Where to Go from Here? An Exploratory Meta-Analysis of the Most Promising Approaches to Depression Prevention Programs for Children and Adolescents

1. Introduction

2. Materials and Methods

Figure 1. Flow diagram of trials.

Figure 1. Flow diagram of trials.

2.5. Subgroup Analysis

Subgroup analysis allows investigation of whether the intervention effects vary with different intervention characteristics. Analysis of subgroups by the therapeutic approach used in the intervention was undertaken according to the following categories: CBT (including online CBT), IPT, and other. We categorized trials as ‘CBT’ if cognitive restructuring was described.

Further subgroup analysis was undertaken of those studies that were categorized as CBT according to the named program that was tested, or approach if there was no specific program name including: the Penn Resiliency Program (PRP), Ease of Handling Social Aspects in Everyday Life Training (LISA-T), Resourceful Adolescent Program (RAP), the stress inoculation approach, the Positive Thinking Program, FRIENDS, The Blues Program, Coping with Stress, Confident Kids, Learn Young Learn Fair, Teaching Kids to Cope, MoodGYM, Problem Solving for Life, with the remainder classified as “unspecified”.

Two authors (SH and GC) independently read the descriptions of the interventions of each included study (see Table 1) and coded them according to the type of intervention and the type of CBT program. Discrepancies in this coding were resolved by a third author (SM).

To investigate treatment effects in these different subgroups, the overlap of the confidence intervals of the summary estimates was considered. In addition, significant differences between subgroups were explored following the method of Borenstein et al [18] as implemented in RevMan 5.1 [19]. The procedure involves undertaking a standard test for heterogeneity across subgroup results rather than across individual study results.

Table 1. Characteristics and coding of nature of interventions tested in included studies.

Table 1. Characteristics and coding of nature of interventions tested in included studies.

Study Name	Description	Therapeutic Approach	Specific CBT Program Name
Arnarson 2009 [20]	Based on a number of previous programs including the Coping with Depression and its derivative Coping with Stress program. The focus was on the development of adaptive coping skills to enhance self-esteem and well-being. Stated it incorporated principles of interpersonal therapy, problem solving, behavioural, and cognitive models (pg 581).	CBT & IPT	Unspecified
Balle 2009 [21]	Based on the FRIENDS program; includes education about anxiety, cognitive restructuring, emotional regulation techniques (activation control strategies, controlled breathing, relaxation and cognitive distraction), and gradual exposure to feared situations.	CBT	FRIENDS
Berry 2009 [22]	The Confident Kids program focuses on anxiety and included psychoeducation, cognitive restructuring and graded exposure. Also included education about bullying, coping strategies for bullying situations and sessions on social skill and self esteem enhancement.	CBT	Confident Kids
Barnet 2007 [23]	Trained home visitors provided parenting curriculum (child development, parenting skills, appropriate health care use), encouraged contraceptive use, connected adolescent with primary care, school continuation, provided mentoring and case management, sought to identify depression, partner abuse and school drop out and follow-up of these issues.	Other
Bond 2004 [24]	The Gatehouse project is a school health promotion program with both individual and ‘whole school’ focused components. The individual component focused on teaching students to identify difficult/conflicting emotional responses to common social situations and develop strategies for responding. The whole school component included a school based adolescent health team as well as interventions to address identified risk and protective factors in the schools social and learning environment.	Other
Cabiya 2008 [25]	Primarily social problem solving that included teaching adolescents how to understand social cues, how to make accurate interpretations of these cues; how to generate a variety of solutions to a problem they perceive in the social setting; how to decide which solution to enact and how to enact the chosen solution.	CBT	Unspecified
Calear 2009 [26]	MoodGYM is an online CBT program that includes cognitive restructuring, interpersonal skills, relaxation and problem solving. It is fully automated and self-directed.	CBT - online	MoodGYM
Cardemil 2002 a [27]-African American	The Penn Resiliency Program (PRP) includes cognitive restructuring, relaxation and emotion regulation, assertiveness, coping skills, negotiation, social skills, creative and social problem solving, and decision-making.	CBT	PRP
Cardemil 2002 b [27]-Latina	Penn Resiliency Program (PRP)	CBT	PRP
Chaplin a 2006 [28]-girls only	Penn Resiliency Program (PRP)	CBT	PRP
Chaplin b2006 [28]-co-ed	Penn Resiliency Program (PRP)	CBT	PRP
Clarke 1993 [29]	Behavioural skill training intervention that focused on increasing daily rates of pleasant activities.	CBT	Unspecified
Clarke 1995 [30]	The Adolescent Coping with Stress program teaches cognitive restructuring and problem solving skills. The course was based on the “Adolescent Coping with Depression Course” (Clarke et al. 1990). Specifically it teaches adolescents to (a) monitor daily moods; (b) identify activating events; (c) discover, challenge, realistically evaluate, and revise negative beliefs; (d) recognize the connections among activating events, beliefs, and consequences (e.g., affect and behaviours); and (e) problem solve and cope with stressful events.	CBT	Coping with Stress
Clarke 2001 [31]	Adolescent Coping with Stress program	CBT	Coping with Stress
Garber 2009 [32]	Adolescent Coping with Stress program with behavioural activation, relaxation and assertiveness training as part of the continuation phase	CBT	Coping with Stress
Gillham 1995 [33]	Included cognitive restructuring, and social problem solving. The social problem solving component focused on conduct problems and interpersonal problems often associated with depression and included teaching children to thinking about their goals before acting, generating a list of possible solutions for problems and making decisions about which solution to enact based on pro’s and con’s of each. They were also taught skills to help cope with parental conflict, and behavioural techniques to enhance assertiveness, negotiation and relaxation.	CBT	PRP
Gillham & Reivich 2006 [34]	Penn Resiliency Program (PRP) with parent component included based on the theory that children learn interpretive and coping styles from their parents, and that helping to prevent or reduce depression in parents interrupts transmission from parents to children.	CBT	PRP
Gillham & Hamilton 2006 [35]	Penn Resiliency Program (PRP)	CBT	PRP
Gillham 2007 [36]	Penn Resiliency Program (PRP)	CBT	PRP
Hains 1990 [37]	Based on cognitive-behavioural stress-inoculation training model developed by Meichenbaum (1985). Included cognitive restructuring around common self defeating cognitions lead to stress and anger.	CBT	Stress Inoculation
Hains 1992 [38]	One group received stress inoculation as in Hains 1990; the second group received anxiety management training following the Suinn 1986 manual that includes learning how to recognise cues that signal the onset of anxiety and the use of relaxation skills to relieve anxiety.	CBT	Stress Inoculation
Horowitz a 2007 [39]	Derived from the Adolescent Coping with Stress program	CBT	Coping with Stress
Horowitz b 2007 [39]	Derived from the IPT–AST (Young & Mufson, 2003) course. IPT-AST includes two individual sessions and 8 group sessions delivering psychoeducation about the relationship between interpersonal difficulties and depression and skill building including communication and interpersonal strategies related to three interpersonal problem areas: interpersonal role disputes, role transitions, and interpersonal deficits.	IPT	IPT-AST
Hyun 2005 [40]	The program integrated cognitive and behavioral components. The cognitive components included identifying reasons for running away from home, identifying high-risk situations including negative emotional states, cognitive distortions and dysfunctional coping strategies, and behavioral components included developing coping strategies such as pleasant activities and relaxation and planning for future life.	CBT	Unspecified
Kraag 2009 [41]	The Learn Young, Learn Fair program addressed stress, stress awareness and coping skills.	CBT	Learn Young, Learn Fair
Lock 2003 [42]	The FRIENDS program (Barrett 2000) was originally based on the Coping Cat (Kendall, 1990) and Coping Koala (Barrett, 1998) programs. It included education about anxiety, cognitive restructuring, emotional regulation techniques (activation control strategies, controlled breathing, relaxation and cognitive distraction), and gradual exposure to feared situations (including interoceptive exposure).	CBT	FRIENDS
Lowry-Webster 2001 [43]	FRIENDS program.	CBT	FRIENDS
Pössel 2004 [44]	The Ease of Handling Social Aspects in Everyday Life-Training (LISA-T) program is based on cognitive behavioural therapy and includes cognitive restructuring as well as a social focus with models of assertiveness and social competence training which targets students ability to develop and maintain social contacts.	CBT	LISA-T
Pössel 2008 [45]	LISA-T	CBT	LISA-T
Puskar 2003 [46]	The Teaching Kids to Cope program is aimed to teach skills that help young people cope with problems and stress. It includes cognitive restructuring but has more emphasis on behavioural skill building including social skills training, assertiveness training, conflict resolution and relaxation. It uniquely includes bibliotherapy, role-playing, and group exercises such as ‘trust-fall’, buddy assignments, and role playing situations from school as well as art activities.	CBT	Teaching Kids to Cope
Quayle 2001 [47]	Adapted PRP and called the Optimism and Life Skills Program	CBT	PRP
Rivet-Duval 2010 [48]	The Resourceful Adolescent Program (RAP) integrates elements of cognitive behavioural therapy (CBT) and interpersonal therapy. It includes behavioural activation with a focus on activities that increase self-esteem, cognitive restructuring, relaxation techniques, problem solving and conflict resolution.	CBT & IPT	RAP
Roberts 2003 [49]	Penn Resiliency Program (PRP)	CBT	PRP
Roberts 2010 [50]	The Aussie Optimism Program (AOP) program is based on PRP but targets anxiety as well as depression.	CBT	PRP
Rooney 2006 [51]	The Positive Thinking Program (PTP) program is based in part on the Aussie Optimism Program (AOP). It includes cognitive restructuring, and training in relaxation and distraction skills.	CBT	Positive Thinking Program
Sawyer 2010 [52]	The beyondblue schools research initiative utilised individual and ‘whole school’ focused components. The individual component aimed to improve problem solving and social skills, resilient thinking style and coping strategies. The whole school component included enhancements to the school climate to improve the quality of social interactions amongst all members of the school; improvements to care pathways to improve adolescents access to support and professional services; and community forums to provide adolescents, their families and school personnel to information about recognising problems and how to seek help.	CBT	beyondblue Schools Research Initiative
Seligman 1999 [53]	Intervention is based on CBT and similar PRP and includes cognitive restructuring, behavioural activation interventions including graded task breakdown, time management, anti-procrastination techniques, creative problem solving, assertiveness training, interpersonal skills including active listening, taking each other’s perspectives, controlling emotions, passive vs. assertive vs. aggressive behaviours, and relaxation training.	CBT	Unspecified
Seligman 2007 [54]	Replication of Seligman 1999 intervention with additional of web-based material and e-coaching primarily aimed at maintaining intervention effects over time.	CBT-partly online	Unspecified
Shatte 1997 [55]	Penn Resiliency Program (PRP)	CBT	PRP
Sheffield 2006 [56]	The Universal intervention included cognitive restructuring as well as problem solving interventions and was similar to the intervention described in Spence 2003. The indicated prevention program included these elements but also included interpersonal skills such as assertiveness, conflict resolution and negotiation and self-reward.	CBT	Problem Solving for Life
Spence 2003 [57]	The Problem Solving for Life (PSFL) program integrates cognitive restructuring and problem-solving skills training.	CBT	Problem Solving for Life
Stice a 2007 [58]	Based on the Coping with Stress program and focused on building rapport, increasing pleasant activities and cognitive restructuring.	CBT	Blues Program
Stice b 2007 [58]	Supportive-expressive group therapy, which aimed to establish and maintain rapport, provide support, and help the client identify and express emotions.	Other
Stice c 2007 [58]	Bibliotherapy, which is the prescription of books for the treatment of a disorder.	Other
Stice d 2007 [58]	Expressive writing in which participants write about issues of emotional significance to them.	Other
Stice e 2007 [58]	Journalling	Other
Stice a 2008 [59]	Based on the Coping with Stress program and focused on building rapport, increasing pleasant activities and cognitive restructuring	CBT	Blues Program
Stice b 2008 [59]	Supportive-expressive group therapy, which aims to establish and maintain rapport, provide support, and help the client identify and express emotions.	Other
Stice c 2008 [59]	Cognitive Behavioural Bibliotherapy	Other
Yu 2002 [60]	Chinese version of the Penn Resiliency Program (PRP)	CBT	PRP
Young 2006 [61]	The Interpersonal Therapy-Adolescent Skills Training (IPT–AST) program was created as an extension of interpersonal therapy. IPT–AST teaches communication and social skills necessary to develop and maintain positive relationships.	IPT

ASQ: Attributional Style Questionnaire; CDI: Children’s depression Inventory; BDI: Beck Depression Inventory; CASQ: Childrens Attributional Style Questionnaire; CBCL-YSR: Child Behaviour Checklist-Youth Self Report; CES-D: Centre for Epidemiologic Studies Depression Scale; CIS-R: Clinical Interview Schedule-Revised; CPQ: child perception questionnaire (measures child’s perception of parental conflict); DSRS: Depression Self-Rating Scale RADS-2 : Reynolds Adolescent Depression Scale; RCADS: Revised Child Anxiety and Depression Scale; SBS-DES: Self-Report Questionnaire-Depression; SDIC: Short Depression Inventory for Children.

Sensitivity analysis allows investigation of the robustness of findings to decisions made about inclusion of studies. We had broad inclusion criteria and therefore we undertook sensitivity analyses using subgroup comparisons to assess the robustness of findings with regard to whether:

• Interventions were delivered to universal versus targeted populations;
• Interventions were delivered by a mental health clinician (including graduate level school counselors, school psychologists, cognitive and other therapists, clinical and other psychologists, psychiatric nurses, psychiatrist and mental health clinicians) versus students being trained in any of these mental health professions versus non mental health personnel;
• Interventions included eight sessions or more versus less than eight sessions;
• Outcomes were measured by the CDI/BDI versus the CES-D versus the RADS versus other measures.

3. Results

3.3. Effects of Intervention

3.3.1. By Type of Intervention

CBT

There was evidence that the risk of having a depressive disorder was reduced by CBT post intervention, and at 3–9 month and 12 month follow-up. The level of depression symptoms was also reduced post intervention and at 12 month follow-up. However, there was a great deal of heterogeneity in findings (see Table 3).

Table 2. General characteristics of included studies.

Table 2. General characteristics of included studies.

Study Name	Size	Format	Targeted or Universal	Therapeutic Approach	Specific CBT Program Name	Number of Sessions	Manualised	Parent Component	Delivered by		Inclusion Criteria for Targeted Populations	Depression Outcome Measure
Arnarson 2009 [20]	171	Group	Targeted	CBT & IPT	Unspecified	14	Yes	No	Mental Health clinician		75th–90th percentile on CDI or >75th percentile on negative composite of the CASQ	CDI
Balle 2009 [21]	145	Group	Targeted	CBT	FRIENDS	6	Yes	No	Student mental health clinicians		High anxiety sensitivity	CDI
Berry 2009 [22]	54	Group	Targeted	CBT	Confident Kids	8	Yes	Yes	Student mental health clinicians		Anxiety symptoms	CES-D
Barnet 2007 [23]	84	Group	Targeted	Other		36	Yes	Yes	Non mental health personnel		Pregnant adolescents	CES-D
Bond 2004 [24]	2678	Group	Universal	Other		20	Yes	No	School teachers		NA	CIS-R
Cabiya 2008 [25]	278	Group	Targeted	CBT	Unspecified	12	Yes	No	Student mental health clinicians		Disruptive behaviour disorders	CDI
Calear 2009 [26]	1384	Individual	Universal	CBT-online	MoodGYM	5	Yes	No	Internet-based		NA	CES-D
Cardemil 2002 [27]	Trial 1: 49; Trial 2: 103	Group	Universal	CBT	PRP	12	Yes	No	Student mental health clinicians		NA	CDI
Chaplin 2006 [28]	234	Group	Universal	CBT	PRP	12	Yes	No	Both mental and non mental health personnel		NA	CDI
Clarke 1993 [29]	622	Group	Universal	CBT		3	Yes	No	Non mental health personnel		NA	CES-D
Clarke 1995 [30]	125	Group	Targeted	CBT	Coping with Stress	15	Yes	No	Mental health clinician		CES-D score of >=24	CES-D
Clarke 2001 [31]	94	Group	Targeted	CBT	Coping with Stress	15	Yes	Yes	Mental health clinician		CES-D score of ≥ 24 & parent with previous or current depressive episode	CES-D
Garber 2009 [32]	316	Group	Targeted	CBT	Coping with Stress	14	Unclear	Yes	Mental health clinician		CES-D score of ≥ 20 & parent with previous or current depressive episode	CES-D
Gillham 1995 [33]	143	Group	Targeted	CBT	PRP	12	Unclear	Yes. In the child-parent group only.	Student mental health clinicians		Children with summed z scores of ≤ 0.50 on CDI & CPQ	CDI
Gillham & Reivich 2006 [34]	44	Group	Targeted	CBT	PRP	8	Yes	Yes	Mental health clinician		High levels of depression and anxiety	CDI
Gillham & Hamilton 2006 [35]	271	Group	Targeted	CBT	PRP	12	Yes	No	Mental health clinician		CDI scores ≥ 7 for girls and ≥ 9 for boys	CDI
Gillham 2007 [36]	697	Group	Universal	CBT	PRP	12	Yes	No	Mental and non mental health personnel and students		NA	CDI
Hains 1990 [37]	24	Group	Universal	CBT	Stress Inoculation	5	Unclear	No	Mental health clinician		NA	BDI
Hains 1992 [38]	25	Group (plus 1 individual session)	Universal	CBT	Stress Inoculation	4	Unclear	No	Mental health clinician		NA	RADS
Horowitz a 2007 [39]	112	Group	Universal	CBT	Coping with Stress	8	Yes	No	Student mental health clinicians		NA	CES-D
Horowitz b 2007 [39]	99	Group	Universal	IPT	IPT-AST	8	Yes	No	Student mental health clinicians		NA	CES-D
Hyun 2005 [40]	32	Group	Targeted	CBT	Unspecified	8	Unclear	No	Mental health clinician	Runaway youth		BDI
Kraag 2009 [41]	1437	Group	Universal	CBT	Learn Young, Learn Fair	13	Yes	No	Non mental health personnel	NA		SDIC
Lock 2003 [42]	977	Group	Universal	CBT	FRIENDS	10	Yes	No	Student mental health clinicians	NA		CDI
Lowry-Webster 2001 [43]	594	Group	Universal	CBT	FRIENDS	10	Yes	Yes	Non mental health personnel	NA		CDI
Pössel 2004 [44]	342	Group	Universal	CBT	LISA-T	10	Yes	No	Mental health clinician	NA		CES-D
Pössel 2008 [45]	301	Group	Universal	CBT	LISA-T	10	Yes	No	Non mental health personnel with student mental health professionals	NA		SBB-DES
Puskar 2003 [46]	89	Group	Targeted	CBT	Teaching Kids to Cope	10	Unclear	No	Mental health clinician	RADS score ≥ 60		RADS
Quayle 2001 [47]	47	Group	Universal	CBT	PRP	8	Yes	No	Student mental health clinician	NA		CDI
Rivet-Duval 2010 [48]	160	Group	Universal	CBT & IPT	RAP	11	Yes	No	Non mental health personnel	NA		RADS
Roberts 2003 [49]	189	Group	Targeted	CBT	PRP	12	Yes	No	Mental health clinician	Elevated scores on the CDI		CDI
Roberts 2010 [50]	496	Group	Universal	CBT	Aussie Optimism Program	10	Yes	No	Non mental health personnel	NA		CDI
Rooney 2006 [51]	136	Group	Universal	CBT	Positive Thinking Program	8	Yes	No	Mental health clinician	NA		CDI
Sawyer 2010 [52]	5634	Group	Universal	CBT	beyondblue Schools Research Initiative	30	Yes	No	Non mental health personnel	NA		CES-D
Seligman 1999 [53]	231	Group	Targeted	CBT	Unspecified	8	Yes	No	Mental health clinician	Scored in the pessimistic quarter of the ASQ		BDI
Seligman 2007 [54]	227	Group	Targeted	CBT-partly online	Unspecified	8	Yes	No	Mental health clinician	BDI score of 9–24		BDI
Shatte 1997 [55]	152	Group	Universal	CBT	PRP	12	Yes	No	Non mental health personnel with student mental health professionals	NA		CDI
Sheffield 2006 [56]	2606	Group	Universal and targeted	CBT	Problem Solving for Life	8	Yes	No	Non mental health personnel for Universal; Mental health clinician for targeted	Score in the top 20% on the combined scores on the CDI & CES-D.		CDI
Spence 2003 [57]	1234	Group	Universal	CBT	Problem Solving for Life	8	Yes	No	Non mental health personnel	NA		BDI
Stice a 2007 [58]	50	Group (CBT)	Targeted	CBT	Blues Program	4	Yes	No	Student mental health clinician	CES-D score of ≥ 20		BDI
Stice b 2007 [58]	19	Group (Supportive expressive)	Targeted	Other		4	Yes	No	Student mental health clinician	CES-D score of ≥ 20		BDI
Stice c 2007 [58]	28	Individual (Bibliotherapy)	Targeted	Other		Not specified	Yes	No	Self-led	CES-D score of ≥ 20		BDI
Stice d 2007 [58]	27	Individual (Expressive writing)	Targeted	Other		4	Yes	No	Self-led	CES-D score of ≥ 20		BDI
Stice e 2007 [58]	34	Individual (Journaling)	Targeted	Other		Not specified	Yes	No	Self-led	CES-D score of ≥ 20		BDI
Stice a 2008 [59]	89	Group (CBT)	Targeted	CBT	Blues Program	6	Yes	No	Student mental health clinician	CES-D score of ≥ 20		CES-D
Stice b 2008 [59]	88	Group (Supportive Expressive)	Targeted	Other		6	Yes	No	Student mental health clinician	CES-D score of ≥ 20		CES-D
Stice c 2008 [59]	80	Individual (Bibliotherapy)	Targeted	Other		Not specified	Yes	No	Self-led	CES-D score of ≥ 20		CES-D
Yu 2002 [60]	270	Group	Targeted	CBT	PRP	10	Yes	No	Non mental health personnel	Elevated scores on the CDI and the Cohesion and Conflict subscales of the Family Environment scale		CDI
Young 2006 [61]	41	Group	Targeted	IPT		10	Yes	No	Mental health clinician	CES-D score of 16–39		CES-D

ASQ: Attributional Style Questionnaire; CDI: Children’s depression Inventory; BDI: Beck Depression Inventory; CASQ: Childrens Attributional Style Questionnaire; CBCL-YSR: Child Behaviour Checklist-Youth Self Report; CES-D: Centre for Epidemiologic Studies Depression Scale; CIS-R: Clinical Interview Schedule-Revised; CPQ: child perception questionnaire (measures child’s perception of parental conflict); DSRS: Depression Self-Rating Scale RADS-2: Reynolds Adolescent Depression Scale; RCADS: Revised Child Anxiety and Depression Scale; SBS-DES: Self-Report Questionnaire-Depression; SDIC: Short Depression Inventory for Children.

IPT

There were two studies that included an intervention that contained elements of both CBT and IPT interventions [20,48], one study that included one arm that tested a purely IPT intervention [39] and one study that tested the efficacy of IPT with a control group [61]. Two studies that included an intervention which contained elements of both CBT and IPT showed that there was no evidence that interventions that included IPT reduced the risk of having a depressive disorder post intervention; however, at 3–9 months there was evidence that interventions that included IPT reduced the risk of depressive disorder, with no heterogeneity evident at this time point. The Young 2006 study [61], which was purely IPT, was combined with the Rivet-Duval 2010 study [48] (which also included elements of CBT) and there was evidence that interventions that include elements of IPT reduced depression symptoms at post intervention, although there was significant heterogeneity and the evidence of effect did not remain at 3–9 month follow-up. Only the Young 2006 study [61] measured depression symptoms at 12-month follow-up and there was no evidence of effect (see Table 3).

Other

There was little evidence that these programs reduced the risk of depressive disorder or reduced depressive symptoms compared with no intervention post intervention, at 3–9 month or 12 month follow-up.

Test for Differences between Types of Intervention

There was evidence that the treatment effect for depressive disorder was modified by the type of therapeutic approach taken to depression prevention at post intervention and 12 month follow-up, and for depression symptoms at 12-month follow-up (see Table 3). When those studies that included both CBT and IPT interventions were excluded in sensitivity analysis, these subgroup differences remained.

Table 3. Summary of meta-analysis results for the therapeutic approach to prevention programs.

Table 3. Summary of meta-analysis results for the therapeutic approach to prevention programs.

Program	Post Intervention		3–9 Month Follow-up		12-Month Follow-up
	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)
CBT	14 studies; 16 intervention arms; N = 1776 RD −0.11; 95% CI −0.17 to −0.05 I2 = 66%	39 studies; 39 intervention arms; N = 11630 SMD −0.12; 95% CI −0.24 to −0.01 I2 = 86%	14 studies; 18 intervention arms; N = 2254 RD −0.11; 95% CI −0.15 to −0.06 I2 = 46%	27 studies; 33 intervention arms; N = 6351 SMD −0.09; 95% CI −0.25 to 0.07 I2 = 87%	9 studies; 10 intervention arms; N = 1149 RD−0.08; 95% CI −0.16 to -0.00 I2 = 75%	16 studies; 21 intervention arms; N = 5047 SMD −0.11; 95% CI −0.17 to −0.04 I2 = 13%
IPT	2 studies; 2 intervention arms; N = 265 RD 0.09; 95% CI −0.35 to 0.17	3 studies; 3 intervention arms; N = 327SMD −0.54; 95% CI −0.94 to −0.13 I2 = 67%	2 studies; 2 intervention arms; N = 252 RD −011; 95% CI −0.19 to −0.04 I2 = 0%	3 studies; 4 intervention arms; N = 327 SMD −0.26 [−0.62, 0.10]	NA	1 study; 1 intervention; N = 41 SMD −0.56 [−1.22, 0.10]
Other	4 studies; 5 intervention arms; N = 1843 RD −0.01; 95% CI −0.05 to 0.02	5 studies; 9 intervention arms; N = 2178 SMD −0.21; 95% CI −0.39 to −0.03 I2 = 52%	3 studies; 5 intervention arms; N = 623 RD −0.02; 95% CI −0.11 to 0.07	4 studies; 9 intervention arms; N = 766 SMD −0.08; 95% CI −0.23 to 0.07	2 studies; 2 intervention arms; N = 1363 RD 0.01; 95% CI −0.03, 0.05	2 studies; 2 intervention arms; N = 1375 SMD 0.14; 95% CI 0.03 to 0.24 I2 =0%
Subgroup differences	χ2 = 8.86,	χ2 = 2.85,	χ2 = 3.18,	χ2 = 0.83,	χ2 = 4.13,	χ2 = 17.07,
	p = 0.01	p = 0.24	p = 0.20	p = 0.66	p = 0.04	p = 0.0002

RD: Risk Difference; SMD: Standardised Mean Difference; Bold font indicates significant results.

3.3.2. By CBT Program Type

Penn Resiliency Program (PRP)

This program is the most studied intervention of all the named CBT programs with 10 studies of this program or its derivatives. Overall, the risk of depressive disorder was reduced at all three time points and depressive symptoms were also reduced at all three time points (see Table 4). There is considerable heterogeneity associated with the results for reduction in depressive disorder at post intervention and 3 to 9 months follow-up, which indicates considerable variation across studies. For example, results based on data from the African American sample in the study by Cardemil [27] are quite different to that of the Latino study to study; and the results for the child only intervention group are different to that of the parent and child intervention group in study by Gillham 1995 [33]. However, even after removing these data, there remains considerable unexplained statistical heterogeneity.

Coping with Stress

Four studies tested the effectiveness of this intervention. There was evidence that it reduced the risk of having a depressive disorder post intervention and at longer-term follow-up. There was also evidence that this program reduced depression symptoms post intervention but not at 3 to 9 or 12 month follow-up. Heterogeneity was high for depressive disorder post intervention (see Table 4).

Table 4. Summary of meta-analysis results for named programs.

Table 4. Summary of meta-analysis results for named programs.

Program	Post Intervention		3–9 Month Follow-up		12-Month Follow-up
	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)
PRP	6 studies; 8 intervention arms; N = 483 RD −0.18 [−0.31, −0.05] I2 = 74%	11 studies; 12 intervention arms; N = 1628 SMD 0.11 [−0.21, 0.00] I2 = 0%	5 studies; 6 intervention arms; N = 363 RD −0.19 [−0.36, −0.01] I2 = 84%	10 studies; 13 intervention arms; N = 1206 SMD −0.17 [−0.29, −0.05] I2 = 0%	4 studies; 5 intervention arms; N = 273 RD −0.05 [−0.14, −0.03] I2 = 16%	7 studies; 10 intervention arms; N = 926 SMD −0.18 [−0.31, -0.05] I2 = 0%
Coping with Stress	2 studies; 2 intervention arms; N = 215 RD −0.16 [−0.27, −0.04] I2 = 49%	4 studies; 4 intervention arms; N = 598 SMD −0.34 [−0.50, −0.17] I2 = 0%	2 studies; 2 intervention arms; N = 427 RD −0.12 [−0.19, −0.04] I2 = 0%	3 studies; 3 intervention arms; N = 494 SMD −0.14 [−0.32, 0.04]	2 studies; 2 intervention arms; N = 195 RD −0.12 [−0.24, −0.01] I2 = 0%	2 studies; 2 intervention arms; N = 196 SMD −0.25 [−0.77, 0.27]
Friends	1 study; 1 intervention arm; N = 239 RD −0.06 [−0.17, 0.04]	3 studies; 3 intervention arms; N = 486 SMD −0.09 [−0.28, 0.09]	NA	1 study; 1 intervention arm; N = 68 SMD 0.19 [−0.29, 0.67]	2 studies; 2 intervention arms; N = 452 RD −0.12 [−0.57, 0.33]	2 studies; 2 intervention arms; N = 418 SMD −0.27 [−0.47, −0.06] I2 = 0%
Positive Thinking Program	1 study; 1 intervention arm; N = 76 RD −0.10 [−0.25, 0.05]	1 study; 1 intervention arm; N = 76 SMD −0.57 [−1.04, −0.10]	1 study; 1 intervention arm; N = 75 RD −0.21 [−0.37, −0.05]	1 study; 1 intervention arm; N = 75 SMD −0.25 [−0.71, 0.21]	NA	NA
Blues Program	NA	2 studies; 2 intervention arms; N = 153 SMD −0.65 [−1.03, −0.26] I2 = 0%	1 study; 1 intervention arm; N = 100 RD −0.09 [−0.25, 0.07]	2 studies; 2 intervention arms; N = 153 SMD −0.38 [−0.76, −0.00] I2 = 0%	NA
Aussie Optimism Program	NA	1 study; 1 intervention arm; N = 427 SMD 0.14 [−0.05, 0.33]	NA	1 study; 1 intervention arm; N = 395 SMD 0.12 [−0.08, 0.32]	NA
Stress focus	NA	2 studies; 2 intervention arms; N = 38 SMD −0.47 [−1.17, 0.23]	NA	NA	NA	NA
Confident kids	NA	1 study; 1 intervention arm; N = 44 SMD −0.66 [−1.58, 0.25]	NA	NA	NA	NA
Learn Young Learn Fair	NA	1 study; 1 intervention arm; N = 1102 SMD 0.00 [−0.12, 0.12]	NA	NA	NA	1 study; 1 intervention arm; N = 1011 SMD −0.02 [−0.15, 0.10]
Teaching Kids to Cope	NA	1 study; 1 intervention arm; N = 80 SMD −0.47 [−0.92, −0.03]	NA	1 study; 1 intervention arm; N = 76 SMD −0.49 [−0.95, −0.04]	NA	1 study; 1 intervention arm; N = 70 SMD −0.30 [−0.77, 0.17]
Moodgym	NA	1 study; 1 intervention arm; N = 719 SMD −0.15 [−0.30, 0.00]	NA	1 study; 1 intervention arm; N = 690 SMD −0.13 [−0.28, 0.03]	NA	NA
LISA-T	NA	2 studies; 2 intervention arms; N = 446 SMD −0.07 [−0.26, 0.11]	NA	2 studies; 2 intervention arms; N = 435 SMD −0.23 [−0.65, 0.20]	NA	NA
Problem solving for Life	NA	2 studies; 4 intervention arms; N = 2310 SMD −0.14 [−0.25, −0.04] I2 = 29%	1 study; 3 intervention arms; N = 714 RD −0.06 [−0.12, 0.01]	1 study; 3 intervention arm; N = 1843 SMD −0.03 [−0.14, 0.08]	1 study; 1 intervention arm; N = 229 RD 0.01 [−0.06, 0.09]	2 studies; 4 intervention arms; N = 2207 SMD 0.00 [−0.09, 0.10]
RAP	1 study; 1 intervention arm; N = 116 RD −0.17 [−0.33, −0.01]	1 study; 1 intervention arm; N = 116 SMD −0.32 [−0.68, 0.05]	1 study; 1 intervention arm; N = 116 RD −0.10 [−0.28, 0.07]	1 study; 1 intervention arm; N = 116 SMD −0.03 [−0.39, 0.34]	NA	NA
Unspecified	3 studies; 4 intervention arm; N = 667 RD −0.03 [−0.06, 0.01]	5 studies; 7 intervention arms; N = 956 SMD −0.26 [−0.50, −0.02] I2 = 63%	2 studies; 3 intervention arms; N = 409 RD −0.09 [−0.15, −0.03] I2 = 0%	3 studies; 4 intervention arms; N = 717 SMD −0.24 [−0.54, −0.05]	NA	1 study; 1 intervention arm; N = 219 SMD −0.25 [−0.52, 0.02]
Subgroup differences	χ2 = 10.64,	χ2 = 36.31,	χ2 = 4.96,	χ2 = 16.18,	χ2 = 4.47,	χ2 = 13.05,
	p = 0.06	p = 0.0009	p = 0.55	p = 0.13	p = 0.21	p = 0.04

RD: Risk Difference; SMD: Standardised Mean Difference; Bold font indicates significant results.

Friends

Three studies investigated the effectiveness of this intervention. There was no evidence that it reduced the risk of depressive disorder at any time point. Likewise, three studies reporting on depressive symptoms post intervention, and one study reporting on this outcome at 3–9 months follow-up showed no evidence that this program reduced depressive symptoms. At 12-month follow-up 2 studies showed some evidence of a reduction in depressive symptoms (see Table 4).

Positive Thinking Program

One study of this intervention showed there was no evidence that this program reduced depressive disorder at post intervention; however, by 3–9 months follow-up there was some evidence of effect. There was evidence from this same study that the program reduced depression symptoms at post intervention; however, the effect was no longer evident at follow-up (see Table 4).

Blues Program

Two studies of this intervention showed there was some evidence that this program reduced depression symptoms post intervention and at 3–9 months follow-up with no evidence of heterogeneity. There was no evidence that it reduced depressive disorder at any time point (see Table 4).

Aussie Optimism Program

One study of this program showed no evidence of this program in reducing depression symptoms or disorder at any time point (see Table 4).

Stress Inoculation (General)

Two very small studies by the same author tested the effectiveness of a program based on the concept of stress inoculation but did not measure depressive disorder. There was no evidence that this program reduced depression symptoms post intervention with no follow-up measurement (see Table 4).

Confident Kids

This program was tested in one small study that measured depression symptoms post intervention and showed no evidence of effect (see Table 4).

Learn Young, Learn Fair

One large study tested this intervention and showed no evidence of effect on reducing depression symptoms post intervention or at 12-month follow-up (see Table 4).

Teaching Kids to Cope

One study tested this program and while not measuring depressive disorder, did show that this program was effective in reducing depression symptoms post intervention and at 3–9 months follow-up but not at 12-month follow-up (see Table 4).

MOOD-GYM

One large study investigating this program showed there was no evidence of the program’s effectiveness in reducing depression symptoms at post intervention or at 3–9 months follow-up (see Table 4).

LISA-T

There were two studies that tested the effectiveness of this program in reducing depression symptoms that showed no evidence of its effectiveness post intervention or at 3–9 months follow-up and no 12-month follow-up data (see Table 4).

Problem Solving for Life

There was some evidence of the effect of this program in reducing the risk of depressive disorder at 3–9 month that did not reach significance but this effect was not evident at 12-months. While two studies did show some evidence of the effectiveness of this program in reducing depression symptoms post intervention, the effect was no longer evident at 12 month follow-up (see Table 4).

RAP

One study testing the effectiveness of this program showed evidence of a reduction in the risk of depressive disorder post intervention; however, this effect was no longer evident at 3–9 months follow-up (there was no 12-month follow-up data). There was no evidence of the effectiveness of this program in reducing depression symptoms at any time point (see Table 4).

Unspecified

While there was no evidence that this group of general CBT programs reduced the risk of depressive disorder post intervention; there was some evidence of effect of this group of programs at 3–9 month follow-up with no evidence of heterogeneity. No study measured this outcome at 12-month follow-up. There was some evidence of the effectiveness of these general CBT programs in reducing depression symptoms post intervention with evidence of heterogeneity. This effect was not evident at follow-up (see Table 4).

Test for Differences Between Types of Named Programs

There was evidence that the effect on depression symptoms post intervention and at 12 months follow-up was modified by the type of CBT program but not at 3 to 9 months follow-up or for depressive disorder (see Table 4).

3.4. Sensitivity Analyses

The planned sensitivity analyses showed that very few factors modified overall treatment effects. Results indicated a small but significant positive effect of universal interventions in reducing depressive disorder but not depression symptoms post intervention and at 3 to 9 month follow-up and in reducing symptoms but not depressive disorder at 12-month follow-up. There were small but significant positive effects of targeted interventions in reducing both depressive disorder and symptoms at all time points. Even though there were no significant differences between the universal intervention and comparison group at some time points, the direction of treatment effect favoured the universal intervention. The subgroup analysis showed that the overall treatment effects (for universal and targeted interventions combined) were not modified by delivery to a universal or targeted population (See Table 5); that is to say, there is no significant variation in mean effects in the different subgroups. The delivery of 8 or more sessions was more effective in reducing depressive disorder but not depression symptoms at all time points, whereas fewer than 8 sessions had no impact on outcomes; however, the overall treatment effects were not modified by the number of sessions delivered (See Table 6). Delivery of programs by mental health professions reduced depressive disorder and symptoms at all time points, whereas delivery by a non mental health expert only reduced depressive disorder post intervention and at 3 to 9 months follow-up and delivery by a student only resulted in reduced depressive disorder post intervention and depressive symptoms at post intervention and 3 to 9 months follow-up. Again, however, there was no evidence that who delivered the intervention modified the treatment effect (See Table 7). There was evidence that the type of outcome measurement used to measure depression symptoms modified the findings post intervention but not at other time points. When the CDI or BDI was used (these were the most commonly used tools) depressive symptoms were shown to be reduced at 12 months only; when the CES-D was used, symptoms were reduced post intervention and at 3 to 9 months follow-up but not at 12 months; when the RADS was used symptoms were reduced only at post intervention, however, the largest effect size was found on the RADS at this time point (see Table 8). Use of other tools did not show reductions in depressive symptoms at any time point.

Table 5. Summary of meta-analysis results for approach to prevention programs analysed by population.

Table 5. Summary of meta-analysis results for approach to prevention programs analysed by population.

Program	Post Intervention		3–9 Month Follow-up		12-Month Follow-up
	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)
Universal	8 studies; 9 intervention arm; N = 1025 RD −0.14 [−0.23, −0.06] I2 = 68%	21 studies; 26 intervention arm; N = 6519 SMD −0.05 [−0.23, 0.13]	8 studies; 10 intervention arm; N = 1228 RD −0.13 [−0.21, −0.06] I2 = 70%	14 studies; 18 intervention arm; N = 4077 SMD −0.02 [−0.27, 0.23]	6 studies; 7 intervention arm; N = 910 RD −0.06 [−0.15, 0.03]	10 studies; 14 intervention arm; N = 3737 SMD −0.08 [−0.14, −0.01] I2 = 68%
Targeted	6 studies; 7 intervention arms; N = 751 RD −0.09 [−0.16, −0.01] I2 = 53%	18 studies; 21 intervention arms; N = 3363 SMD −0.25 [−0.37, −0.14] I2 = 44%	7 studies; 9 intervention arms; N = 1255 RD −0.09 [−0.14, −0.05] I2 = 0%	13 studies; 16 intervention arms; N = 2880 SMD −0.18 [−0.30, −0.07] I2 = 41%	3 studies; 3 intervention arm; N = 239 RD −0.14 [−0.24, −0.04] I2 = 0%	7 studies; 8 intervention arm; N = 1902 SMD −0.14 [−0.28, 0.00] I2 = 41%
Subgroup differences	χ2 = 0.99,	χ2 = 3.37,	χ2 = 0.75,	χ2 = 1.39,	χ2 = 1.38,	χ2 = 0.61,
	p = 0.32	p = 0.07	p = 0.39	p = 0.24	p = 0.24	p = 0.44

RD: Risk Difference; SMD: Standardised Mean Difference; Bold font indicates significant results.

Table 6. Summary of meta-analysis results for approach to prevention programs analysed by number of sessions delivered.

Table 6. Summary of meta-analysis results for approach to prevention programs analysed by number of sessions delivered.

Sessions	Post Intervention		3–9 Month Follow-up		12-Month Follow-up
	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)
8 or more	13 studies; 15 intervention arm; N = 1503 RD −0.13 [−0.20, −0.07] I2 = 71%	32 studies; 39 intervention arm; N = 8014 SMD −0.13 [−0.28, 0.01]	12 studies; 16 intervention arm; N = 1881 RD −0.12 [−0.17, −0.07] I2 = 55%	22 studies; 28 intervention arm; N = 5167 SMD −0.09 [−0.28, 0.10]	9 studies; 10 intervention arms; N = 1149 RD −0.08 [−0.16, −0.00] I2= 75%	16 studies; 21 intervention arm; N = 5047 SMD −0.11 [−0.17, −0.04]
<8	1 study; 1 intervention arm; N = 273 RD −0.01 [−0.11, 0.09]	7 studies; 7 intervention arms; N = 1251 SMD −0.17 [−0.36, 0.02]	2 studies; 2 intervention arms; N = 373 RD −0.07 [−0.14, 0.01]	5 studies; 5 intervention arms; N = 1184 SMD −0.13 [−0.26, 0.00]	0 studies	0 studies
	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)
Subgroup differences	χ2 = 4.50, p = 0.03	χ2 = 0.09, p = 0.76	χ2 = 1.28, p = 0.26	χ2 = 0.09, p = 0.76	NA	NA

RD: Risk Difference; SMD: Standardised Mean Difference; Bold font indicates significant results.

Table 7. Summary of meta-analysis results for approach to prevention programs analysed by who delivered the intervention.

Table 7. Summary of meta-analysis results for approach to prevention programs analysed by who delivered the intervention.

Delivery	Post Intervention		3–9 Month Follow-up		12-Month Follow-up
	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)	Depressive disorder (RD)	Depression symptoms (SMD)
Mental health expert	5 studies; 5 intervention arm; N = 665 RD −0.10 [−0.18, −0.01] I2 = 71%	15 studies; 15 intervention arm; N = 2649 SMD −0.24 [−0.37, −0.11] I2 = 54%	5 studies; 5 intervention arm; N = 883 RD −0.11 [−0.16, −0.06] I2 = 0%	12 studies; 12 intervention arm; N = 2612SMD −0.21 [−0.33, −0.09] I2 = 52%	2 studies; 2 intervention arm; N = 195 RD −0.12 [−0.24, −0.01] I2 = 0%	8 studies; 8 intervention arm; N = 1718SMD −0.17 [−0.29, −0.05] I2 = 21%
Non mental health expert	4 studies; 4 intervention arms; N = 597 RD −0.18 [−0.35, −0.02] I2 = 80%	14 studies; 15 intervention arms; N = 5267 SMD 0.04 [−0.20, 0.28]	5 studies; 5 intervention arms; N = 1065 RD -0.13 [−0.22, −0.05] I2 = 63%	8 studies; 8 intervention arms; N = 2861 SMD 0.12 [−0.24, 0.47]	4 studies; 4 intervention arm; N = 595 RD −0.02 [−0.09, 0.04]	7 studies; 8 intervention arm; N = 3397 SMD −0.06 [−0.13, 0.01]
Student	5 studies; 5 intervention arms; N = 514 RD −0.08 [−0.13, −0.03] I2 = 0%	12 studies; 13 interventionarms; N = 1143 SMD −0.24 [−0.41, −0.07] I2 = 36%	5 studies; 5 intervention arms; N = 306 RD −0.08 [−0.18, 0.02]	8 studies; 9 intervention arms; N = 597 SMD −0.19 [−0.37, −0.00] I2 = 15%	3 studies; 3 intervention arm; N = 359 RD −0.09 [−0.28, 0.11]	3 studies; 3 intervention arms; N = 340 SMD −0.21 [−0.53, 0.10]
Subgroup differences	χ2 = 1.30, p = 0.52	χ2 = 4.44, p = 0.11	χ2 = 0.55, p = 0.76	χ2 = 2.82, p = 0.24	χ2 = 2.55, p = 0.28	χ2 = 2.79, p = 0.25

RD: Risk Difference; SMD: Standardised Mean Difference; Bold font indicates significant results.

Further sensitivity analyses were undertaken where the effect of moderators was explored separately in programs delivered to universal populations and for programs delivered to targeted populations. This was undertaken on the basis that the factors that may modify overall treatment effect systematically differed across universal and targeted programs, for example, targeted programs were most often delivered by mental health clinicians, whereas, universal programs were mostly delivered by non mental health clinicians and students (See Table 2).

The overall effect of targeted programs on depression symptoms was modified by the type of therapeutic approach taken to depression prevention (CBT vs. IPT vs. other) post intervention and at 3 to 9 month but the treatment effect on depressive disorder was not modified by the therapeutic approach. For universal programs, the overall effect on depressive disorder was modified by the therapeutic approach post intervention and at 3 to 9 months but not at 12 months and the overall effect on symptoms was modified at 12 months only.

Table 8. Summary of meta-analysis results for approach to prevention programs analysed by the outcome measurement tool used.

Table 8. Summary of meta-analysis results for approach to prevention programs analysed by the outcome measurement tool used.

Tool	Post Intervention	3–9 Month Follow-up	12-Month Follow-up
	Depression Symptoms (SMD)	Depression Symptoms (SMD)	Depression Symptoms (SMD)
CDI/BDI	24 studies; 30 intervention arm; N = 5686 SMD −0.06 [−0.26, 0.13] I2 = 90%	17 studies; 22 intervention arm; N = 4085 SMD −0.05 [−0.29, 0.19]I2 = 91%	12 studies; 17 intervention arm; N = 3770 SMD −0.10 [−0.18, -0.03] I2 = 4%
CES-D	9 studies; 10 intervention arms; N = 2022 SMD −0.24 [−0.35, −0.13] I2 = 17%	7 studies; 8 intervention arms; N = 1832 SMD −0.18 [−0.29, −0.06] I2 = 23%	2 studies; 2 intervention arm; N = 196 SMD −0.25 [−0.77, 0.27]
RADS	3 studies; 3 intervention arms; N = 213SMD −0.42 [−0.69, −0.14]I2 = 0%	2 studies; 2 intervention arms; N = 192SMD −0.24 [−0.69, 0.22]	1 study; 1 intervention arms; N = 70 SMD −0.30 [−0.77, 0.17]
Other	3 studies; 3 intervention arms; N = 1344 SMD −0.00 [−0.11, 0.11]	1 study; 1 intervention arm; N = 242 SMD −0.02 [−0.27, 0.24]	1 study; 1 intervention arm; N = 1011 SMD −0.02 [−0.15, 0.10]
Subgroup differences	χ2 = 14.45, p = 0.002	χ2 = 2.11, p = 0.55	χ2 = 2.46, p = 0.48

RD: Risk Difference; SMD: Standardised Mean Difference; Bold font indicates significant results.

For targeted programs, the overall effect on depression symptoms was modified by the specific program type only at post intervention (and no longer at 12 months); and for universal programs there was no evidence that the specific type of program modified the overall treatment effect. The numbers of studies in each subgroup was greatly reduced by splitting the analysis.

While we found no modifying effect on outcome of the number of sessions delivered when universal and targeted programs were analysed together; when investigated separately, the overall effect on depression symptoms of targeted programs was modified by the number of sessions delivered post intervention only. For universal programs, the overall treatment effect on depressive disorder was modified by the number of sessions delivered post intervention only. In both cases, delivery of 8 or more sessions resulted in a significantly greater reduction in symptoms or depressive disorder respectively, whereas there was no difference in outcomes when fewer than 8 sessions were delivered. Again the small number of studies, particularly in the subgroup in which the intervention comprised fewer than 8 sessions should be noted; indeed often there were no data available for these intervention.

There was no evidence the treatment effect was modified by who delivered the intervention for either targeted or for universal programs. Similarly, there was no evidence that the tool that was used to measure outcome modified the treatment effect when targeted and universal programs were considered separately, in contrast to when they were considered together.

4. Discussion

5. Conclusions

References

1. Costello, J.E.; Erkanli, A.; Angold, A. Is there an epidemic of child or adolescent depression? J. Child Psychol. Psychiatry 2006, 47, 1263–1271. [Google Scholar] [PubMed]
2. Kessler, R.C.; Kessler, R.C.; Berglund, P.; Demler, O.; Jin, R.; Merikangas, K.R.; Walters, E.E. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication. Arch. General Psychiatry 2005, 62, 593–602. [Google Scholar] [CrossRef]
3. Belsher, G.; Costello, C.G. Relapse after recovery from unipolar depression: A critical review. Psychol. Bull. 1988, 104, 84–96. [Google Scholar] [CrossRef] [PubMed]
4. Birmaher, B.; Ryan, N.D.; Williamson, D.E.; Brent, D.A.; Kaufman, J.; Dahl, R.E.; Perel, J.; Nelson, B.L. Childhood and adolescent depression: A review of the past 10 years: Part 1. J. Am. Acad. Child Adolesc. Psychiatry 1996, 35, 1427–1439. [Google Scholar] [CrossRef] [PubMed]
5. Lewinsohn, P.M.; Rohde, P.; Seeley, J.R. Major depressive disorder in older adolescents: Prevalence, risk factors and clinical implications. Clin. Psychol. Rev. 1998, 18, 765–794. [Google Scholar] [CrossRef] [PubMed]
6. Gould, M.S.; King, R.; Greenwald, S.; Fisher, P.; Schwab-Stone, M.; Kramer, R.; Flisher, A.J.; Goodman, S.; Canino, G.; Shaffer, D. Psychopathology associated with suicidal ideation and attempts among children and adolescents. J. Am. Acad. Child Adolesc. Psychiatry 1998, 37, 915–923. [Google Scholar] [CrossRef] [PubMed]
7. Stice, E.; Shaw, H.; Bohon, C.; Marti, C.N.; Rohde, P. A meta-analytic review of depression prevention programs for children and adolescents: Factors that predict magnitude of intervention effects. J. Consult. Clin. Psychol. 2009, 77, 486–503. [Google Scholar] [CrossRef] [PubMed]
8. Horowitz, J.; Garber, J. The prevention of depressive symptoms in children and adolescents: A meta-analytic review. J. Consult. Clin. Psychol. 2006, 74, 401–415. [Google Scholar] [CrossRef] [PubMed]
9. Neil, A.L.; Christensen, H. Australian school-based prevention and early intervention programs for anxiety and depression: A systematic review. Med. J. Aust. 2007, 186. [Google Scholar] [CrossRef] [PubMed]
10. Gillham, J.E.; Shatté, A.J.; Freres, D.R. Preventing depression: A review of cognitive-behavioral and family interventions. Appl. Prev. Psychol. 2000, 9, 63–88. [Google Scholar] [CrossRef]
11. Gladstone, T.; Beardslee, W. The prevention of depression in children and adolescents: A review. Can. J. Psychiatry 2009, 54, 212–221. [Google Scholar] [PubMed]
12. Merry, S.N.; Hetrick, S.E.; Cox, G.R.; Brudevold-Iversen, T.; Bir, J.J.; McDowell, H. Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Database Syst. Rev. 2011. [Google Scholar] [CrossRef]
13. Stellard, P.; Sayal, K.; Phillips, R.; Taylor, J.A.; Spears, M.; Anderson, R.; Araya, R.; Lewis, G.; Milings, A.; Montgomery, A.A. Classroom based cognitive behavioural therapy in reducing symptoms of depression in high risk adolescents: Pragmatic cluster randomised controlled trial. Br. Med. J. 2012, 345. [Google Scholar] [CrossRef]
14. Harnett, P.H.; Dadds, M.R. Training school personnel to implement a universal school-based prevention of depression program under real-world conditions. J. School Psychol. 2004, 42, 343–357. [Google Scholar] [CrossRef]
15. Brunwasser, S.M.; Gillham, J.E.; Kim, E.S. A meta-analytic review of the Penn Resiliency Program’s effect on depressive symptoms. J. Consult. Clin. Psychol. 2009, 77, 1042–1054. [Google Scholar] [CrossRef]
16. Higgins, J.P.T.; Green, S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. 2011. Available online: http://www.cochrane-handbook.org (accessed on 18 March 2011).
17. Higgins, J.P.; Altman, D.G.; Gotzsche, P.C.; Juni, P.; Moher, D.; Oxman, A.D.; Savovic, J.; Schulz, K.F.; Weeks, L.; Sterne, J.A. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011, 343. [Google Scholar] [CrossRef]
18. Borenstein, M.; Hedges, L.V.; Higgins, J.P.T.; Rothstein, H.R. Introduction to Meta-Analysis; John WIley & Sons: Chichister, UK, 2008. [Google Scholar]
19. RevMan. In Review Manager (RevMan). Version 5.0; The Nordic Cochrane Centre, The Cochrane Collaboration: Copenhagen, Denmark, 2008.
20. Arnarson, E.Ö.; Craighead, W.E. Prevention of depression among Icelandic adolescents. Behav. Res. Therapy 2009, 47, 577–585. [Google Scholar]
21. Balle, M.; Tortella-Feliu, M. Efficacy of a brief school-based program for selective prevention of childhood anxiety. Anxiety Stress Coping 2010, 23, 71–85. [Google Scholar] [CrossRef]
22. Berry, K.; Hunt, C.J. Evaluation of an intervention program for anxious adolescent boys who are bullied at school. J. Adolesc. Health 2009, 45, 376–382. [Google Scholar] [CrossRef]
23. Barnet, B.; Liu, J.; DeVoe, M.; Alperovitz-Bichell, K.; Duggan, A.K. Home visiting for adolescent mothers: Effects on parenting, maternal life course, and primary care linkage. Ann. Fam. Med. 2007, 5, 224–232. [Google Scholar] [CrossRef] [PubMed]
24. Bond, L.; Patton, G.; Glover, S.; Carlin, J.B.; Butler, H.; Thomas, L.; Bowes, G. The gatehouse project: Can a multilevel school intervention affect emotional wellbeing and health risk behaviours? J. Epidemiol. Community Health 2004, 58, 997–1003. [Google Scholar] [CrossRef] [PubMed]
25. Cabiya, J.J.; Padilla-Cotto, L.; Gonzalez, K.; Sanchez-Cestero, J.; Martinez-Taboas, A.; Sayers, S. Effectiveness of a cognitive-behavioral intervention for Puerto Rican children. Rev. Interam. Psicol. 2008, 42, 195–202. [Google Scholar]
26. Calear, A.L.; Christensen, H.; Mackinnon, A.; Griffiths, K.M.; O’Kearney, R. The YouthMood Project: A cluster randomized controlled trial of an online cognitive behavioral program with adolescents [ISRCTN67189839]. J. Consult. Clin. Psychol. 2009, 77, 1021–1032. [Google Scholar] [CrossRef]
27. Cardemil, E.V.; Reivich, K.J.; Seligman, M. The prevention of depressive symptoms in low-income minority middle school students. Prev. Treat. 2002, 5. [Google Scholar] [CrossRef]
28. Chaplin, T.M.; Gillham, J.E.; Reivich, K.; Elkon, A.G.; Samuels, B.; Freres, D.R.; Winder, B.; Seligman, M.E. Depression prevention for early adolescent girls a pilot study of all girls versus co-ed groups. J. Early Adolesc. 2006, 26, 110–126. [Google Scholar] [CrossRef]
29. Clarke, G.N.; Hawkins, W.; Murphy, M.; Sheeber, L. School-based primary prevention of depressive symptomatology in adolescents findings from two studies. J. Adolesc. Res. 1993, 8, 183–204. [Google Scholar] [CrossRef]
30. Clarke, G.N.; Hawkins, W.; Murphy, M.; Sheeber, L.B.; Lewinsohn, P.M.; Seeley, J.R. Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents: A randomized trial of group cognitive intervention. J. Am. Acad. Child Adolesc. Psychiatry 1995, 34, 312–321. [Google Scholar] [CrossRef]
31. Clarke, G.N.; Hornbrook, M.; Lynch, F.; Polen, M.; Gale, J.; Beardslee, W.; O’Connor, E.; Seeley, J.R. A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents. Arch. Gen. Psychiatry 2001, 58, 1127–1134. [Google Scholar] [CrossRef] [PubMed]
32. Garber, J.; Clarke, G.N.; Weersing, V.R.; Beardslee, W.R.; Brent, D.A.; Gladstone, T.R.G.; DeBar, L.L.; Lynch, F.L.; Hollon, S.D.; Shamseddeen, D.; et al. Prevention of Depression in at-risk adolescents: A randomized controlled trial. JAMA 2009, 301, 2215–2224. [Google Scholar]
33. Gillham, J.E.; Reivich, K.J.; Jaycox, L.H.; Seligman, M.E. Prevention of depressive symptoms in schoolchildren: Two-year follow-up. Psychol. Sci. 1995, 6, 343–351. [Google Scholar] [CrossRef]
34. Gillham, J.E.; Reivich, K.J.; Freres, D.R.; Lascher, M.; Litzinger, S.; Shatté, A.; Seligman, M.E. School-based prevention of depression and anxiety symptoms in early adolescence: A pilot of a parent intervention component. School Psychol. Q. 2006, 21, 323–348. [Google Scholar] [CrossRef]
35. Gillham, J.E.; Hamilton, J.; Freres, D.R.; Patton, K.; Gallop, R. Preventing depression among early adolescents in the primary care setting: A randomized controlled study of the Penn Resiliency Program. J. Abnorm. Child Psychol. 2006, 34, 203–219. [Google Scholar] [CrossRef] [PubMed]
