R o l f Manz, Juliane Junge, S i m o n Neumer, Jiirgen Margraf
Primary Prevention of Anxious and
Depressive Symptoms in Adoleseents
First Results from a Quasi-Experimental Study
Prim~ire Pr~ivention von Angst- und depressiven S y m p t o m e n
bei Adoleszenten. Erste Ergebnisse einer quasi-experimentellen
Studie
This paper describes the design of a large scaled intervention study to prove the effectiveness of a prevention programme for anxiety and depression.
In addition the development and application of a programme for the primary prevention of anxiety and depression in adolescents is presented. The treatment targets
anxious and depressive symptoms, cognitive distortions and attributional styles as
well as social skills in 14 to 18 year old high-school students.
First results on the efficacy of the prevention treatment are reported. Wefound small
but positive effects on cognitive and social risk factors over a 6 months period. The
effects of the prevention programme depend on the fidelity of the treatment implementation.
Keywords: prevention, anxiety, depression, adolescents, treatment fidelity
Die A rbeit beschreibt das Design einer umfangreichen [nterventionsstudie zur Uberpriifung der Effektivitdt eines Programms zur primdren Prdvention von Angst und
Depression.
Die Entwickhmg und Anwendung eines Programms zur primiiren Priivention von
Angst und Depression J~r Jugendliche wird vorgestellt. Das Programm thematisiert
Angst~ und depressive Symptome, kognitive Verzerrungen und Attributionsstile
ebenso wie soziale Fertigkeiten bei 14- bis 18jiihrigen Gymnasiasten.
Erste Ergebnisse zu den Effekten des Prdventionsprogrammes werden berichtet. Wir
fanden zwar kleine aber positive Effekte auf kognitive und soziale Risikofaktoren
iiber einen Nachuntersuchungszeitraum von 6 Monaten. Die Programmeffekte zeigen einen deutlichen Zusammenhang mit der Giite der Programmumsetzung.
Stichworte." Prdvention, Angst, Depression, Jugendliche, Giite der Programmumsetzung
Introduction
Recent investigations of the WHO have shown the high prevalence of mental
disorders in European countries (Ostfin/Sartorius 1995). In spite of the high
prevalence rates of mental disorders and the increasing knowledge about them,
only rare attempts for primary prevention exist. While in the US the Clarkegroup (Clarke et al. 1995) and the Seligman-group (Seligman et al. 1999) have
developed prevention programmes for depression and have shown them to be
effective. In Europe up to now there are no such attempts.
With support from the German Ministry for Research and Technology, the Dresden University of Technology launched a large research project to develop and
Z. f. Gesundheitswiss., 9. Jg. 2001, H. 3
229
test a programme for primary prevention of anxiety and depressive disorders
in adolescents and young adults. It is the first project on primary prevention
of mental disorders in Germany. This article will give an overview of the study's aims, design, methods and first results.
Epidemiology of mental disorders in adolescents
There are only few recent epidemiological studies on mental disorders that cover adolescents and young adults (Wittchen 1995; Wittchen et al. 1999). Nevertheless there is limited knowledge about the onset of some of these disorders. In most disorders it can be located in late childhood and early adolescence (Burke et al. 1990; Kovacs et al. 1997). Especially simple phobias and
social phobias have an onset at the age of 13 (Kessler et al. 1994). For major
depressive disorders (MDD) the age of onset is about 14 years (Lewinsohn et
al. 1994). Panic disorders and agoraphobia have an age of onset at 20 but in
contrast to panic attacks they are highly indicative for more severe psychopathology (Reed/Wittchen 1998).
The course of anxiety and depressive disorders is of additional importance.
Both anxiety and depressive disorders in adolescents show relatively low proportions of complete remission. The complete remission rates for MDD and
dysthymia are about 43% and 33%, respectively (Oldehinkel et al. 1999). Comorbidity with other mental disorders are common, increasing the risk for poor
outcome. Moreover other unfortunate impacts of these disorders are social isolation, alcohol, drug and tobacco abuse. Behavioural and cognitive impairment
is likely to lead the young person to learning deficits and school problems. The
prevention of anxiety disorders and depression therefore is of high Public
Health relevance.
