Title: Harnessing mental imagery in a brief school-based intervention for depression: an efficacy randomised controlled trial
Funder: Department of Health and Social Care

Abstract: Research question: Can a brief imagery-based intervention reduce depression in young people? Background: Depression is common, costly and usually begins in youth. Intervening early, before depression becomes entrenched, could significantly improve long-term outcomes and mitigate a lifetime of depression risk. Yet, current interventions are difficult to access and suboptimal. Brief, evidence-based interventions are required urgently, particularly those which can be readily accessed in schools. In my successful NIHR clinical doctoral research fellowship, I co-designed (with young people with lived experience, teachers and practitioners) a novel imagery-based psychological intervention (Integrating Memories and Generating New Experiences, IMAGINE). IMAGINE was conceptualised and initially evaluated with inner-city schools with high diversity. It targets two core mechanisms that trigger and maintain depression: dysfunctional mental imagery and maladaptive memory processes. My feasibility randomised controlled trial (RCT; n=56; ISRCTN85369879), exceeded pre-defined continuation rules: recruitment within eleven months; 89% retention; high acceptability; and no evidence of harm. Descriptive results suggest IMAGINE may reduce depression relative to an active control (d=1.34, 95% CI [0.80, 1.87]; 86% exceeding minimum clinically important difference, MCID, compared to 33% in control group). Whilst IMAGINE is designed for non-specialist practitioners to deliver, for this test of feasibility, both interventions were delivered by me (Clinical Psychologist). Aims and Objectives: (1) To establish the efficacy of IMAGINE, when delivered by non-specialist practitioners in school-settings, in a fully powered efficacy RCT. (2) To identify barriers and facilitators of implementation in a process evaluation. Methods: The design is a parallel-group, multi-school RCT. Based on MCID criteria, and accounting for drop-out, 156 young people (age 16-18) scoring above the cut-off for depression will be randomly allocated to receive four individual sessions of IMAGINE or a control intervention. There will be a pre-randomisation assessment and then blinded assessments at 6-, 18- and 30-weeks following randomisation. The primary clinical outcome is change in depression symptoms (measured by Mood and Feelings Questionnaire) at 18-weeks. A process evaluation, using interviews and questionnaires with young people, practitioners and school staff, will investigate how the intervention could be optimally embedded into school-settings. Timelines for delivery: In months 1-8, alongside seeking ethical approval, I will refine IMAGINE and develop a practitioner training package. Recruitment will take place in months 8-32 with final follow-up assessments completed by month 42. The process evaluation will be completed alongside the trial in months 30-44 with dissemination in months 44-48. Dissemination and anticipated impact: Plans for dissemination are at local, national and international levels. Collaboration with an education think and action-tank will further optimise dissemination. This research could provide a brief and evidence-based intervention for depression in schools, critically needed in current practice. IMAGINE could enable young people to harness their imagination, to let go of negative and move towards positive experiences. If successful, IMAGINE could be readily incorporated into current services with training quickly cascaded to a large number of non-specialist practitioners for school delivery. My research capitalises on the powerful relationship between emotion and imagery to address a nationwide crisis in youth mental health.

Lay abstract: Aims: I aim to enable young people with depression to receive effective help sooner. I have developed, with lived experience representatives and schools, a new psychological treatment (known as IMAGINE). This project aims to test if IMAGINE reduces depression and understand how best to embed it in schools. Background: Every school class will have at least one person struggling with depression. Yet three-quarters of young people with depression do not receive any mental health support. When depression begins before adulthood, it is associated with ten times the economic costs and significantly worse outcomes, from stress to suicide. Age 16 to 18 is a crucial period for intervention. It is when depressive symptoms commonly begin and when our thinking habits are more possible to change. Recently, there has been large public investment in a new workforce of practitioners for schools. However, existing approaches only provide small benefits (if any). An innovative treatment is urgently needed to reduce depression and maximise the usefulness of this investment. IMAGINE enables young people to harness their imagination. It targets three factors known to drive depression: (A) frequent upsetting memories, (B) struggling to imagine anything positive in the future, and (C) difficulty recalling memories in detail. For example, a young person might be plagued by a memory of being bullied, think about being rejected in their future, and struggle to remember having fun with friends. IMAGINE was developed with inner-city schools with high diversity, groups often under-represented when developing treatments. My work has demonstrated IMAGINE is possible and acceptable to deliver in schools, and shows promising signs to reduce depression. Now, I need to establish whether IMAGINE reduces symptoms of depression when delivered by other practitioners (those likely to be working in schools) and how best to deliver it in schools. Methods: There are two main parts. Testing IMAGINE. 156 young people aged 16-18 with depression (measured using a questionnaire) will be invited to take part in their school. Participants will be allocated at random to IMAGINE (4 individual sessions) or to another recommended intervention for low mood, similar to school counselling. Data will be collected on symptoms and on the targets of the treatment (e.g. memories) before and after the intervention, and also 3 and 6 months later. School delivery. To understand the factors that would influence successful delivery, young people, practitioners, and teachers will be invited to interviews and to complete questionnaires.[If necessary (e.g. due to COVID-19), this can all be conducted remotely.] Patient/service user, carer and public involvement: Young people with experience of depression, parents, teachers and clinicians have been central in shaping this project. For example, young people strongly recommended a brief intervention and to use imagery (rather than words) to make changes. Lived experience representatives will play an active role throughout (e.g. joining the committee overseeing the project and analysing the interviews). I will also work with an education think-tank (Centre for Education and Youth) to ensure effective engagement with schools/colleges. Benefits: The results of the project and associated materials will be shared at local, national, and international levels with key stakeholders. If IMAGINE successfully reduces depression, a larger study will train school practitioners to deliver it in their everyday work and determine if it is value for money. The new school workforce, that the government has pledged investment in, could be quickly trained to deliver IMAGINE. This ease of scalability would mean approximately 14,500 young people would benefit per year. This innovative intervention could transform our ability to treat depression early and put a stop to it returning in the future. Written with two lived experience representatives.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH