Randomized Clinical Trial of Primary Care Based Online Depression Prevention Intervention: Impact on Adolescent Modifiable Factors and Behaviors
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design and Setting
2.2. CATCH-IT Intervention
2.3. Health Education Intervention
2.4. Intervention Shared Elements
2.5. Measures
2.6. Outcomes
3. Analysis
4. Results
5. Discussion
6. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Domain | Measure | Description | Sample Item |
---|---|---|---|
1. Modifiable Factors Related to Program Completion | Trans-Theoretical Model | A 3-item (plus a fourth separate item) self-report of motivation that measures self-efficacy and intention to change risk-factor behaviors before, during, and after the intervention. The standard motivation measure approach described by Miller and Rollnick (Miller and Rollnick 1991) was adapted for our study. A higher score indicates a higher ranking on three items assessing importance, ability, or readiness to reduce depression risk on a 10-point Likert scale ranging from 1 = not important to 10 = very important, which are reported together as the scale. The fourth item assessing stage of change asked adolescents about their current position on reducing depression risk (ranging from precontemplation to decision, with plan) and is analyzed separately. Measures were taken at baseline and 2, 12, and 24 months. | Rate the importance of preventing/stopping an episode of clinical depression over the next two weeks. Question 4: Please click the bubble next to the one statement that best fits your current position with regard to changing the way you think about and solve everyday problems to reduce /lower your risk of developing clinical depression (severe enough to need a treatment). |
Theory of Planned Behavior | A 19-item self-report on motivation utilizing a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree, with higher scores indicating stronger agreement with positive attitudes toward subthreshold depression intervention participation. Measures were taken at baseline and 12 and 24 months (Armitage and Conner 2001). | I believe going through an online program like this one would help me be healthy. | |
Physician Relationship Scale | A 9 question self-report, which rates the adolescent’s relationship with their primary care provider in the following areas: understanding, engagement, helpfulness, comfort, and trust, reported on a 5 point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree (Van Voorhees et al. 2009b). | I am more likely to change behaviors or thought patterns because of the interview with the primary care provider. | |
Satisfaction, Usefulness, and Peer Recommendation | Adolescents responded to six items about satisfaction, usefulness, and recommendation for peers who may become depressed regarding the intervention on a 10 point Likert scale ranging from 1 = very unsatisfied to 10 = very satisfied, with higher scores being more positive. | I would recommend this program to a friend who could develop depression. | |
2. Modifiable Factors Related to Adolescent Development | Social Adjustment Scale | A 36-item self-report with higher scores indicating worse social functioning on a Likert scale ranging from 1 = never or none to 5 = always or all or vice versa depending on the question. Measures were taken at baseline and at 12 and 24 months (Weissman et al. 1978). | How many days of classes did you miss in the last 2 weeks? |
Quality of Life | A self-report of 26 total items regarding overall health (2 items, scored 0–100, on a Likert scale of 1 = very poor or dissatisfied to 5 = very good or satisfied) and four domains scored 0–100 generally on a Likert scale ranging from 1 = not at all or very dissatisfied or very poor or never to 5 = completely or very satisfied or very good or always: physical health (7 items), psychological (6 items scored), social relationships (3 items), and environment (8 items). Measures were taken at baseline and 6, 12, and 24 months (Group 1998). | How satisfied are you with your health? | |
Adolescent Life Events Questionnaire | A six-month retrospective self-report scored in a range of 0–51 and includes seven subscales of specific groups of life events scored on a range from 0–9 using yes/no questions, with higher scores indicating more life events. Measures were taken at baseline and 2, 6, 12, 18, and 24 months (Hankin and Abramson 2002). | You were seriously ill or injured, hospitalized, or had surgery. | |
3. Modifiable Factors Related to Coping | Perceived Benefits of Behavioral Principles | Adolescents were asked to respond to 10 items about perceived behavior-related cognitive skill acquisition or perceived behavior modification due to a lesson relating to the core content of CATCH-IT based on either cognitive behavioral therapy (CBT), behavioral activation (BA), or interpersonal therapy (IPT). Higher scores on the 10 point Likert scale (1 = very unhelpful to 10 = extremely helpful) represented a stronger perceived benefit of a given type of therapy. The scale was created by Zubinski et al. assessing an eating disorder technology intervention (Zabinski et al. 2001) and the items were rephrased by Van Voorhees et al. to apply to CATCH-IT (referred to as sociocultural relevance scale in protocol paper) (Gladstone et al. 2015; Van Voorhees et al. 2015). Measures were taken at 2 and 12 months (Gladstone et al. 2015; Van Voorhees et al. 2015). | The program has helped me challenge negative thought patterns about everyday situation and problems. |
Beck Hopelessness Scale | A self-report on a scale of 0–20 utilizing 20 true or false items, with higher scores indicating increased hopelessness. Administered at baseline and at 2, 6, 18, and 24 months (Beck et al. 1974). | I look forward to the future with hope and enthusiasm. | |
4. Modifiable Factors Related to Family Relations | Conflict Behavior Questionnaire | A self-report of conflict with mother or father, with a higher score indicating increased conflict on a scale of 0–20. Adolescents responded to 40 true or false questions. Measures were taken at baseline and 6 and 18 months (Prinz et al. 1979). | At least three times a week, my father and I get angry at each other. |
Children’s Report of Parent Behavior Inventory | A self-report by adolescents and parents where higher scores indicate increased acceptance, psychological control, and monitoring by the mother or father. Participants responded to 15 items on a 3 point Likert scale with options being 1 = not like him/her, 2 = somewhat like him/her, or 3 = a lot like him/her at baseline and 24 months (Schaefer 1965). | Makes me feel better after talking over my worries with him. | |
Sibling Relationships Questionnaire | A self-report of relationship with sibling in four domains, with higher scores indicating increased warmth/closeness (scored 1–5), relative status/power (scored −4 to 4), conflict (scored 1–5), and rivalry (scored 0–2) (Buhrmester and Furman 1990). Measures were taken at baseline, 12 and 24 months. | Who usually gets treated better by your mother, you or this sibling? | |
The Sibling Differential Experience | A self-report of relative relationship with parent in comparison to sibling in affection and control by mother or father, with higher scores indicating a greater difference between participant and sibling. Participants responded to 18 items on a Likert scale of 1 = In general, this parent has been much more this way toward my sibling than me to 5 = in general, this parent has been much more this way toward me than my sibling. Measures were taken at baseline and at 24 months (Daniels and Plomin 1985). | Mother has been strict with us. | |
Center for Epidemiological Studies-Depression Scale (CES-D10). | The CES-D10 is a seven-day self-report (or administered over the phone) of depressive symptoms with 20 items on a 4-point Likert scale ranging from 0 = rarely or none of the time to 3 = most or all of the time. Higher scores indicate increased symptoms on a score range of 0–30 (Radloff 1991). Measures from adolescents and parents were taken at baseline and at 2, 6, 12, 18, and 24 months. | During the past week I was bothered by things that usually don’t bother me. | |
5. Modifiable Factors Related to General Health Behaviors | Teen Behavior Questionnaire | A self-report questionnaire, with questions about diet, exercise, religion, and internet use. The questionnaire uses a variety of formats, some open ended, some no/yes, and some Likert scales (Gladstone et al. 2015; Van Voorhees et al. 2015). We identified the items used in the questionnaire by conducting a series of analyses using the National Longitudinal Study of Adolescent Health data set to examine the relationship between various reported behaviors at baseline and likelihood of experiencing a depressive episode at one-year follow-up (Booth et al. 2008; Van Voorhees et al. 2008b). These items have been previously reported by our group in relationship to depression risk (Booth et al. 2008; Van Voorhees et al. 2008b). Measures were taken at baseline and 2 and 12 months. Physical activity was assessed by asking adolescents how frequently they engaged in certain exercises (team sport, weightlifting, yoga, or others) over the previous week, in terms of both number of sessions and total minutes spent exercising. Adolescents selected activities and provided text answers. Religious activity was assessed via an open-ended question, while frequency of prayer or attendance at religious services was assessed via a Likert scale (5-point scale for prayer, from 1 = never to 5 = at least once a day, and a 4 point scale for religious service attendance and attendance at special activities at place of worship, from 1 = never to 4 = at least once a week. Diet was assessed by asking adolescents to responded to 9 items of dietary preferences: on a 6 point Likert scale ranging from 1 = less than once a month to 6 = more than 2 times a week for eating fish and yes/no items on willing to eat applesauce, pudding, yogurt, milk, apple juice, mango juice, orange juice, takes omega-3 fatty acids fish oil supplements. Internet use and media use was assessed via a self-report of number of internet activities adolescents engaged in the past week (six options provided, scored on a scale 0–6) and mental health website use was assessed via a self-report of number of websites adolescents visited (six options provided, scored on a scale 0–6). | Did you engage in any of the following activities during the past week? If yes please check the box and indicate the number of times and how many total minutes spent on each activity. |
Body Mass Index | BMI was calculated from self-reported height and weight at baseline, 2, 6, 12, and at 24 months. | Self-reported height and weight. | |
6. Modifiable factors related to externalizing disorders | Disruptive Behaviors Disorder Scale | A self-report by the adolescent and parent regarding the adolescent measuring the level of adolescent’s behavioral problems. Adolescents answered 41 questions on a Likert scale ranging from 1 = not at all to 5 = very much. Measures were taken at baseline and at 6, 12, and 24 months (Pelham et al. 1992). | Often loses temper. |
The CRAFT | The CRAFT measures drug use using 6 yes or no items regarding context and family/friend concern to detect substance use disorders in adolescents. Measures were taken at baseline and at 2, 6, 12, and 24 months (Knight et al. 1999, 2002). | Have you used alcohol or drugs to relax, feel better about yourself, or to fit in? |
CATCH-IT (N = 193) | HE (N = 176) | ||||||
Total N | N | % | Total N | N | % | p-Value a | |
Trans-Theoretical Model Question 4 | |||||||
Baseline | 104 | 85 | 0.19 | ||||
Precontemplation | 25 | (24.0%) | 17 | (20.0%) | |||
Contemplation | 33 | (31.7%) | 23 | (27.1%) | |||
Preparation | 27 | (26.0%) | 21 | (24.7%) | |||
Decision, no plan | 13 | (12.5%) | 19 | (22.4%) | |||
Decision with plan | 6 | (5.8%) | 5 | (5.9%) | |||
2 months | 90 | 83 | 0.47 | ||||
Precontemplation | 7 | (7.8%) | 12 | (14.5%) | |||
Contemplation | 24 | (26.7%) | 25 | (30.1%) | |||
Preparation | 23 | (25.6%) | 16 | (19.3%) | |||
Decision, no plan | 26 | (28.9%) | 15 | (18.1%) | |||
Decision with plan | 10 | (11.1%) | 15 | (18.1%) | |||
12 months | 74 | 64 | 0.02 | ||||
Precontemplation | 8 | (10.8%) | 18 | (28.1%) | |||
Contemplation | 20 | (27.0%) | 17 | (26.6%) | |||
Preparation | 14 | (18.9%) | 10 | (15.6%) | |||
Decision, no plan | 16 | (21.6%) | 11 | (17.2%) | |||
Decision with plan | 16 | (21.6%) | 8 | (12.5%) | |||
24 months | 32 | 53 | 0.61 | ||||
Precontemplation | 7 | (21.9%) | 12 | (22.6%) | |||
Contemplation | 8 | (25.0%) | 17 | (32.1%) | |||
Preparation | 9 | (28.1%) | 10 | (18.9%) | |||
Decision, no plan | 4 | (12.5%) | 11 | (20.8%) | |||
Decision with plan | 4 | (12.5%) | 3 | (5.7%) | |||
N | Mean | SD | N | Mean | SD | p-Value b | |
Physician Relationship Scale (1–5) c | |||||||
2 months | 76 | 4.0 | (0.7) | 58 | 3.9 | (0.9) | 0.28 |
12 months | 43 | 4.2 | (0.6) | 37 | 3.8 | (0.7) | 0.02 |
Would recommend to friend who could develop depression (1–10) d | |||||||
2 months | 81 | 7.8 | (2.4) | 70 | 7.7 | (2.4) | 0.85 |
12 months | 26 | 8.3 | (2.3) | 40 | 7.0 | (2.1) | 0.02 |
Unadjusted Means | Within-Group Slopes a | Between-Group Slope Difference p-Value a | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
CATCH-IT (N = 193) | Health Ed (N = 176) | CATCH-IT | Health Ed | ||||||||
N | Mean | SD | N | Mean | SD | b | p-Value a | b | p-Value a | p-Value a | |
Adolescents Life Events Questionnaire (ALEQ) b | |||||||||||
LEQ total score (0–51) | −0.122 | <0.001 | −0.158 | <0.001 | 0.25 | ||||||
Baseline | 168 | 8.1 | (5.8) | 134 | 8.2 | (5.7) | |||||
6 months | 69 | 4.5 | (3.8) | 90 | 5.5 | (6.1) | |||||
12 months | 82 | 4.7 | (4.5) | 70 | 3.7 | (4.6) | |||||
18 months | 65 | 4.9 | (4.6) | 81 | 4.6 | (4.7) | |||||
24 months | 39 | 4.9 | (5.4) | 54 | 3.9 | (4.6) | |||||
Health and loss (0–9) | −0.038 | <0.001 | −0.067 | <0.001 | 0.03 | ||||||
Baseline | 176 | 2.6 | (2.1) | 141 | 2.9 | (2.1) | |||||
6 months | 72 | 1.8 | (1.9) | 90 | 1.9 | (2.1) | |||||
12 months | 84 | 1.7 | (1.9) | 72 | 1.3 | (1.5) | |||||
18 months | 65 | 1.7 | (1.8) | 81 | 1.4 | (1.7) | |||||
24 months | 39 | 1.7 | (2.2) | 55 | 1.1 | (1.7) | |||||
Arguments or conflicts (0–9) | −0.041 | <0.001 | −0.033 | <0.001 | 0.51 | ||||||
Baseline | 174 | 2.3 | (1.8) | 140 | 2.3 | (1.9) | |||||
6 months | 70 | 1.3 | (1.5) | 88 | 1.5 | (1.9) | |||||
12 months | 83 | 1.3 | (1.8) | 72 | 0.8 | (1.3) | |||||
18 months | 65 | 1.4 | (1.7) | 81 | 1.5 | (1.8) | |||||
24 months | 39 | 1.2 | (1.7) | 55 | 1.2 | (1.6) | |||||
Moves and changes (0–6) | −0.010 | 0.06 | −0.020 | <0.001 | 0.16 | ||||||
Baseline | 173 | 0.6 | (1.0) | 140 | 0.7 | (1.1) | |||||
6 months | 70 | 0.3 | (0.6) | 89 | 0.4 | (0.9) | |||||
12 months | 83 | 0.4 | (0.7) | 70 | 0.3 | (0.7) | |||||
18 months | 65 | 0.3 | (0.7) | 81 | 0.3 | (0.6) | |||||
24 months | 39 | 0.4 | (0.8) | 54 | 0.2 | (0.6) | |||||
School and job (0–9) | −0.013 | 0.02 | −0.017 | 0.002 | 0.62 | ||||||
Baseline | 169 | 0.9 | (1.1) | 136 | 1.0 | (1.1) | |||||
6 months | 69 | 0.5 | (0.9) | 89 | 0.6 | (0.9) | |||||
12 months | 82 | 0.5 | (0.8) | 70 | 0.6 | (1.0) | |||||
18 months | 65 | 0.6 | (1.0) | 80 | 0.6 | (1.0) | |||||
24 months | 39 | 0.6 | (0.9) | 54 | 0.6 | (0.9) | |||||
Finances/money (0–4) | −0.010 | 0.02 | −0.009 | 0.03 | 0.89 | ||||||
Baseline | 168 | 0.8 | (1.1) | 134 | 0.7 | (1.0) | |||||
6 months | 69 | 0.3 | (0.7) | 90 | 0.4 | (0.8) | |||||
12 months | 82 | 0.5 | (0.9) | 70 | 0.3 | (0.8) | |||||
18 months | 65 | 0.4 | (0.8) | 81 | 0.4 | (0.9) | |||||
24 months | 39 | 0.5 | (0.9) | 54 | 0.3 | (0.8) | |||||
Crime and legal issues (0–8) | −0.015 | <0.001 | −0.018 | <0.001 | 0.69 | ||||||
Baseline | 168 | 0.7 | (1.3) | 133 | 0.6 | (1.2) | |||||
6 months | 70 | 0.2 | (0.6) | 90 | 0.5 | (1.1) | |||||
12 months | 82 | 0.2 | (0.6) | 72 | 0.2 | (0.5) | |||||
18 months | 65 | 0.3 | (0.7) | 81 | 0.2 | (0.7) | |||||
24 months | 39 | 0.4 | (0.7) | 54 | 0.2 | (0.7) | |||||
Other (0–6) | 0.001 | 0.68 | −0.001 | 0.56 | 0.48 | ||||||
Baseline | 169 | 0.2 | (0.5) | 135 | 0.2 | (0.4) | |||||
6 months | 71 | 0.1 | (0.3) | 90 | 0.2 | (0.5) | |||||
12 months | 81 | 0.1 | (0.4) | 72 | 0.2 | (0.5) | |||||
18 months | 64 | 0.2 | (0.4) | 81 | 0.2 | (0.5) | |||||
24 months | 39 | 0.2 | (0.4) | 54 | 0.1 | (0.4) |
CATCH-IT (N = 193) | Health Ed (N = 176) | ||||||||||
N | Mean | SD | N | Mean | SD | p-Value a | |||||
Perceived Benefits of Behavioral Principles Scale (1–10) b | |||||||||||
2 months | 83 | 6.5 | (2.1) | 71 | 5.5 | (2.2) | 0.008 | ||||
12 months | 47 | 6.9 | (2.1) | 42 | 5.5 | (2.1) | 0.003 | ||||
Subscales (1–10) b | |||||||||||
Behavioral Activation (BA) | |||||||||||
2 months | 80 | 6.8 | (2.1) | 71 | 5.8 | (2.4) | 0.005 | ||||
12 months | 47 | 7.0 | (2.2) | 42 | 5.8 | (2.2) | 0.01 | ||||
Cognitive Behavioral Therapy (CBT) | |||||||||||
2 months | 80 | 6.5 | (2.1) | 70 | 5.6 | (2.4) | 0.01 | ||||
12 months | 45 | 6.8 | (2.3) | 42 | 5.6 | (2.2) | 0.02 | ||||
Interpersonal Psychotherapy (IPT) | |||||||||||
2 months | 80 | 5.9 | (2.4) | 70 | 5.3 | (2.4) | 0.14 | ||||
12 months | 46 | 6.8 | (2.2) | 41 | 5.0 | (2.2) | <0.001 | ||||
Unadjusted Means | Within-Group Slopes c | Between-Group Slope Differences p-Value c | |||||||||
CATCH-IT | HE | CATCH-IT | HE | ||||||||
N | Mean | SD | N | Mean | SD | b | p-Value a | b | p-Value a | p-Value a | |
Children’s Report of Parent Behavior Inventory (CRPBI) d | |||||||||||
CRPBI, Mother | |||||||||||
Acceptance (10–30) | 0.024 | 0.45 | 0.003 | 0.92 | 0.60 | ||||||
Baseline | 109 | 25.0 | (4.8) | 87 | 24.7 | (4.6) | |||||
