, C. L. (2016) · Clinical Child and Family Psychology Review · doi:10.1007/s10567-016-0203-4 · Cited by 39 · see citing works
“RAP-A is based on integral elements of CBT and interpersonal psychotherapy (IPT), both of which are supported as effective, evidence-based interventions for treating depression in young people (e.g. Clarke et al. 2001; Merry et al. 2004; Rivet-Duval et al. 2011).”
BackgroundInfluentialWhat are the active ingredients in preventative interventions for depression?
Collins, K., & Dozois, D. J. A. (2008) · Clinical Psychology Science and Practice · doi:10.1111/j.1468-2850.2008.00143.x · Cited by 37 · see citing works
Beaudry, M. B., Swartz, K., Miller, L., Schweizer, B., Glazer, K., & Wilcox, H. (2019) · Journal of School Health · doi:10.1111/josh.12725 · Cited by 33 · see citing works
Study protocol RapMusicTherapy for emotion regulation in a school setting
Uhlig, S., Jansen, E., & Scherder, E. (2015) · Psychology of Music · doi:10.1177/0305735615608696 · Cited by 37 · see citing works
- Authors
- Merry, S., McDOWELL, H., Wild, C. J., Bir, J., & Cunliffe, R.
- Affiliations
- University of Auckland (NZ)
- Corresponding author
- Merry, Sally
- Venue
- Journal of the American Academy of Child & Adolescent Psychiatry
- Publisher
- Elsevier BV
- Published
- 2004-05
- Volume
- 43
- Issue
- 5
- Pages
- 538-547
- ISSN
- 0890-8567 (ISSN-L)
- OpenAlex
- W2088454316
- Cited by
- 249
- References
- 40
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 2 · 2023: 19 · 2022: 7 · 2021: 8 · 2020: 8 · 2019: 11 · 2018: 7 · 2017: 13 · 2016: 14 · 2015: 11 · 2014: 18 · 2013: 9 · 2012: 20
- FWCI
- 16.77
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of the American Academy of Child & Adolescent Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Funders
- the Health Research Council (99/039)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Health Sciences › Health Professions › Speech and Hearing › School Health and Nursing Education
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- depression prevention, school-based intervention, adolescent depression, cognitive behavioral therapy, universal prevention programs, program retention, public health prevention
- MeSH terms
- Adolescent, Depression, Female, Humans, Male, Preventive Health Services, School Health Services, United States, Single-Blind Method
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