REVIEW URRENT C OPINION
Is e-health the answer to gaps in adolescent mental health service provision? Bridianne O’Dea a, Alison L. Calear b, and Yael Perry a
Purpose of review Depression and anxiety are prevalent among adolescents; however, many young people do not seek help from professional services. This is due, in part, to the inadequacies of existing healthcare systems. This article aims to review the current evidence for e-health interventions for depression and anxiety in youth, as a potential solution to the gaps in mental health service provision. Recent findings Five randomized controlled trials reporting on e-health interventions for youth depression or anxiety were identified. Of these, two trials focused exclusively on anxiety symptoms, and three trials examined both anxiety and depression. The majority of trials assessed online cognitive behavioral therapy and focused on prevention rather than treatment. In all but one trial, results demonstrated positive effects for the e-health interventions, relative to the control. Summary There is growing evidence for the effectiveness of online cognitive behaviour therapy interventions for reducing the level of anxiety and depressive symptoms in adolescents aged between 12 and 18 years, when delivered in school and clinical settings, with some level of supervision. However, there are a number of gaps in the literature. More research is needed to strengthen the evidence base for prevention and treatment programs that are delivered via the internet, particularly for depression. Keywords adolescent, anxiety, depression, internet, prevention, treatment
INTRODUCTION Depression and anxiety are prevalent among adolescents. Population-based surveys suggest that 10–30% of adolescents experience depressive symptoms at any one time [1]. Both depression and anxiety are associated with social withdrawal, poorer academic performance, greater functional disability and are risk factors for suicide [2,3]. Symptoms of depression and anxiety in adolescence may mark the development of a mental illness, as up to 75% emerge before the age of 25 [4]. Early intervention is critical to prevent chronic impairment [5], with a number of evidence-based treatments available to prevent and reduce symptoms of anxiety and depression [6–8]. However, many adolescents do not seek help for mental health problems from professional services. This is often because of a poor awareness of the signs and symptoms, perceived stigma, and an inability to access services because of extended waiting lists, expense and geographical dispersion, highlighting the inadequacies of existing healthcare systems [9–11]. www.co-psychiatry.com
The internet is a viable alternative for the treatment of depression and anxiety in young people, particularly given their heightened familiarity with online technology [12]. There are a number of potential advantages associated with internet delivered treatments, including increased access to services among those who are not willing to seek face-toface help; lower cost to the individual and mental healthcare system; increased availability as individuals can access treatment at times and locations suited to them; increased fidelity due to automated delivery; ease of use; and the potential for rapid dissemination [13,14]. The aim of this article is to a
Black Dog Institute, UNSW Australia, Randwick, NSW and bNational Institute for Mental Health Research, The Australian National University, Canberra, ACT, Australia Correspondence to Bridianne O’Dea, Black Dog Institute, UNSW Australia, Hospital Road, Randwick, NSW 2031, Australia. Tel: +1 61 2 9382 8509; e-mail: [email protected] Curr Opin Psychiatry 2015, 28:336–342 DOI:10.1097/YCO.0000000000000170 Volume 28 Number 4 July 2015
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KEY POINTS There is growing evidence for the effectiveness of ehealth interventions, particularly online CBT, for reducing the level of anxiety and depressive symptoms in adolescents aged between 12 and 18 years, when delivered in school and clinical settings with some level of supervision. Online CBT delivered with remote therapist support was found to be equally as efficacious as face-to-face CBT for the treatment of anxiety disorders. However, the heterogeneity in sample sizes, randomization procedures and outcome measures of these studies makes it difficult to compare and identify the aspects of the interventions responsible for success. The evidence base needs to be expanded before ehealth interventions are integrated into the system of care for young people experiencing or at risk of developing mental health problems.
ascertain whether e-health interventions, also known as internet interventions, are able to fill the gaps in mental health services by identifying recent research trials and reviews of these interventions to establish their efficacy in the adolescent population. For the purpose of this review, adolescents are defined as secondary school-aged youth between 12 and 18 years. We outline key research outcomes, issues surrounding the online prevention and treatment of anxiety and depression in this population, and discuss the potential for health service reform and future research.
LITERATURE SEARCH A comprehensive literature search was conducted to identify relevant research articles and reviews published between January 2014 and January 2015 in MEDLINE and PsychInfo using the following search terms: adolescen or teen AND depress or mood or anx or worry, AND screen or assess or interven or prevent or treat or program AND web or online or internet or computer or mobile or tele or game or app or e-health. This search was also repeated separately in the peer-reviewed journal Internet Interventions, as it is currently not listed in MEDLINE or PsychInfo and is relevant to this field. Articles were included if they reviewed or reported on a randomized controlled trial (RCT) evaluating the effectiveness of an online or mobile application designed to prevent or treat anxiety or depression in adolescents aged between 12 and 18 years. Studies were excluded if outcome measures did not specifically assess symptoms of depression and/or anxiety. The search
generated 320 abstracts of which 289 did not fulfill the inclusion criteria and were excluded from review. The full-text of the remaining 31 articles was collected for further review. Six of the full-text articles fulfilled the inclusion criteria and are discussed below.
FINDINGS Systematic reviews and meta analyses published in the last 12 months Four relevant review articles were identified [15 ,16 ,17 ,18 ]. These reviews focused on the treatment and prevention of anxiety and depression in adolescents, although one of the reviews included studies with a range of mental health outcomes [15 ]. The reviews collectively identified 88 studies published between January 1990 and December 2013. Of these 88 studies, only three were RCTs of an online prevention or treatment intervention for anxiety and/or depression in adolescents aged between 12 and 18 years [19–21]. All of these particular trials were published between 2009 and 2013. Of the three relevant RCTs, one evaluated an online, school-based, universal prevention program for depression and generalized anxiety [19], one evaluated an online, school-based, indicated prevention program for social anxiety and test anxiety [21] and one evaluated an online treatment program for anxiety disorders in a clinical setting [20]. No treatment trials for depression alone were found. The trials identified delivered the interventions for a period ranging between 6 and 12 weeks, with all studies including a 6-month follow-up and two of the three studies including a 12-month follow-up. Participants in these studies were aged between 12 and 18 years with a mean age of 14 years. The majority of participants were female. In both of the school-based trials, more than half of the participants were in Grade 10 or below when recruited. The school-based trial for the prevention of depression and generalized anxiety used a universal sample of high-school students with no exclusion criteria based on symptoms or diagnosis [19]. No significant differences in depression and anxiety were found at preintervention between the control and intervention groups; although, when compared with male participants, a higher proportion of female participants reported elevated levels of anxiety (13 vs. 4%) and depression (15 vs. 7%). The school-based trial for social and test anxiety only included participants with self-reported social and test anxiety at baseline, with different cutoff scores used for male participants and female participants [21]. Eligible &
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participants were required to complete a clinical assessment and only those with low-level social and test anxiety were included in the final sample. Adolescents with DSM IV diagnoses other than anxiety and/or with severely interfering anxiety diagnoses and/or who expressed a need for regular treatment were excluded. The online treatment program for anxiety disorders [20] was conducted in a clinical setting and included only those with a primary clinical diagnosis of generalized anxiety disorder (48%), social phobia (35%), separation anxiety (13%) or a specific phobia (4%). Participants with a primary diagnosis of panic disorder, obsessive compulsive disorder or posttraumatic stress disorder were excluded. Adolescents reporting a mood disturbance rated as ‘moderately disturbing’ or greater were also excluded, as were those with a pervasive developmental, learning or behavioral disorder, substance abuse, suicidal ideation or current self-harm. Two out of the three internet interventions used cognitive behavior therapy (CBT) [19,20] with the other using cognitive bias modification (CBM) [21]. Internet-delivered CBT (MoodGYM) in the schoolbased prevention trial for depression and anxiety was found to be more effective in significantly reducing anxiety symptoms in both male participants and female participants, and depressive symptoms in male participants only, when compared with a wait-list control condition at postintervention and 6-month follow-up [19]. In terms of the prevention of anxiety, a larger percentage of participants in the wait-list control condition than in the intervention condition (2 vs. 1%) became a case at postintervention and 6-month follow-up, although these differences were not significant. In terms of the prevention of depression, a larger percentage of male participants in the wait-list control condition than in the intervention condition (9 vs. 2%) met criteria for caseness at postintervention and 6-month follow-up. These differences were significant at both time points. The treatment trial for anxiety disorders compared internet-delivered CBT (Brave-Online) with face-to-face CBT (Brave-Clinic) and a wait-list control condition [20]. Both of the active interventions significantly reduced anxiety symptoms more than the control condition. Clinical improvement was defined as the percentage of adolescents who were free of their primary diagnoses. At 12 weeks, 37% of those in the online condition no longer met the criteria for their primary diagnosis compared with 33% in the face-to-face condition and 4.2% in the control condition. Post-hoc tests revealed significant differences between the control and online conditions, the control and face-to-face conditions, 338
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but not between the online and face-to-face conditions. These improvements were maintained at 6-month and 12-month follow-up. The effect sizes between the face-to-face and online conditions were not significantly different indicating that the faceto-face treatment was equal in effectiveness to the online treatment. In the school-based trial for social and test anxiety [21], internet-delivered CBM was compared with face-to-face group CBT and a wait-list control condition. Participants in the face-to-face CBT condition showed a significantly larger reduction in social and test anxiety symptoms than those in the control condition, and a similar trend was evident in the CBM condition; although, this trend was not significant. The differences between CBT and CBM were not replicated at 12-month follow-up, as the control condition showed similar reductions in anxiety symptoms. However, the CBM condition had a significantly stronger decrease in negative automatic associations than both the CBT and control group at 12-month follow-up. The provision of support varied within these interventions. The treatment trial for anxiety disorders provided remote therapist support via E-mail and telephone from a trained psychologist for the online CBT condition [20]. The universal prevention program for depression and anxiety [19] provided face-to-face nonclinical supervision from school teacher staff, and the school-based internet intervention for social and test anxiety [21] was completely self-directed.
Randomized controlled trials published in the last 12 months &
Two RCTs were identified [22 ,23] as being published in the last 12 months. One of these studies [23] was a universal school-based prevention trial examining the efficacy of two online CBT programs (This Way Up Combatting Depression and This Way Up Overcoming Anxiety) for lowering depressive and anxiety symptoms in high school students in Grades 9 and 10, with no symptom exclusion criteria. Only pretest and posttest measures were taken and clinical improvement was not reported. Participants were aged between 14 and 16 years and 68% were female. No significant differences in symptoms were found between the conditions at baseline. The internet programs were delivered in class time, with teacher supervision, as part of the school curriculum. Both of the internet interventions were compared with a control condition, which was attending personal development, health, and physical education classes as usual. When compared with the control condition, the online intervention for depression was found to Volume 28 Number 4 July 2015
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significantly reduce both depressive and anxiety symptoms, whereas the online anxiety intervention was found to only significantly reduce anxiety symptoms. The second study [22 ] compared the effectiveness of a positive psychology website with an attention-control website for lowering depression and anxiety symptoms in a nonclinical youth sample aged 12–18 years, over a period of 6 consecutive weeks. Only pretest and posttest measures were taken. This study was conducted in a nonclinical sample recruited via schools and youth centers. The active intervention website (Bite Back) consisted of interactive exercises and information across a variety of positive psychology domains. The control condition consisted of two neutral entertainmentbased youth websites that contained no psychology information, but equal levels of interactivity. Participants in the active intervention reported significantly lower depression scores at posttest compared with the control condition. At posttest, participants were divided into two groups based on the frequency of their site visits and the amount of time they spent on their assigned website during the study. Participants who visited the active intervention website three or more times a week reported significantly greater reductions in depression and anxiety scores than those who visited the site less than three times per week. No such differences were found in the control condition. Participants in the active intervention who visited the site for 30 min or more per week also reported significantly greater reductions in depression compared with those who visited the site for less than 30 min. Those in the control condition who reported less than 30 min of time per week using their site reported a significant increase in anxiety levels at posttest. &
Noteworthy themes and issues Efficacy There is growing evidence for the effectiveness of online CBT interventions for reducing the level of anxiety and depressive symptoms in adolescents aged between 12 and 18 years, when delivered in school and clinical settings, with some level of supervision [19,20,24 ]. Where available, the effect sizes for the internet interventions aimed at reducing depression and anxiety symptoms ranged from 0.1 to 0.3. The effectiveness of online CBT for the treatment of anxiety disorders [20] was similar to that of face-to-face treatment, with particularly large effect sizes reported for each of the five outcome measures (d ¼ 0.3–2.0) [20]. There is some evidence supporting the efficacy of a positive psychology website for lowering symptom levels of depression; &
although the decrease in symptoms was related to the frequency and duration of site usage. In terms of disorder prevention, one school-based trial found that, when compared with the wait-list control condition, online CBT significantly lowered the risk of developing clinical levels of depression, but only in male participants [19]. No significant results were found for preventing the onset of clinical levels of anxiety. Self-directed CBM showed a statistically nonsignificant trend for lowering social and test anxiety [21]. None of the studies examined the treatment efficacy of internet interventions for depressive disorders. More research using RCTs to directly compare online treatments with face-toface psychosocial treatments, and psychotropic medication, particularly for depression, is needed to further validate these findings. Therapeutic approaches All of the online interventions identified in this review were based on adaptations of evidence-based therapies including CBT, CBM and positive psychology. Internet-delivered CBT currently has the most research evidence supporting its effectiveness [25–27]. This review included three studies that utilized online CBT for lowering both depression and anxiety symptoms [19,24 ], or treating anxiety disorders [20]. In all studies, online CBT was found to be significantly more effective than the control conditions for lowering symptoms. However, because of the heterogeneity across studies, it is currently not possible to determine which of the specific online CBT modules resulted in the greatest positive outcomes on depression and anxiety. Only one study evaluated an online, self-directed positive psychology resource [22 ]. Given that the efficacy for the online delivery of other therapies (CBM and positive psychology) remains limited, adapting and testing additional evidence-based therapies for online delivery, such as Acceptance and Commitment Therapy and Interpersonal Therapy, will help to expand the number and types of psychological therapies offered by the internet, ultimately increasing access. &
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Support and supervision Only one study provided clinical support alongside the internet intervention [20]. Two of the three school-based studies [19,23] provided nonclinical support and supervision for the internet interventions delivered via the classroom teachers. Although both of these trials found significant positive effects for the internet intervention compared with the control, the level of supervision and the nature of support were not manipulated, so no firm conclusions can be made about the unique effect of
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these on the effectiveness of the interventions. Studies in adults have generally found that support, regardless of its clinical or nonclinical nature, increases the effect of internet interventions [28]. Little research exists in adolescents. As the positive psychology website had significant effects without any supervision or support [22 ], future research that compares the type and intensity of support or supervision will help to determine the minimum level of resources and input required for maximum clinical efficacy. &
Program adherence, study retention, and user satisfaction Adherence among those allocated to the modular CBT internet programs was low with only 32–39% of participants completing all modules [19,20]. These findings suggest that despite the greater accessibility afforded by internet interventions, adherence is problematic, although the one study that compared the completion of internet therapy with the completion of face-to-face therapy found no difference in completion rates [20]. It is unclear from the studies reviewed here, how many completed modules are needed for a significant decrease in symptoms, and it is likely that this would be partially dependent on the nature of the intervention itself. The relationship between baseline symptom severity and adherence also remains unclear. One study found that those with lower anxiety at baseline were less likely to complete modules [21]. A secondary analysis of adherence to an online intervention for anxiety and depression in adolescents [29] found that greater adherence to the online intervention was correlated with better clinical outcomes: school grade, location (rural) and higher symptoms of depression or self-esteem at baseline were predictive of greater adherence. All but one of the studies examined here [23] retained more than 60% of the sample at posttest, which is similar to the rates reported by face-to-face studies [30], suggesting that internet trials do not result in higher drop-out; however, one of the school-based trials did report a 63% drop-out rate, which is surprising given the purported advantage of school-based interventions having a captive audience. Only one study examined participants’ perceptions of treatment credibility and satisfaction [20]. In this study, adolescents reported moderateto-high satisfaction with the internet treatment and these scores were not significantly different from those in the face-to-face condition. The limited nature of program acceptance data precludes clear conclusions being drawn about the broad acceptability of internet interventions in youth; however, it highlights the importance of further 340
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research investigating the interactions between adherence, acceptability, and clinical outcomes. Internet medium All interventions included in this review were delivered using an internet web browser. The development and rigorous evaluation of mobile phone or tablet interventions for adolescents should be examined due to the portability of such devices [31], as well as the increasing rates of app development [32] and tablet usage [33], particularly in lowmiddle income counties [34]. Sample bias Most studies included in this review relied on school-based recruitment [19,21,23]. Two studies used community recruitment methods such as advertisements. Only one of the school-based studies reported the locality of students, of which only 16% were living in a rural location [19]. Neither of the community samples indicated the locality of participants. Only two studies reported the ethnicity of participants [19,20] and neither of these samples were particularly diverse with over 90% born in Australia or speaking English as their first language. As such, the cultural sensitivity of the included internet interventions remains unknown. All included studies were conducted in high-income countries. Given that most of the world’s young people live in low-middle income countries [35], inclusion of such youth in effectiveness trials needs to occur for broader generalization of results. In future studies, investigators should attempt to have a more diverse range of participants, including those from rural areas, different cultural backgrounds and other minority youth, such as those who do not attend mainstream schools. Cost-effectiveness None of the studies examined cost-effectiveness. In future studies, investigators should endeavor to include a measure of cost-effectiveness to confirm the reduced economic burden associated with internet treatment for youth [36].
CONCLUSION There is growing evidence for the effectiveness of online CBT interventions for reducing the level of anxiety and depressive symptoms in adolescents aged between 12 and 18 years, when delivered in school and clinical settings, with some level of supervision. However, a number of gaps in knowledge remain. The heterogeneity in sample sizes, randomization procedures, and outcome measures made it difficult to compare trial results and the study designs did not attempt to identify the specific Volume 28 Number 4 July 2015
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aspects of the internet interventions responsible for success. These factors, alongside the lack of cost effectiveness data, mean that the likelihood of internet interventions being adopted by governments and healthcare providers in their current form remains limited. If internet interventions are to adequately address the shortfalls in the current healthcare systems, future research needs to include larger RCTs, more diverse samples, longer follow-up periods, assessments of clinically significant change and user satisfaction, comparisons of internet-based programs with face-to-face interventions and other online programs, and examination of the role of clinical and nonclinical support and supervision in maintaining adherence and increasing effectiveness. Despite these issues, the evidence is clear that some internet interventions, mainly online CBT, are effective for lowering symptoms of depression and anxiety in youth and have the potential to fill the gap for some mental health service providers. However, for this potential to be realized, rigorous implementation trials need to be conducted which attempt to integrate e-health interventions into existing and future healthcare services for adolescents, as well as school settings. To date, this has been a largely neglected field of research and represents a significant opportunity for the future. Acknowledgements We acknowledge the editorial support of the journal staff as they conducted the MEDLINE and PyschInfo literature searches. Financial support and sponsorship None. Conflicts of interest All authors declare that there are no conflicts of interest. A.L.C. is supported by a NHMRC Early Career Fellowship (1013199).
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 2010; 49:980–989. 2. Sareen J, Cox BJ, Afifi TO, et al. Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study of adults. Arch Gen Psychiatry 2005; 62:1249–1257. 3. Thapar A, Collishaw S, Pine DS, Thapar AK. Depression in adolescence. Lancet 2012; 379:1056–1067. 4. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-ofonset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:593–602. 5. Sawyer SM, Afifi RA, Bearinger LH, et al. Adolescence: a foundation for future health. Lancet 2012; 379:1630–1640.
6. James AC, James G, Cowdrey FA, Soler AC. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database of Syst Rev 2015. (2):Art. No. CD004690: 1–105. 7. Cox GR, Callahan P, Churchill R, et al. Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane: 1–130 Database of Syst Rev 2014. (11):Art. No. CD008324: 1–130. 8. Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STARD: implications for clinical practice. Am J Psychiatry 2006; 163:28–40. 9. Gulliver A, Griffiths KM, Christensen H. Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry 2010; 10:113. 10. Cohen A, Medlow S, Kelk N, et al. Young people’s experiences of mental healthcare. Youth Studies Australia 2009; 28:13–20. 11. Rickwood D, Deane FP, Wilson CJ, Ciarrochi JV. Young people’s helpseeking for mental health problems. Australian e-Journal for the Advancement of Mental Health 2005; 4:1–34. 12. Madden M, Lenhart A, Duggan M, et al. Teens and technology 2013. Washington, United States. Pew Internet Research Centre 2013; pp. 1–19. 13. Andrews G. We can manage depression better with technology. Aust Fam Physician 2014; 43:838–841. 14. Andrews G, Cuijpers P, Craske MG, et al. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical healthcare: a meta-analysis. PloS One 2010; 5:e13196. 15. Clarke AM, Kuosmanen T, Barry MM. A systematic review of online youth & mental health promotion and prevention interventions. J Youth Adolesc 2015; 44:90–113. A narrative synthesis of the evidence on the effectiveness of online mental health promotion and prevention interventions for youth aged 12–25 years. Combined, the results from the online prevention interventions indicated a significant positive effect of computerized CBT on adolescent and emerging adults’ anxiety and depression symptoms. However, this review found that the quality of studies varied significantly, arguing for more rigourous scientific evaluations of interventions in more diverse samples of youth. 16. Corrieri S, Heider D, Conrad I, et al. School-based prevention programs for & depression and anxiety in adolescence: a systematic review. Health Promot Int 2014; 29:427–441. An examination of school-based prevention interventions for depression and anxiety. This review did not focus explicity on interventions which were delivered via the internet, although one of these studies was included. In this particular study, the effect size for the internet intervention on depression was not significant immediately postintervention but was moderate and significant 20 weeks followup. This study was not included in the current review as it was not an RCT. 17. Reyes-Portillo JA, Mufson L, Greenhill LL, et al. Web-based interventions for & youth internalizing problems: a systematic review. J Am Acad Child Adolesc Psychiatry 2014; 53:1254–1270. A review on web-based treatment and prevention programs for depression, anxiety and suicide prevention in children, adolescents and emerging adults. Of the 17 trials identified, 10 found significant posintervention reductions in symptoms of depression and/or anxiety or improvements in diagnostic ratings, with small to large effect sizes. Many of these studies found that the significant improvements were sustained at follow-up. However, the authors argue that additional research and program development are needed to confirm the effectiveness of web-based interventions for youth depression and anxiety. 18. Ye X, Bapuji SB, Winters SE, et al. Effectiveness of internet- based interventions & for children, youth, and young adults with anxiety and/or depression: a systematic review and meta-analysis. BMC Health Serv Res 2014; 14:313–322. A systematic review on the most recent findings in this area including overall effect estimates. Compared with wait-list controls, internet-based interventions reduced anxiety severity and increased remission rate. The effect for depression was not significant. This review concluded that internet-based interventions were effective in reducing anxiety but further research is needed to confirm their effectiveness for depression. 19. Calear AL, Christensen H, Mackinnon A, et al. The YouthMood Project: a cluster randomized controlled trial of an online cognitive behavioral program with adolescents. J Consult Clin Psychol 2009; 77:1021–1032. 20. Spence SH, Donovan CL, March S, et al. A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety. J Consult Clin Psychol 2011; 79:629–642. 21. Sportel BE, de Hullu E, de Jong PJ, Nauta MH. Cognitive bias modification versus CBT in reducing adolescent social anxiety: a randomized controlled trial. PLoS One 2013; 8:e64355. 22. Manicavasagar V, Horswood D, Burckhardt R, et al. Feasibility and effective& ness of a web-based positive psychology program for youth mental health: randomized controlled trial. J Med Inter Res 2014; 16:e140. doi: 10.2196/ jmir.3176. An RCT examining the effectiveness of an online positive psychology website for decreasing depression, anxiety and stress among adolescents over a 6-week period. Participants in the intervention group who visited the site at least three times per week or spent more than 30 min per week on the site reported significant decreases in depression. No significant effects were found for participants who had low levels of adherence or used the website less frequently. These findings suggest that online psychology websites may assist in lowering depression and anxiety in youth.
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Provision of services to people with mental illness 23. Li TM, Chau M, Yip PS, Wong PW. Temporal and computerized psycholinguistic analysis of the blog of a Chinese adolescent suicide. Crisis 2014; 35:168–175. 24. Wong N, Kady L, Mewtown L, et al. Preventing anxiety and depression in & adolescents: a randomised controlled trial of two school based internetdelivered cognitive behavioural therapy programmes. Internet Interventions 2014; 1:90–94. An RCT examining the efficacy of two, 7-week internet prevention programs aimed to reduce anxiety and depressive symptoms in adolescents. Participants who received the online interventions had significant improvements in symptom levels when compared with the control group. The depression intervention was found to reduce both anxiety and depressive symptoms, whereas the anxiety program only reduced anxiety. The study was limited by attrition and data corruption, thus findings can only be considered tentative. 25. Andersson G. Using the internet to provide cognitive behaviour therapy. Behav Res Ther 2009; 47:175–180. 26. Andrews G, Cuijpers P, Craske MG, et al. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical healthcare: a meta-analysis. PLoS One 2010; 5:. doi: 10.1371/journal.pone. 0013196. 27. Griffiths KM, Farrer L, Christensen H. The efficacy of internet interventions for depression and anxiety disorders: a review of randomised controlled trials. Med J Aust 2010; 192 (11 Suppl):S4–S11.
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28. Palmqvist B, Carlbring P, Andersson G. Internet-delivered treatments with or without therapist input: does the therapist factor have implications for efficacy and cost? Exp Rev Pharm Out Res 2007; 7:291–297. 29. Calear AL, Christensen H, Mackinnon A, Griffiths KM. Adherence to the MoodGYM program: outcomes and predictors for an adolescent schoolbased population. J Affect Disord 2013; 147:338–344. 30. Bados A, Balaguer G, Saldan˜a C. The efficacy of cognitive–behavioral therapy and the problem of drop-out. J Clin Psychol 2007; 63:585–592. 31. Proudfoot J. The future is in our hands: the role of mobile phones in the prevention and management of mental disorders. Austr and New Zealand J Psychiatry 2013; 47:111–113. 32. Madden M, Lenhart A, Cortesi S, Gasser U. Teens and mobile apps privacy. United States. Pew Research Centre 2013; pp. 1–20. 33. Zickhuhr K. Tablet ownership 2013. Washington, United States. Pew Internet Research Center 2013; pp. 1–11. 34. Wike R, Oates R. Emerging nations embrace internet, mobile technoloy. Washington, United States: Pew Research Center 2014; pp. 1–43. 35. United Nations Children’s Fund (UNICEF). Progress for Children: A report card on adolescents. New York: United Nations Children’s Fund, 2012. 36. Stikkelbroek Y, Bodden DH, Dekovic M, van Baar AL. Effectiveness and cost effectiveness of cognitive behavioral therapy (CBT) in clinically depressed adolescents: individual CBT versus treatment as usual (TAU). BMC Psychiatry 2013; 13:314.
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Is e-health the answer to gaps in adolescent mental health service provision? Bridianne O’Dea a, Alison L. Calear b, and Yael Perry a
Purpose of review Depression and anxiety are prevalent among adolescents; however, many young people do not seek help from professional services. This is due, in part, to the inadequacies of existing healthcare systems. This article aims to review the current evidence for e-health interventions for depression and anxiety in youth, as a potential solution to the gaps in mental health service provision. Recent findings Five randomized controlled trials reporting on e-health interventions for youth depression or anxiety were identified. Of these, two trials focused exclusively on anxiety symptoms, and three trials examined both anxiety and depression. The majority of trials assessed online cognitive behavioral therapy and focused on prevention rather than treatment. In all but one trial, results demonstrated positive effects for the e-health interventions, relative to the control. Summary There is growing evidence for the effectiveness of online cognitive behaviour therapy interventions for reducing the level of anxiety and depressive symptoms in adolescents aged between 12 and 18 years, when delivered in school and clinical settings, with some level of supervision. However, there are a number of gaps in the literature. More research is needed to strengthen the evidence base for prevention and treatment programs that are delivered via the internet, particularly for depression. Keywords adolescent, anxiety, depression, internet, prevention, treatment
