An online school-based prevention programme targeting substance use, depression, and anxiety in adolescence: improving impact and accessibility
Authors: Catia Magalhães, Bruno Carraça
Journal: The Lancet Digital Health (2020)

Substance use, depression, and anxiety often share common risk factors which may interact. If we wish to address the major public health issues that substance use and mental ill health pose on society, specifically in adolescence, continued research into novel and scalable prevention strategies that target these problems together is crucial.1Erskine HE Moffitt TE Copeland WE et al.A heavy burden on young minds: the global burden of mental and substance use disorders in children and youth.Psychol Med. 2015; 45: 1554-1563Crossref Scopus (309) Google Scholar In The Lancet Digital Health, Maree Teesson and colleagues2Teesson M Newton NC Slade T et al.Combined prevention for substance use, depression, and anxiety in adolescence: a cluster-randomised controlled trial of a digital online intervention.Lancet Digital Health. 2020; (published online Jan 3)https://doi.org/10.1016/S2589-7500(19)30213-4Summary Full Text Full Text PDF Scopus (40) Google Scholar report a multicentre, cluster-randomised controlled trial in secondary schools to assess the effectiveness of the first combined, online, universal, school-based preventive intervention targeting substance use, depression, and anxiety in adolescence. 71 participating schools were randomly assigned to one of four intervention conditions: (1) Climate Schools–Substance Use, focusing on substance use only; (2) Climate Schools–Mental Health, focusing on depression and anxiety only; (3) Climate Schools–Combined, focusing on the prevention of substance use, depression, and anxiety; or (4) active control. A combined prevention model has the potential to maximise prevention effects by capitalising on primary and secondary benefits. Using an online format, these courses were designed to overcome common barriers to effective implementation, such as poor teacher training or time constraints. The authors found evidence that an intervention concurrently targeting substance use, depression, and anxiety in adolescence could reduce the odds of any drinking and heavy episodic drinking, and reduced symptoms of anxiety over a 30-month period. This study is important because innovative prevention approaches that are scalable are needed to address the substantial burden of disease attributed to substance use, depression, and anxiety across the world.3Kessler RC Amminger GP Aguilar-Gaxiola S Alonso J Lee S Ustun TB Age of onset of mental disorders: a review of recent literature.Curr Opin Psychiatry. 2007; 20: 359-364Crossref PubMed Scopus (1783) Google Scholar Also, scaling up online prevention programmes can increase fidelity, reduce costs, and increase the effect and accessibility, not only in a school setting, but also in family or community settings. Randomised controlled trials are needed to test the effectiveness of online courses and compare the delivery method with other group or individual delivery methods.4Kumpfer K Magalhães C Strengthening families program: an evidence based family intervention for parents of high-risk children and adolescents.J Child Adol Subst Abus. 2018; 27: 174-179Crossref Scopus (34) Google Scholar, 5Kumpfer K Magalhães C Xie J Cultural adaptation and implementation of family evidence-based interventions with diverse populations.Prev Sci. 2017; 18: 649-659Crossref PubMed Scopus (51) Google Scholar, 6Ye X Bapuji SB Winters SE et al.Effectiveness of internet-based interventions for children, youth, and young adults with anxiety and/or depression: a systematic review and meta-analysis.BMC Health Serv Res. 2014; 14: 1-9Crossref PubMed Scopus (82) Google Scholar, 7Champion KE Newton NC Barrett EL Teesson M A systematic review of school-based alcohol and other drug prevention programs facilitated by computers or the Internet.Drug Alcohol Rev. 2013; 32: 115-123Crossref PubMed Scopus (113) Google Scholar Data to support self-reported drinking outcomes were not corroborated; although the data were collected using structured and validated instruments and these self-report methods have been shown to be reliable for measuring substance use and mental health in previous studies, it is important in future to corroborate results using additional methods to monitor drinking outcomes. The study included pupils from participating schools in year 8 (New South Wales and Western Australia) or year 9 (Queensland), aged approximately 13–14 years, from schools located in areas less than 1 standard deviation above-average socioeconomic status. 54.8% of the total sample were girls. More than 97% of participants completed at least one wave of follow-up and pupils who missed a follow-up occasion were more likely to be male than female (odds ratio 1·59, p<0·0001), have reported consuming a full standard alcoholic drink in the past 6 months at baseline (2·12, p<0·0001), and to have had a probable diagnosis of anxiety or depression at baseline (1·41, p<0·0001). The authors found no evidence to suggest that these findings affected the results or interpretation of findings across groups, but this finding could limit the generalisability of the findings and should be taken into account in future studies. This study is one of several to assess the effectiveness of online programmes to target substance use and other mental health issues, such as anxiety and depression, which are gaining increased attention in the literature. For example, other studies have shown the effectiveness of online programmes in reducing the severity of anxiety symptoms compared with no intervention, and this effect might be equal to that of face-to-face interventions (or usual care).8Gropper M Computer integrated drug prevention—combining multi-media and social group work practice to teach inner city Israeli 6th graders how to say no to drugs.J Technol Hum Serv. 2002; 20: 49-65Crossref Scopus (6) Google Scholar, 9Duncan TE Duncan SC Beauchamp N Wells J Ary DV Development and evaluation of an interactive CD-ROM refusal skills program to prevent youth substance use: “Refuse to Use”.J Behav Med. 2000; 23: 59-72Crossref PubMed Scopus (39) Google Scholar However, these findings might not apply to adolescents because interventions for these patients usually require parent and schoolteacher involvement. Although the capacity to deliver engaging and interactive interventions online has greatly improved in the past decade, the benefit of online delivery is often overlooked despite the method's advantages. For example, this type of intervention might lower the overall cost by reducing the number of staff members required and time needed and by minimising the use of other resources, such as materials.4Kumpfer K Magalhães C Strengthening families program: an evidence based family intervention for parents of high-risk children and adolescents.J Child Adol Subst Abus. 2018; 27: 174-179Crossref Scopus (34) Google Scholar, 5Kumpfer K Magalhães C Xie J Cultural adaptation and implementation of family evidence-based interventions with diverse populations.Prev Sci. 2017; 18: 649-659Crossref PubMed Scopus (51) Google Scholar The findings by Teesson and colleagues might mean that scalable, innovative, prevention approaches are needed to address the substantial burden of disease attributed not only to substance use, but also to depression and anxiety across the world.7Champion KE Newton NC Barrett EL Teesson M A systematic review of school-based alcohol and other drug prevention programs facilitated by computers or the Internet.Drug Alcohol Rev. 2013; 32: 115-123Crossref PubMed Scopus (113) Google Scholar, 10Calear AL Christensen H Review of internet-based prevention and treatment programs for anxiety and depression in children and adolescents.Med J Aust. 2010; 192: S12-S14Crossref PubMed Scopus (164) Google Scholar Hence, the current study addresses an important gap in the literature by evaluating the effectiveness of the first universal online programme to concurrently target substance use, anxiety, and depression in adolescence. Another promising aspect of this study is that previous universal school-based programmes have demonstrated small to moderate effects in reducing alcohol use. Future studies would benefit from longer-term follow-up to examine the effect of the intervention as exposure to substance use and mental health symptoms increases during the transition out of secondary school. Collection of comprehensive data for costs and long-term effects would also be of interest to allow economic analysis. We declare no competing interests. Combined prevention for substance use, depression, and anxiety in adolescence: a cluster-randomised controlled trial of a digital online interventionCombined online prevention of substance use, depression, and anxiety led to increased knowledge of alcohol, cannabis, and mental health, reduced increase in the odds of any drinking and heavy episodic drinking, and reduced symptoms of anxiety over a 30-month period. These findings provide the first evidence of the effectiveness of an online universal school-based preventive intervention targeting substance use, depression, and anxiety in adolescence. Full-Text PDF Open Access