A single-session intervention (SSI) can produce long-lasting reductions in depression, anxiety, and internalizing problems in high-risk adolescents, new research shows.
Investigators compared levels of anxiety and depression in high-risk youngsters aged 12 to 15 years who participated in a half-hour computerized SSI to those of control patients who received only supportive therapy.
Results showed that compared to the control intervention, the mindset intervention significantly improved depression and anxiety. The benefits continued through the 9-month follow-up period.
The mindset group also experienced more rapid improvements in depression, as reported both by participants and their parents, as well as improvements in self-reported behavioral control.
“It is always very exciting when these very brief targeted programs can effect positive change,” lead author Jessica Schleider, a PhD candidate at Harvard University and psychology fellow at Yale Medical School, told Medscape Medical News.
“We are cautiously optimistic that this program can have broader impact on youth depression and anxiety,” she said.
The study was published in the February issue of the Journal of Child Psychology and Psychiatry.
“Keystone” Beliefs
As many as 80% of youths who require mental health services do not receive them, the authors note.
“There is a need for brief, scalable interventions for youth psychopathology — particularly interventions deliverable beyond brick-and-mortar clinics and via nontraditional means (eg, computer-based programs) to maximize potential for accessibility,” they write.
Previous research suggests that SSIs may help address this need and have “shown promising effects for diverse youth problems.” However, these studies have been limited by reliance on youth self-report, weak comparison conditions, and insufficient follow-up.
To address these previous limitations, the researchers used multi-informant measurement, an active control intervention, and extended follow-up assessment to test a mindset SSI that “differs conceptually from the most frequently used intervention approaches.”
The mindset approach does not focus directly on symptoms of depression and anxiety but rather on “implicit self-relevant beliefs thought to underlie internalizing symptoms.”
In particular, it teaches “growth mindset of personality, or belief that personality traits are malleable — as opposed to fixed mindset, the belief that personality is unchangeable,” the authors explain.
Personality mindsets “are thought to represent ‘keystone’ beliefs for adolescents” that “powerfully shape responses to the distinctive challenges that adolescents face,” the authors observe, adding that fixed mindsets correlate with and predict higher degrees of depression and anxiety in adolescents.
“The mindset construct is based on the work of Carole Dwek, who pioneered its use in school settings, and it was subsequently adapted to address youngsters with anxiety and depression,” Schleider said.
“By fostering the belief that personality traits, such as shyness or sadness, are malleable, the intervention can help adolescents cope with their stressors.
“We wanted to study the effects of the intervention on internalizing symptoms, which constituted the primary study outcomes,” she reported.
Secondary study outcomes focused on the intervention’s effects on two facets of the capacity to effectively cope with setbacks — perceived control over one’s behaviors, and perceived control over emotions (referred to as primary and secondary control, respectively).
Enhanced Psychoeducation
The intervention, which lasted 20 to 30 minutes, was a self-administered, computer-based program “designed to maximize relevance for youths experiencing internalizing stress.”
It included an explanation of neuroplasticity, testimonials and vignettes from older youths, a worksheet describing strategies for applying these principles, and an exercise in which participants wrote notes to younger children, using their newly gleaned information.
The control group participated in a 20- to 30-minute computer-based session of supportive therapy designed to encourage the patients to identify and express their feelings.
To assess depression and anxiety symptoms, the researchers used the Children’s Depression Inventory (CDI) and the Screen for Child Anxiety and Related Disorders-Child version (SCARED-C), respectively.
Parents completed the parent version of both scales.
Perceived primary (behavioral) and secondary (emotional) control were assessed with the Perceived Control Scale for Children and the Secondary Control Scale for Children, respectively.
Changes in mindsets were measured via the Implicit Personality Theory Questionnaire, which assesses beliefs about the malleability of personality.
Follow-up at 3, 6, and 9 months was conducted online.
The researchers recruited participants (n = 96) through advertising in local schools, afterschool programs, and clinics. Participants were randomly assigned to the mindset and control interventions (n = 48 for each).
At baseline, 14.58% of participants self-reported subclinical internalizing problems, and 85.42% reported clinically elevated symptoms of depression, overall anxiety, or a specific anxiety disorder
After the intervention, youths in the intervention group reported greater increases in growth mindsets than their counterparts in the control group, after controlling for baseline mindsets (F [1, 93] = 21.68, R2 = 0.13; P < .001).
Youths in the intervention group also experienced significantly greater improvements in perceived primary control from baseline to 9-month follow-up (d = 0.27), compared to control group youths.
The improvements in perceived secondary control from baseline to 9-month follow-up did not significantly differ by intervention condition.
Focus on Neuroplasticity
Participants in the intervention group reported more rapid declines in depression symptoms across the follow-up and also significantly greater declines in depression symptoms from baseline to 9-month follow-up, compared to the control group (d = 0.32).
Notably, by 9-month follow-up, the percentage of youths reporting depressive symptoms at a level higher than the CDI clinical cutoff decreased by 33.32% in the intervention group, vs 10.85% in the control group.
Parental report also indicated significant decreases in depression symptoms between the intervention and the control groups (55.63% vs 9.66%, respectively).
By contrast, by 9-month follow-up, reductions in anxiety did not differ between the groups, although the effect size was numerically small to medium in favor of the intervention (d = 0.33).
Nevertheless, by 9-month follow-up, there were differences between the intervention and the control groups, with decreases of 31.01% vs 17.71, respectively, in the percentages of youth reporting anxiety symptoms at a level higher than the SCARED-C clinical cutoff.
Parent-reported anxiety showed significantly greater declines in the intervention group from baseline to 9-month follow-up.
“These are the first findings we know of suggesting that a 30-minute, self-administered program may help reduce depression, and to a lesser degree, anxiety, in high-symptom and high-risk youths,” the authors state.
“Indeed, the intervention reduced rates of clinically elevated depression and anxiety at higher rates than did an active, clinically plausible comparison program, corroborating its clinical utility,” they note.
Schleider regards the intervention as “psychoeducation, enhanced in important ways.”
The “main education” involves the focus on neuroplasticity, she said.
“But, unlike traditional psychoeducation, which is framed as something that will help youngsters learn about the symptoms, mindset interventions actually ask participants to read about these concepts and then present them in ways that will be helpful to other kids going through challenging times in their lives.”
Additionally, the intervention is scalable, low-cost, and can effect rapid, long-lasting change, she said.
“Well-Timed Nudge”
Commenting on the study for Medscape Medical News,John T. Walkup, MD,
chair of the Department of Psychiatry, Anne and Robert H. Lurie Children’s Hospital of Chicago, Illinois, who was not involved with the study, called it “a great article by great people” and a good example of a “small intervention that is trajectory-deflecting.”
He explained that a “trajectory-deflecting” intervention provides “a well-timed, well-structured nudge to someone at the right moment that can change or deflect a person from one trajectory to a newer, better one.”
He advised clinicians to “explore exactly what was done here and begin to think about whether they can incorporate some of it into their work.”
Schleider added, “While the specific program we used is not available yet, the mindset approach, which is used educationally, is available and can be adapted in a mental health context.”
Jessica Schleider work was supported by a National Research Service Award from the National Institute of Mental Health; an Elizabeth Munsterberg Koppitz Fellowship by the American Psychological Foundation; and a Julius B. Richmond Fellowship by the Center on the Developing Child at Harvard University. Her coauthor and Dr Walkup have disclosed no relevant financial relationships.
J Child Psychol Psychiatry. 2018;59:160-170. Abstract
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