Primary prevention of mental disorders
Although there is no doubt about the importance of primary prevention within
the scope of Public Health, at least in Germany this branch of research is deficient. This is unfortunate, considering that the proof of successful interventions is an evidence for causal risk models (H/ifner 1996).
Whereas programmes for the primary prevention of tobacco and drug use are
well known and proved to work effectively only partially (Bruvold et al. 1988;
Ennet et al. 1994; Lynam et al. 1999), primary prevention of mental disorders
is a relatively young research interest. Durlak and Wells (1997) recently reported results of a meta-analysis on primary prevention mental health programmes for children and adolescents. Programmes modifying the school environment and individually focussed programmes yielded significant effects
ranging from .24 to .93. Especially in young children these programmes seemed to work effectively where affective and competence promoting programmes
showed effects between .69 and .85. Behavioural and cognitive-behavioural
forms of interventions were twice as effective than non-behavioural techniques.
Objectives
The study's main objective is the development, evaluation and implementation
of a programme for the prevention of depressive and anxiety disorders in adolescents.
230
z . f . Gesundheitswiss., 9. Jg. 2001, H. 3
In addition to the general psychopathology knowledge base, programme development was based on the work of Beck (1976) and others on depressive disorders as well as the work of Margraf and Schneider (1990) on anxiety disorders. Although the role of cognitive distortions and deficiencies in the aetiology
of depressive and anxiety disorders is not yet completely understood (Sweeny
et al. 1986), their potential as risk factors are at least probable. The programme
contains both disorder-specific and general health promoting components. Cognitive-behavioural techniques, information about stress and mental disorders as
well as training of social skills are used to enhance coping, mastery and competence of the students to face negative life events and other situations that might
enhance their risk for developing mental disorders. Practice transfer will be
achieved by implementing the programme in mental health care and educational settings in Saxony. The development of extensive training materials and the
training of moderators such as teachers will serve this purpose.
Methods
Design
With the use of a quasi-experimental intervention study design, adolescents
who are at an increased risk for developing depressive or anxiety disorders are
investigated. To test the effectiveness of our prevention programme after preintervention measurement high-school classes are randomly admitted to either
treatment or control groups. Programme evaluation will involve a prospective
18 months follow-up.
Screening measures and definition of implicit risk-groups
The use of diagnostic instruments such as the Beck Depression and Anxiety
Inventories (BDI: Beck et al. 1961 [German: Hautzinger 1991 ]; and BAI: Beck
et al. 1988 [German: Margraf/Ehlers 1996]) and the Youth Self Report (YSR:
Achenbach 1991 [German: Drpfner et al. 1994]) will allow for the identification of high risk individuals. BAI and BDI are well known self-rating instruments.
The Youth Self-Report (YSR; Achenbach & Edelbrock 1987) is a standardised, empirically-based dimensional inventory for the assessment of adolescent
problem behaviours and competencies. The self-report instrument has been used
extensively in previous research on psychopathology in childhood and adolescence. As a general indicator for psychopathological impairment a total score
is computed.
Psychiatric diagnoses: To assess clinical diagnoses in our sample the original Diagnostic Interview for Mental Disorders (DIPS; Margraf et al. 1991) was adopted for the use with adolescents and to obtain current and lifetime diagnoses, including childhood diagnoses (Mini-DIPS-J; Margraf/Junge 1998). The structured clinical interview is based on the Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. (DSM-IV; APA 1994). The structured interviews were
conducted individually in a private location after regular classroom periods.
Interviewers were recruited from the clinical psychology programme at the
Dresden University of Technology. They were already extensively pre-trained
in the use of structured clinical interviews, especially the DIPS, through the
Z. f. Gesundheitswiss., 9. Jg. 2001, H. 3
231
university psychology programme. Nevertheless interviewers took part in a
comprehensive additional training seminar consisting of two 8-hour training
sessions during which the criteria for the relevant disorders were reviewed. Coding and interviewing skills for the modified DIPS-version were taught with the
use of role-playing techniques under supervision. Interviewers were continually supervised by the authors during the study. Interview forms were reviewed on-site to assure quality and address difficulties immediately.
Subjects
Letter of consent forms describing the prevention programme were sent to all
parents of 9th and 10'h grade students of 4 randomly selected high schools in
Dresden, Germany. After this a total of 627 male and female adolescent students aged 15-17 took part. These are 90,2% of the initial pool of all 9th and
10th graders of these schools. The prevention programme was administered to
325 students in the classroom setting. Further 302 students served as a control
group. All school classes were randomly assigned to either treatment or control conditions. High risk criteria for the development of anxiety or depressive
disorders have been expected to be met by 30% of the students in both, the
treatment and the control group. This procedure was employed so that the investigation could be carried out within the classroom setting and to reduce selection bias (for details see Manz et al. 2000).
Measures of risk factors
In addition to the impairment and symptom measurements mentioned above
we administered instruments that cover cognitive, social and behavioural risk
factors. An extensive examination before treatment included the registration
of the mental state of health as well as typical risk factors for the development
of depressive and anxiety disorders. Cognitive styles, attributive patterns and
self-efficacy expectations, self security and self esteem, social support and social behaviour and avoidance behaviour were assessed. These factors serve as
predictors of changes in the dependent constructs (anxiety and depression) during the course of the training.
The cognitive factors considered were dysfunctional attitudes and anxiety sensitivity as risk and self-efficacy as protective factors.
Explanatory styles were measured by the Dysfunctional Attitude Scale (DAS:
Weissmann/Beck 1978 [German: Hautzinger et al. 1985]) a self-report measure
that contains 40 items that represent different aspects of cognitive distortions.
Anxiety sensitivity (Peterson/Reiss 1987; Reiss et al. 1986) describes a person's
tendency to interpret his or her physical reactions as dangerous and health threatening. The construct was measured by a 16 items self-rating questionnaire.
Self-efficacy (Bandura 1982) enhances a person's ability to cope with threatening situations. Individuals feel that they have the ability to master stressful
situations. The self-report measure applied (German: SWE; Schwarzer 1994)
includes I0 items.
The social factors considered were social support and self-security as protective factors:
232
z . f . Gesundheitswiss., 9. Jg. 2001. H. 3
Social support was measured by a comprehensive questionnaire for social support (German: SOZU-K; Fydrich et al. 1987).
Self-security was measured by three sub-scales of a social security and social
behaviour questionnaire (German: U-Fragebogen; Ullrich de MyncMUllrich
1976).
The behavioural factors considered were avoidance behaviour and social behaviour.
Avoidance behaviour was measured by three scales of the fear questionnaire
(FQ; Marks/Mathews 1979).
Social behaviourwas measured by three sub-scales of the ,,U-Fragebogen" (see
above).
Measure of psychological knowledge
To assess the gain in psychological knowledge during the programme we administered a 30 items multiple choice test regarding the programme specific
psychological knowledge. The test was administered pre and post intervention
in the treatment and the control group.
Data analyses
We used analyses of variance for repeated measurement to analyse our data.
To reduce the number of variables to be compared between treatment and control group factor analyses were carried out for each set of variables representing cognitive, social and behavioural factors and for the variables measuring
symptoms. For each set of variables main component analyses were carried
out for each time point. On the basis of these main components factor scores
were calculated and z-transformed. The following analyses are based on these
factor scores. As the factor scores are standardised for each time point with its
mean set to zero the pure time effects which are not of interest here were diminished from the data. The first components showed variance explanation between 38,9 and 46,9% for the cognitive, 57,8 and 62,0% for the social, 46,2
and 55,2% for the behavioural and 65,5 and 68,1% for the impairment variables. Therefore each construct is well represented by these first factors. The
cognitive construct was defined by risk factors as well as by a protective factor (self efficacy). Self efficacy was represented by a negative factor loading
on the first components of the cognitive variables.
Sample characteristics
The age cohort to be studied is particularly relevant to the early manifestation
of anxiety and depressive disorders and their prevention. Table l gives an overview of demographic characteristics of the students. There are no differences
between the treatment and control groups with regard to age, marital status of
the parents and family social status.
According to the central question of our work, the primary prevention of mental disorders, we defined three subgroups. Where ,,cases" are students that suffer from impairment of clinical relevance, ,,at risk" are students that reach impairment not actually at clinical relevance but subclinical and therefore at risk
Z. f. Gesundheitswiss., 9. Jg. 2001. H. 3
233
Table 1: Demographic Variables by group (percentages)
Variables
Age (mean/SD)
(range)
High-School
(treatment)
n=325
High-School
(control)
n=302
t 5,5/0,8
1 4 - 18
15,4/0,8
1 4 - 17
41/59
42/58
79
78
8,3
14,1
t0,2
55,6
10,9
0,9
7,2
16,6
7,2
58,6
8,2
2,4
Sex (male/female; %)
Parents married (%)
Family Social Status (%)
academic
self-employed
civil servant
white collar worker
blue collar worker
other
to develop a disorder, ,,normal" are students without any clinically relevant impairment.
Case definition: by using self rating instruments there must be an operational
case definition. ,,Cases" of self rated clinical anxiety or depression are students
that score 18 and above on the BDI or 24 and above on the BAI (cases: BDI >
17 or BAI > 23). For both instruments these are the cut-offs for the 90 'h percentile. ,,At risk" is defined as 11 to 17 points on the BDI or 16 to 23 points
on BAI and neither on BAI nor on BDI scores that would define a ,,case"(at
risk: BDI 11 - 17 and BAI < 24; or BAI 16 - 23 and BDI < 18). For both instruments this defines the 75 th to 89 th percentile. ,,Normal" is defined by
scores on BDI lower than 11 and scores lower than 16 on BAI (normals: BDI
< 11 andADt < 16). Prevalence o f , a t risk" status indeed is about 28,2% ranging from 21,8% in males to 32.6% in females (see Fig. 1). Additional 13,1%
already reached the ,,case" criteria.
Figure 1: Anxiety and depressive impairment of 627 Dresden students aged 14 to
18 (prevalence rates according to operational criteria, BDI and BAI)
-iii
74,S
Ss,7
47,4
tG~SI(r1=627)
234
m~
- ~ h school (r[=,260)
females - high s t i e d (n=,367)
z . f . Gesundheitswiss., 9. Jg. 2001, H. 3
The prevention programme ,, GO. t" (Health and Optimism)
The development of the programme began within a pre-test target group of 75
students 15 to 17 years old. These first experiences led to a number of modifications of the programme. An overview of the topics of the final ,,GO!" programme gives table 2.
The programme is based on a method by Gillham and co-workers successfully
applied to prevent depressive symptoms in younger children (10 to 13 years
old) (Gillham et al. 1995; Jaycox et al. 1994). For the application in Germanspeaking areas this programme was considerably modified and supplemented
by a specific part for the prevention of anxiety disorders.
Table 2: Topics of the prevention program ,,GO!" by session
Session Topics
Introduction: what is stress, analysis of risk factors for adolescents, development of a four component stress model
Cognition and Emotions: personal aims, stress experiment, cognition emotion-behaviour circle, automatic thoughts
Anxiety: three components of anxiety, maladaptive anxiety, self confrontation
Depression: depressive thinking, cognitive distortions, logical mistakes,
dysfunctional attitudes
Social Competence and Assertiveness: insecure - aggressive - self secure
behaviour, assertive behaviour
Stress and Coping: habits - attitudes - behaviour, time management techniques, relaxation techniques
Problem-solving: general structure of rational problem solving, techniques
for solving social problems
Repetition, feedback, outlook, discussion
One part of the curriculum (see Table 2) involves general information about
anxious and depressive moods as well as on anxiety and depressive disorders.
The treatment components specifically relating to depression are based on the
work of Beck (1976), Ellis (1962), and Seligman (1991) (i.e., correcting negative convictions, elaborating explanatory styles as well as replacing negative and inappropriate causal attributions by realistic ones). Components specifically relating to anxiety disorders are based on the studies of Margraf &
Schneider (1990) (i.e., information about anxiety such as three-componentmodel, temporal course of anxiety reactions and implications for ways of coping with them, meaning of misinterpretation and auto-suggestive processes,
vicious-circle-model, training of self-exposure techniques, and techniques for
modifying cognitive distortions). In addition, the programme contains unspecific components like the training of personal skills because health and social
competence promotion is an effective way to prevent mental health problems
(Elias 1995; Leon et al. 1980). These are social skills and problem solving techniques, clarification of personal goals and intentions prior to engaging in action, anticipation of the consequences of one's actions, self-confidence training, and relaxation techniques.