36. Gillham, J.E.; Reivich, K.J.; Freres, D.R.; Chaplin, T.M.; Shatté, A.J.; Samuels, B.; Elkon, A.G.L.; Litzinger, S.; Lascher, M.; Gallop, R.; et al. School-based prevention of depressive symptoms: A randomized controlled study of the effectiveness and specificity of the Penn Resiliency Program. J. Consult. Clin. Psychol. 2007, 75. [Google Scholar] [CrossRef]
37. Hains, A.A.; Szyjakowski, M. A cognitive stress-reduction intervention program for adolescents. J. Couns. Psychol. 1990, 27, 79–84. [Google Scholar] [CrossRef]
38. Hains, A. Comparison of cognitive-behavioural stress management techniques with adolescent boys. J. Cons. Dev. 1992, 70, 600–605. [Google Scholar] [CrossRef]
39. Horowitz, J.L.; Garber, J.; Ciesla, J.A.; Young, J.F.; Mufson, L. Prevention of depressive symptoms in adolescents: A randomized trial of cognitive-behavioral and interpersonal prevention programs. J. Consult. Clin. Psychol. 2007, 75, 693–706. [Google Scholar] [CrossRef] [PubMed]
40. Hyun, M.; Chung, H.I.; Lee, Y.J. The effect of cognitive-behavioral group therapy on the self-esteem, depression, and self-efficacy of runaway adolescents in a shelter in South Korea. Appl. Nurs. Res. 2005, 18, 160–166. [Google Scholar] [CrossRef] [PubMed]
41. Kraag, G.; Van Breukelen, G.J.P.; Kok, G.; Hosman, C. “Learn Young, Learn Fair”, a stress management program for fifth and sixth graders: Longitudinal results from an experimental study. J. Child Psychol. Psychiatry 2009, 50, 1185–1195. [Google Scholar] [CrossRef] [PubMed]
42. Lock, S.; Barrett, P.M. A longitudinal study of developmental differences in universal preventive intervention for child anxiety. Behav. Chang. 2003, 20, 183–199. [Google Scholar] [CrossRef]
43. Lowry-Webster, H.M.; Barrett, P.M.; Lock, S. A universal prevention trial of anxiety symptomology during childhood: Results at 1-year follow-up. Behav. Chang. 2003, 20, 25–43. [Google Scholar] [CrossRef]
44. Pössel, P.; Horn, A.B.; Groen, G.; Hautzinger, M. School-based prevention of depressive symptoms in adolescents: A 6-month follow-up. J. Am. Acad. Child Adolesc. Psychiatry 2004, 43, 1003–1010. [Google Scholar] [CrossRef] [PubMed]
45. Pössel, P.; Seemann, S.; Hautzinger, M. Impact of comorbidity in prevention of adolescent depressive symptoms. J. Couns. Psychol. 2008, 55, 106–117. [Google Scholar] [CrossRef]
46. Puskar, K.; Sereika, S.; Tusaie Mumford, K. Effect of the Teaching Kids to Cope (TKC©) program on outcomes of depression and coping among rural adolescents. J. Child Adolesc. Psychiatr. Nurs. 2003, 16, 71–80. [Google Scholar] [CrossRef] [PubMed]
47. Quayle, D.; Dziurawiec, S.; Roberts, C.; Kane, R.; Ebsworthy, G. The effect of an optimism and lifeskills program on depressive symptoms in preadolescence. Behav. Chang. 2001, 18, 194–203. [Google Scholar] [CrossRef]
48. Rivet-Duval, E.; Heriot, S.; Hunt, C. Preventing adolescent depression in Mauritius: A universal school-based program. Child Adolesc. Mental Health 2010, 16, 86–91. [Google Scholar] [CrossRef]
49. Roberts, C.; Kane, R.; Thomson, H.; Bishop, B.; Hart, B. The prevention of depressive symptoms in rural school children: A randomized controlled trial. J. Consult. Clin. Psychol. 2003, 71, 622–628. [Google Scholar] [CrossRef] [PubMed]
50. Roberts, C.M.; Kane, R.; Bishop, B.; Cross, D.; Fenton, J.; Hart, B. The prevention of anxiety and depression in children from disadvantaged schools. Behav. Res. Therapy 2010, 48, 68–73. [Google Scholar] [CrossRef]
51. The Prevention of Depression in 8- to 9-Year-Old Children: A Pilot Study. Available online: http://espace.library.curtin.edu.au/R/?func=dbin-jump-full&object_id=148912&local_base=GEN01-ERA02 (accessed on 6 August 2014).
52. Sawyer, M.G.; Pfeiffer, S.; Spence, S.H.; Bond, L.; Graetz, B.; Kay, D.; Sheffield, J. School based prevention of depression: A randomised controlled study of the beyondblue schools research initiative. J. Child Psychol. Psychiatry 2010, 51, 199–209. [Google Scholar] [CrossRef] [PubMed]
53. The Prevention of Depression and Anxiety. Available online: http://www.ppc.sas.upenn.edu/depprevseligman1999.pdf (accessed on 6 August 2014).
54. Seligman, M.E.P.; Schulman, P.; Tryon, A.M. Group prevention of depression and anxiety symptoms. Behav. Res. Therapy 2007, 45, 1111–1126. [Google Scholar] [CrossRef]
55. Shatte, A.J. Prevention of depressive symtpoms in adolescents: Issues of dissemination and mechanisms of change. Diss. Abstr. Int. Sect. B: Sci. Eng. 1997, 57. [Google Scholar] [CrossRef]
56. Sheffield, J.K.; Spence, S.H.; Rapee, R.M.; Kowalenko, N.; Wignall, A.; Davis, A.; McLoone, J. Evaluation of universal, indicated, and combined cognitive-behavioral approaches to the prevention of depression among adolescents. J. Consult. Clin. Psychol. 2006, 74, 66–79. [Google Scholar] [CrossRef] [PubMed]
57. Spence, S.H.; Sheffield, J.K.; Donovan, C.L. Preventing adolescent depression: An evaluation of the problem solving for life program. J. Consult. Clin. Psychol. 2003, 71, 3–13. [Google Scholar] [CrossRef] [PubMed]
58. Stice, E.; Burton, E.; Bearman, S.K.; Rohde, P. Randomized trial of a brief depression prevention program: An elusive search for a psychosocial placebo control condition. Behav. Res. Therapy 2007, 45, 863–876. [Google Scholar] [CrossRef]
59. Stice, E.; Rohde, P.; Seeley, J.R.; Gau, J.M. Brief cognitive-behavioral depression prevention program for high-risk adolescents outperforms two alternative interventions: A randomized efficacy trial. J. Consult. Clin. Psychol. 2008, 76, 595–606. [Google Scholar] [CrossRef] [PubMed]
60. Yu, D.L.; Seligman, M.E. Preventing depressive symptoms in Chinese children. Prev. Treat. 2002, 5. [Google Scholar] [CrossRef]
61. Young, J.F.; Mufson, L.; Davies, M. Efficacy of interpersonal psychotherapyadolescent skills training: An indicated preventive intervention for depression. J. Child Psychol. Psychiatry 2006, 47, 1254–1262. [Google Scholar] [PubMed]
62. Araya, R.; Fritsch, R.; Soears, M.; Rojas, G.; Martinez, V.; Barroihet, S.; Vohringer, V.; Gunnell, D.; Stallard, P.; Guajardo, V.; et al. School intervention to improve mental health of students in Santiago, Chile. JAMA Pediatr. 2013, 167, 1004–1010. [Google Scholar] [CrossRef] [PubMed]
63. Rose, G. The Strategy of Preventive Medicine, 1st ed.; Oxford University Press: Oxford, UK, 1992. [Google Scholar]
64. Merry, S.; McDowell, H.; Wild, C.; Bir, J.; Cunliffe, R. A randomized placebo-controlled trial of a school-based depression prevention program. J. Am. Acad. Child Adolesc. Psychiatry 2004, 43, 538–547. [Google Scholar] [CrossRef] [PubMed]
65. Van Voorhees, B.W.; Fogel, J.; Reinecke, M.A.; Gladstone, T.; Stuart, S.; Gollan, J.; Bradford, N.; Domanico, R.; Fagan, B.; Ross, R.; et al. Randomized clinical trial of an Internet-based depression prevention program for adolescents (Project CATCH-IT) in primary care: 12-Week outcomes. J. Dev. Behav. Pediatr. 2009, 30, 123–137. [Google Scholar] [CrossRef]
66. McCarty, C.A.; Weisz, J.R. Effects of psychotherapy for depression in children and adolescents: What we can (and can’t) learn from meta-analysis and component profiling. J. Am. Acad. Child Adolesc. Psychiatry 2007, 46, 879–886. [Google Scholar] [CrossRef] [PubMed]
67. Whittaker, R.; Merry, S.M.; Stasiak, K.; McDowell, H.; Doherty, I.; Shepherd, M.; Dorey, E.; Parag, V.; Ameratunga, S.; Rodgers, A. MEMO—A mobile phone depression prevention intervention for adolescents: Development process and postprogram findings on acceptability from a randomized controlled trial. J. Med. Internet Res. 2012, 14. [Google Scholar] [CrossRef]
68. Weersing, V.R.; Rozenman, M.; Gonzalez, A. Core components of therapy in youth: Do we know what to disseminate? Behav. Modif. 2009, 33, 24–47. [Google Scholar] [CrossRef] [PubMed]
69. Hetrick, S.E.; Cox, G.R.; Fisher, C.A.; Bhar, S.S.; Rice, S.M.; Davey, C.G.; Parker, A.G. Back to basics: Could behavioural therapy be a better treatment option for youth depression? A critical review. Early Interv. Psychiatry 2015, 9, 93–99. [Google Scholar] [CrossRef]
70. Pennant, M.E.; Loucas, C.E.; Whittington, C.; Creswell, C.; Fonagy, P.; Fuggle, P.; Kelvin, P.; Naqvi, S.; Stockton, S.; Kendall, T. Computerised therapies for anxiety and depression in children and young people: A systematic review and meta-analysis. Behav. Res. Ther. 2015, 67, 1–18. [Google Scholar] [CrossRef] [PubMed]