24 months | 33 | 26.3 | (4.6) | 52 | 24.8 | (5.1) | |||||
Psychological control (8–24) | −0.052 | 0.03 | 0.013 | 0.50 | 0.04 | ||||||
Baseline | 110 | 12.3 | (3.5) | 87 | 11.6 | (3.3) | |||||
24 months | 33 | 10.9 | (3.0) | 51 | 12.0 | (3.7) | |||||
Monitoring (5–15) | −0.009 | 0.55 | −0.014 | 0.29 | 0.84 | ||||||
Baseline | 103 | 13.5 | (2.0) | 84 | 12.8 | (2.4) | |||||
24 months | 32 | 13.5 | (1.9) | 49 | 12.7 | (2.7) | |||||
CRPBI, Father | |||||||||||
Acceptance (10–30) | 0.035 | 0.36 | −0.012 | 0.72 | 0.36 | ||||||
Baseline | 102 | 22.6 | (5.4) | 74 | 21.9 | (5.6) | |||||
24 months | 33 | 23.4 | (6.3) | 46 | 21.5 | (6.3) | |||||
Psychological control (8–24) | −0.031 | 0.16 | 0.027 | 0.17 | 0.053 | ||||||
Baseline | 102 | 11.8 | (3.6) | 74 | 11.8 | (3.6) | |||||
24 months | 33 | 11.2 | (3.2) | 46 | 12.6 | (4.4) | |||||
Monitoring (5–15) | 0.023 | 0.24 | −0.005 | 0.77 | 0.28 | ||||||
Baseline | 97 | 11.1 | (2.9) | 73 | 11.0 | (3.3) | |||||
24 months | 32 | 11.4 | (3.2) | 44 | 11.0 | (3.2) | |||||
Sibling Relationships Questionnaire (SRQ) | |||||||||||
Warmth/closeness (1–5) e | 0.012 | 0.01 | 0.009 | 0.04 | 0.62 | ||||||
Baseline | 107 | 3.1 | (0.8) | 89 | 3.2 | (0.8) | |||||
12 months | 69 | 3.1 | (0.8) | 56 | 3.2 | (0.8) | |||||
24 months | 27 | 3.3 | (0.9) | 44 | 3.3 | (0.8) | |||||
Relative status/power (−4 to 4) f | 0.003 | 0.57 | −0.011 | 0.01 | 0.03 | ||||||
Baseline | 111 | 0.1 | (0.9) | 99 | 0.2 | (1.0) | |||||
12 months | 68 | 0.2 | (0.8) | 57 | 0.3 | (0.9) | |||||
24 months | 27 | 0.1 | (0.8) | 44 | 0.1 | (0.8) | |||||
Conflict (1–5) g | −0.017 | 0.002 | −0.008 | 0.11 | 0.19 | ||||||
Baseline | 107 | 2.7 | (0.9) | 92 | 2.6 | (0.8) | |||||
12 months | 69 | 2.5 | (0.8) | 57 | 2.4 | (0.8) | |||||
24 months | 27 | 2.4 | (0.8) | 44 | 2.5 | (0.9) | |||||
Rivalry (0–2) h | −0.007 | 0.03 | −0.005 | 0.11 | 0.57 | ||||||
Baseline | 105 | 0.5 | (0.5) | 90 | 0.5 | (0.5) | |||||
12 months | 64 | 0.5 | (0.5) | 53 | 0.4 | (0.5) | |||||
24 months | 26 | 0.2 | (0.4) | 42 | 0.4 | (0.5) |
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Gupta, K.B.; Rusiewski, C.; Koczara, C.; Fitzgibbon, M.; Reinecke, M.; Fogel, J.; Schiffer, L.; Lee, M.; Sykes, E.; Griffiths, K.; et al. Randomized Clinical Trial of Primary Care Based Online Depression Prevention Intervention: Impact on Adolescent Modifiable Factors and Behaviors. Soc. Sci. 2021, 10, 385. https://doi.org/10.3390/socsci10100385
Gupta KB, Rusiewski C, Koczara C, Fitzgibbon M, Reinecke M, Fogel J, Schiffer L, Lee M, Sykes E, Griffiths K, et al. Randomized Clinical Trial of Primary Care Based Online Depression Prevention Intervention: Impact on Adolescent Modifiable Factors and Behaviors. Social Sciences. 2021; 10(10):385. https://doi.org/10.3390/socsci10100385
Chicago/Turabian StyleGupta, Kushagra B., Calvin Rusiewski, Camilla Koczara, Marian Fitzgibbon, Mark Reinecke, Joshua Fogel, Linda Schiffer, Miae Lee, Emily Sykes, Kathy Griffiths, and et al. 2021. "Randomized Clinical Trial of Primary Care Based Online Depression Prevention Intervention: Impact on Adolescent Modifiable Factors and Behaviors" Social Sciences 10, no. 10: 385. https://doi.org/10.3390/socsci10100385
APA StyleGupta, K. B., Rusiewski, C., Koczara, C., Fitzgibbon, M., Reinecke, M., Fogel, J., Schiffer, L., Lee, M., Sykes, E., Griffiths, K., Gladstone, T. R. G., & Van Voorhees, B. W. (2021). Randomized Clinical Trial of Primary Care Based Online Depression Prevention Intervention: Impact on Adolescent Modifiable Factors and Behaviors. Social Sciences, 10(10), 385. https://doi.org/10.3390/socsci10100385