Title: A brief early intervention for adolescent depression that targets emotional memories: a feasibility randomised controlled trial
Funder: Health Education England

Abstract: Background Key stakeholders and parliamentary committees highlight the urgent need to develop early interventions for adolescents to prevent depression becoming entrenched. The National Institute for Health and Care Excellence specifies a clear stepped-care approach for adolescent depression, beginning with psychological intervention. Pharmacotherapy is not recommended for initial treatment, partly due to serious concerns about its longer term implications. However, whilst preferred, psychological interventions are (i) difficult to access and (ii) lack convincing evidence of effectiveness. Access could be improved by delivering interventions in school-settings to reduce barriers of time, cost and stigma. Effectiveness could be enhanced by focussing on a promising new treatment target - memory biases - as people with depression frequently experience past distressing memories and struggle to imagine positive events in their future. There are effective interventions using imagery-based methods that target these memory biases in adults. The lack of similar research in adolescence is surprising given depressive symptoms commonly begin in adolescence, cognitive biases are likely to stabilise during this time and adolescents may harness imagery techniques more readily than traditional verbal approaches. Translating these effective psychological treatments from adults to adolescents therefore offers the potential for a brief early intervention, anchored in cognitive science, which could reduce the devastating and long-term impact of depression. Objectives The primary aim is to develop a brief easy-to-access psychological intervention for adolescent depression that can be delivered in schools by practitioners without extensive training. This intervention will combine key components of current evidence-based practice in adults to (1) reduce the emotional power of memories from distressing experiences and (2) improve mood and enhance goal-directed behaviour, through increasing recall of positive memories and ability to imagine future goals. The proposal has been developed alongside service-users who have, for example, strongly recommended delivering the intervention in schools and advised on practicalities, including recruitment strategies. Service-user consultants will join the trial steering group, develop outcome measures, conduct post-therapy interviews, and contribute to qualitative analysis and dissemination. Elements of experience-based co-design will be incorporated, including individual interviews with key stakeholders. Plan of Investigation The proposed design is a feasibility randomised controlled trial. Seventy adolescents (aged 12-18) with symptoms of depression will be recruited from schools. Participants will be randomly assigned to one of two groups: intervention (3 sessions) versus control (3 sessions: non-directive supportive therapy). Data on feasibility will be recorded and symptom assessment will take place pre-intervention, post-intervention and at 3 month follow-up. Individual interviews with participants, parents and frontline practitioners will provide qualitative feedback and inform intervention development.Expected Outcomes The main outcome is data on intervention feasibility and acceptability, including recruitment, retention and response rates, and participant ratings of acceptability. Clinical measures of symptom change following treatment, including objective assessment of arousal (i.e. heart rate), will provide an estimate of the number of participants needed for a fully powered efficacy randomised controlled trial. A key deliverable will be an easy to understand treatment manual for practitioners. Anticipated Benefits Feasibility, acceptability and clinical data for this brief psychological intervention will inform whether an efficacy randomised controlled trial is warranted and aid planning of this trial. If this intervention is identified as safe and effective, it can be rolled out as an intervention in Tier 2 services (e.g. delivered by counsellors or primary mental health workers). The proposed research could, therefore, significantly change current clinical practice within five years of completion. This psychological intervention capitalises on the powerful relationship between emotion and memory to begin to address a nationwide crisis in adolescent mental health, including stress and suicide.

Lay abstract: Background Depression in adolescence is common and impairing. Almost a third of adolescents will experience a depressive episode by age 19. When depression begins in adolescence rather than adulthood, it is associated with ten times the economic costs and significantly worse outcomes, from stress to suicide. The Health Committee (House of Commons) emphasise the importance of early interventions for depression which are clearly specified in National Institute for Health and Care Excellence guidelines. However, current interventions for adolescent depression are (i) difficult to access and (ii) suboptimal. First, evidence-based therapies are rarely implemented in everyday clinical settings, with few adolescents gaining access to expensive gold-standard treatments that frequently have long wait-lists. Schools offer an ideal setting to improve access as they maximize contact with adolescents, stakeholders recommend them and they reduce barriers to treatment including cost, location, time and stigma. Second, treatment options for adolescent depression urgently need innovation. There are serious concerns about the longer term implications of pharmacotherapy and, whilst psychological interventions are preferred, they frequently fail to show sustained improvements. Recent advances in the understanding of what drives adult depression raise new ways to focus treatment efforts. These have large potential but are currently untested in adolescents. The way we remember events and think about our future hugely impacts on how we see ourselves, navigate and plan our lives. People with depression experience frequent negative distressing memories, yet struggle to remember positive events and imagine anything positive happening in the future. For example, an adolescent with depression might be plagued by a memory of being teased by their classmates, struggle to remember occasions when they had fun with friends and, when they think about their future, only situations in which they are bullied and rejected come into their minds rather than other more positive possibilities. Extremely promising, imagery-based approaches are emerging that can modify these tendencies to recall negative rather than positive memories. These approaches have produced encouraging results in adults with a range of mental health difficulties, including depression, and could be particularly suitable for adolescents who may more readily use imagery rather than verbal techniques. Capitalising on the close relationship between memory and emotion offers a promising and unexplored early intervention to prevent the transition of common, disabling and costly depressive symptoms into adulthood. Aims of the research The primary aim is to develop a brief easy-to-access psychological intervention for adolescents with depression that can be delivered in schools by professionals without extensive training (e.g. school counsellors). This intervention will combine key components of current evidence-based practice in adults to (1) reduce the emotional power of memories from past distressing experiences and (2) improve mood, build hope and enhance engagement in important activities, through increasing the ability to recall positive memories and imagine future positive events. The primary outcome will be feasibility data (e.g. time taken to recruit participants and participant feedback on intervention acceptability) and initial data on changes symptoms of depression. Design and methods used Seventy adolescents (aged 12-18) scoring above clinical cut-off on a questionnaire measure of depression will be recruited from local schools. The design will be a feasibility randomised controlled trial': participants will be randomly allocated to the intervention group (3 sessions) or a control group (3 sessions of non-directive supportive therapy) and data will be collected on feasibility, acceptability and symptoms before and after the intervention, and 3 months following the intervention. Participants, parents and frontline practitioners likely to implement the intervention will be invited to individual interviews to provide feedback to inform intervention development. This feasibility study is essential preparatory work for a future trial to determine treatment effectiveness, which could take place within three years of completing this trial. Therefore, the proposed research could significantly benefit adolescents with depression within five years of completion. Patient and public involvement Adolescents and adults with a history of mental health difficulties, parents, teachers and practitioners have been central in developing the intervention content and trial methodology. For example, they strongly recommended a school-setting for intervention delivery and suggested strategies to maximise recruitment, including a question and answer' evening for parents. Service-user consultants will join the trial steering group, develop outcome measures, conduct post-therapy interviews, and contribute to qualitative analysis and dissemination of the results. DisseminationThe results will be disseminated to participants, practitioners and service managers as well as academics and service-users. Plans for dissemination are at local, UK wide and international levels, including presentations and publications in peer-reviewed academic journals.

Research activity codes: 5.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH