Prevention versus intervention in school mental health
Authors: Mina Fazel, Brandon A Kohrt
Journal: The Lancet Psychiatry (2019)

Exciting changes are taking place in schools to reinforce the important inter-relationship of education and mental health. Improving child and adolescent mental health will improve the individual's life trajectory and reap untold benefits to the socioeconomic fabric of society.1Patton GC Sawyer SM Santelli JS et al.Our future: a Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Summary Full Text Full Text PDF PubMed Scopus (1543) Google Scholar Mental health services are shifting away from traditional models of health care and into locations such as schools, to improve access to care and increase the availability and diversity of non-specialist mental health workers.2Whitley R Global mental health: concepts, conflicts and controversies.Epidemiol Psych Sci. 2015; 24: 285-291Crossref PubMed Scopus (44) Google Scholar Finally, the conceptualisation of mental health is expanding from the focus on clinically defined disorders to a broader dimensional approach to mental health,3Patel V Saxena S Lund C et al.The Lancet Commission on global mental health and sustainable development.Lancet. 2018; 392: 1553-1598Summary Full Text Full Text PDF PubMed Scopus (924) Google Scholar approaches that are well suited the school environment. Mental health interventions can be perceived as those that promote mental health (such as improving self-esteem), those that prevent mental illness developing (especially in children with known risk factors), and those that treat diagnosed illnesses. The school environment provides opportunities to promote resilience (eg, enhancing teacher support and positive peer networks) and reduce exposure to risk factors (eg, bullying and academic stressors). However, it can be more difficult to define the actual scope of an intervention than in traditional settings. Given the potential benefit of working in schools, we raise concerns that the approach used by Deborah Caldwell and colleagues in The Lancet Psychiatry4Caldwell MC Davies SR Hetrick SE et al.School-based interventions to prevent anxiety and depression in children and young people: a systematic review and network meta-analysis.Lancet Psychiatry. 2019; (published online Nov 13)https://doi.org/10.1016/S2215-0366(19)30403-1Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar might lead to the potentially premature conclusion that there is little evidence to support preventive school-based initiatives. First, the review is limited by a disconnect between the Institute of Medicine's definition of prevention and the manner in which prevention programmes are typically evaluated.5US National Research CouncilInstitute of MedicinePreventing mental, emotional, and behavioral disorders among young people: progress and possibilities. National Academies Press, Washington, DC2009Google Scholar This definition refers to preventions as “interventions that occur prior to the onset of a disorder that are intended to prevent or reduce risk for the disorder”, and therefore, “reduce the incidence of common disorders”. Some of the studies included in the analysis provide outcomes that mix treatment of existing disorders and prevention of new incidences. Caldwell and colleagues4Caldwell MC Davies SR Hetrick SE et al.School-based interventions to prevent anxiety and depression in children and young people: a systematic review and network meta-analysis.Lancet Psychiatry. 2019; (published online Nov 13)https://doi.org/10.1016/S2215-0366(19)30403-1Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar included studies with both symptomatic and asymptomatic students (ie, up to 40% could have depression or anxiety at baseline) and then evaluated outcomes among this mixed group (figure A). A truly preventive analysis needs to evaluate the longer-term novel incidence among students who did not have anxiety or depression at baseline (figure B). Going forward, we recommend that universal prevention evaluations provide outcome information that distinguishes between preventive effects (ie, impact on new incidence) and treatment effects (ie, remission among individuals symptomatic at baseline). Second, from a youth development perspective, the findings in the current meta-analysis do not report other outcomes that might been improved by the interventions. Although the mixed symptomatic and asymptomatic student sample did not show statistical improvement, there might have been population benefits to educational performance, future employment, social functioning, and risk-taking behaviours (figure C). For example, a cognitive-behavioural therapy-based intervention for war-affected youth in Sierra Leone was beneficial for retention in school among all participants, but mental health improvement was limited to youth with more severe distress at baseline.6Betancourt T McBain R Newnham E et al.A behavioral intervention for war-affected youth in Sierra Leone: a randomized controlled trial.J Am Acad Child Adolesc Psychiatry. 2014; 53: 1288-1297Summary Full Text Full Text PDF PubMed Scopus (74) Google Scholar Third, intervention approaches effective for prevention might have been excluded (figure D), such as programmes targeting bullying, mental health promotion programmes, and programmes to help students manage the consequences of a specific event (eg, parental divorce). Moreover, multi-gated interventions (with different approaches for different levels of need) are becoming the mainstay of more evolved school mental health systems.7Fazel M Hoagwood K Stephan S Ford T Mental health interventions in schools in high-income countries.Lancet Psychiatry. 2014; 1: 377-387Summary Full Text Full Text PDF PubMed Scopus (280) Google Scholar, 8Weist MD Hoover S Lever N et al.Testing a package of evidence-based practices in school mental health.School Mental Health. 2019; : 1-15Google Scholar These interventions can have components incorporating environmental, social, and contextual factors, as well as specific cognitive and emotional interventions to treat specific disorders. Some school interventions have a great range and breadth, underlining the complexity of multi-dimensional interventions that will have components aimed at the staff, parents, whole school and specific year groups, and then for children with identified need. Excluding these programmes could misrepresent observed effects across the network. As we herald an exciting new phase in mental health delivery, with increasing access and acceptability of interventions reaching more children with mental health difficulties, we must build the evidence base, and ensure that only interventions that have proven benefit are able to enter these somewhat unregulated new mental health environments. We must identify the right interventions for a school and ensure that they are associated with implementation support to strengthen the evidence base appropriately. This is well demonstrated by a school-based randomised controlled trial of modular evidence-based practice allowing for flexibility and individualisation, alongside family components, quality assessment, and implementation support.8Weist MD Hoover S Lever N et al.Testing a package of evidence-based practices in school mental health.School Mental Health. 2019; : 1-15Google Scholar Rigour is needed to ensure that any statistically sensible method is also clinically meaningful. For children to thrive at school, their needs must be considered and addressed to enable a smooth journey. We declare no competing interests. School-based interventions to prevent anxiety and depression in children and young people: a systematic review and network meta-analysisConsidering unclear risk of bias and probable small study effects for anxiety, we conclude there is little evidence that educational setting-based interventions focused solely on the prevention of depression or anxiety are effective. Future research could consider multilevel, systems-based interventions as an alternative to the downstream interventions considered here. Full-Text PDF Open Access