Z. f. Gesundheitswiss., 9. Jg. 200l, H. 3
235
Programme application
Carrying it out in the unit of a class is an easy access to a group homogenous
in the age of the first manifestation of the discussed disorders. The prevention
programme ,,GO!" was conducted within groups of 15-18 participants in a classroom setting. The net time to be spent on the programme was 12 hours, the
programme's overall duration 8 weeks. The newly developed prevention programme (Junge et al. in press) was carried out by two supervised trainers in
school classes in eight double lessons. 23 trainers carried out the programme
at 4 high-schools. 12 of them only carried out only I, 11 trainers 2 and 1 trainer 3 groups. 21 of them were females and 2 were males.
Results
Since our programme is educative and knowledge is one precondition for behavioural and cognitive change we assessed the effects of the treatment on the
psychological knowledge of the students. Boys and girls showed considerably
good improvement of their knowledge in comparison to the control group
(F = 111.1, p = .000) (Fig. 2).
Figure 2: Psychological knowledge before and after the prevention programme GO!
(treatment n= 106; control n=t55)
30.
27.
-~
24
~,,~~
21
0
'
18.
15.
12.
E~
9.
6,
3.
0
I
Pre-test
Post-test
To examine the efficacy of preventive strategies it is useful to distinguish between proximal and distal effects. Proximal effects are effects on the risk factors themselves i.e. cognitive, behavioural and social factors that lead to psychological impairment and mental disorders. Distal effects are effects on psychopathological state. In general we found considerably small effects of the treatment.
Proximal effects
As we assessed a lot of variables representing the different proximal areas we
carried out principal component analyses to reduce data. The cognitive area
was represented by dysfunctional attitudes (DAS), anxiety sensitivity (ASI)
and self-efficacy (SWE). For the first component of these variables we found
significant pre-post differences that remain stable until 6 month follow-up for
boys (F = 2.925, d f = 2/252, p = .050, (eta 2= .023). The mean scores are shown
in figure 3. For the girls this effect did not reach statistical significance (F =
0.492, df = 2/528, p = .61 I).
236
z . f . Gesundheitswiss.. 9. Jg. 2001, H. 3
Figure 3: Mean z-scores for the first social factor; boys: treatment (n=72) vs. control (n=65)
First social factor
male
,2
(
,1,
0,0 ,
*.1,
.................................
*.2 1
-,3,
~i~.,,.......~..~..~,~......~....~g...............
roup
m
c
m
E:3 t r e l t m l l n l
-,4,
[3 control
post
Ire
follow-up
time
The first component of the behavioural risk factors did not show significant
pre-post differences and no effect during the follow-up period.
Social factors were assessed by sub-scales of a questionnaire on self-security
(UFB) and a questionnaire on social support (SOZU-K). For the first main factor of these variables we found treatment effects neither for boys nor for girls.
Distal effects
Although our prevention programme includes some therapeutic techniques the
main elements are educational and only small effects on psychopathology are
to be expected. We found no significant treatment effects on psychopathology
measured by theYSR, BAI and BDI. Fig. 4 shows the mean scores for the first
component o f these instruments. Neither the boys nor the girls gained from the
treatment. The girls showed increasing scores from pre to post that may indicate a ,,sensibilisation" by the treatment.
Figure 4: Mean z-scores of the first component of the impairment measures for boys
and girls, each treatment by control group.
Rrst~eirmat fact~
r
-,4
/
/
/
/
.........
/
.......................
-.6
__
a ~
trno
Other effects
Comparing the effects of the treatment for the different schools lead to the following results: There are significant three way effects (time x treatment x school)
Z. f. Gesundheitswiss., 9. Jg. 2001, H. 3
237
for the cognitive (F = 2.154, d f = 6/802, p = .045, (eta 2= .016) and the social
(F= 2.828, df = 6/794, p = .010, (eta 2= .021) factors indicating different efficacy of the programme. The students of school # 4 in treatment gained significantly in two proximal areas (see fig. 5). The time x treatment effects for
school # 4 are as follows: social (F = 5.282, df = 2/122, p = .006, (eta 2= .080)
and behavioural (F = 3.389, df = 2/108, p = .037, (eta 2= .060).
Figure 5: Mean z-scores of the first components of the social (n=20/43) and behavioural (n= 19/37) measures for students of school # 4, each treatment by control group
First social factor
~
First behavloural factor
j
J
1j
"'..
-2;
|
.,3
..4
pm
~ne
'..
aco~
l
o m
tim
Discussion
Our prevention programme ,,GO!" (Junge et al., in press) has been developed
based on the work of Seligman, J.M. and others on depressive and anxiety disorders. The programme includes the modification of dysfunctional thinking
and attributional styles. Thus, we expect it to work effectively in the prevention of anxiety and depression for people ,,at risk" and ,,cases". Beside these
specific components, the programme also contains general health promoting
components like the training of social skills. These health promoting components are necessary at least for two reasons. First they enhance protective resources of the person like social support and reduce risk for developing mental disorders. A further reason to introduce health promoting components to
our programme comes from the application in an unselected sample. Unlike
Gillham and colleagues we did not explicitly select people at risk for intervention, so we might expect to have a mixed sample of,,normals" people ,,at
risk" and ,,cases" together when administering the programme. Mufios (1993)
pointed out that an overlap of primary prevention and therapy always is to be
expected because ,,normals" and people ,,at risk" can not be distinguished perfectly by operational criteria. Therefore the claims to the programme are high.
It should work effectively for ,,cases", people ,,at risk" and at the same time it
should be interesting enough for ,,normals" to take part.
This concept offers some advantages to the study of primary preventive programmes. First of all, to avoid selection bias to programme participation. This
strategy worked well because 90,7% of the high-school students who have been
selected for treatment took part and selection bias is reduced to a minimum.
Of additional advantage is the possibility to prove the programm's preventive
as well as its health promoting effects.
The health promoting as well as the preventive effects of the programme are
considerably small. We found effects only for the cognitive, the social and the
238
z . f . Gesundheitswiss., 9. Jg. 2001, H. 3
behavioural proximal factors and for treatment specific knowledge. This is in
line with the experiences of Clarke et al. (1993). The authors reported that they
found no effects of two educational oriented prevention programmes administered to unselected pupils. In a later study (Clarke et al. 1995) found good
preventive effects of a modified prevention programme. Gillham et al. (1995)
reported positive effects of their prevention programme, and Seligman et al.
(1999) also found positive effects in a highly selected sample of high-school
students. These authors used different strategies for pre-setection of the participants by the psychopathological or the cognitive risk status. Therefore it can
be speculated that using a pre-selection strategy would lead to considerably
better effects of our prevention programme (Manz 2000). In an unselected population the programme yet does not work sufficiently.
A comparison of the schools involved in the study showed different treatment effects. Particularly the students in school # 4 gained from the treatment. A comparison of socio-economic factors between the schools indicated no difference
between them (chi2 = 25,508, df = 21, p = 0,371). But school # 4 was the last
school where the treatment started. All the trainers that have been working in school
# 4 had good experience with the programme while in the other 3 schools most
of the programmes had been administered by un-experienced trainers. It is wellknown that the effect of preventive programmes for instance in drug prevention
depend on the fidelity of the programme application (Botvin et al. 1990). Trainer
competence and adherence to the manual significantly enhance the effects of preventive strategies. At school # 4 these criteria have been fulfilled sufficiently and
these results underline the preventive as well as the health promoting potential of
our prevention programme GO! They also point out the importance of a quality
assurance strategy when implementing the programme into routine.
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Acknowledgement - this study was funded by the German Federal Ministry of Education, Science, Research and Technology (BMBF+T): 01EG973144
Kontakt:
Dr. Rolf Manz, Dresden University of Technology, Research Association Public
Health Saxony
FiedlerstraBe 33
01307 Dresden, Germany
Tel. 0049 -351 -4333016, Fax 0049 -351 -433300
eMail: [email protected]
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