INTRODUCTION Depression and anxiety are prevalent among adolescents. Population-based surveys suggest that 10–30% of adolescents experience depressive symptoms at any one time [1]. Both depression and anxiety are associated with social withdrawal, poorer academic performance, greater functional disability and are risk factors for suicide [2,3]. Symptoms of depression and anxiety in adolescence may mark the development of a mental illness, as up to 75% emerge before the age of 25 [4]. Early intervention is critical to prevent chronic impairment [5], with a number of evidence-based treatments available to prevent and reduce symptoms of anxiety and depression [6–8]. However, many adolescents do not seek help for mental health problems from professional services. This is often because of a poor awareness of the signs and symptoms, perceived stigma, and an inability to access services because of extended waiting lists, expense and geographical dispersion, highlighting the inadequacies of existing healthcare systems [9–11]. www.co-psychiatry.com
The internet is a viable alternative for the treatment of depression and anxiety in young people, particularly given their heightened familiarity with online technology [12]. There are a number of potential advantages associated with internet delivered treatments, including increased access to services among those who are not willing to seek face-toface help; lower cost to the individual and mental healthcare system; increased availability as individuals can access treatment at times and locations suited to them; increased fidelity due to automated delivery; ease of use; and the potential for rapid dissemination [13,14]. The aim of this article is to a
Black Dog Institute, UNSW Australia, Randwick, NSW and bNational Institute for Mental Health Research, The Australian National University, Canberra, ACT, Australia Correspondence to Bridianne O’Dea, Black Dog Institute, UNSW Australia, Hospital Road, Randwick, NSW 2031, Australia. Tel: +1 61 2 9382 8509; e-mail: [email protected] Curr Opin Psychiatry 2015, 28:336–342 DOI:10.1097/YCO.0000000000000170 Volume 28 Number 4 July 2015
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KEY POINTS There is growing evidence for the effectiveness of ehealth interventions, particularly online CBT, for reducing the level of anxiety and depressive symptoms in adolescents aged between 12 and 18 years, when delivered in school and clinical settings with some level of supervision. Online CBT delivered with remote therapist support was found to be equally as efficacious as face-to-face CBT for the treatment of anxiety disorders. However, the heterogeneity in sample sizes, randomization procedures and outcome measures of these studies makes it difficult to compare and identify the aspects of the interventions responsible for success. The evidence base needs to be expanded before ehealth interventions are integrated into the system of care for young people experiencing or at risk of developing mental health problems.
ascertain whether e-health interventions, also known as internet interventions, are able to fill the gaps in mental health services by identifying recent research trials and reviews of these interventions to establish their efficacy in the adolescent population. For the purpose of this review, adolescents are defined as secondary school-aged youth between 12 and 18 years. We outline key research outcomes, issues surrounding the online prevention and treatment of anxiety and depression in this population, and discuss the potential for health service reform and future research.
LITERATURE SEARCH A comprehensive literature search was conducted to identify relevant research articles and reviews published between January 2014 and January 2015 in MEDLINE and PsychInfo using the following search terms: adolescen or teen AND depress or mood or anx or worry, AND screen or assess or interven or prevent or treat or program AND web or online or internet or computer or mobile or tele or game or app or e-health. This search was also repeated separately in the peer-reviewed journal Internet Interventions, as it is currently not listed in MEDLINE or PsychInfo and is relevant to this field. Articles were included if they reviewed or reported on a randomized controlled trial (RCT) evaluating the effectiveness of an online or mobile application designed to prevent or treat anxiety or depression in adolescents aged between 12 and 18 years. Studies were excluded if outcome measures did not specifically assess symptoms of depression and/or anxiety. The search
generated 320 abstracts of which 289 did not fulfill the inclusion criteria and were excluded from review. The full-text of the remaining 31 articles was collected for further review. Six of the full-text articles fulfilled the inclusion criteria and are discussed below.
FINDINGS Systematic reviews and meta analyses published in the last 12 months Four relevant review articles were identified [15 ,16 ,17 ,18 ]. These reviews focused on the treatment and prevention of anxiety and depression in adolescents, although one of the reviews included studies with a range of mental health outcomes [15 ]. The reviews collectively identified 88 studies published between January 1990 and December 2013. Of these 88 studies, only three were RCTs of an online prevention or treatment intervention for anxiety and/or depression in adolescents aged between 12 and 18 years [19–21]. All of these particular trials were published between 2009 and 2013. Of the three relevant RCTs, one evaluated an online, school-based, universal prevention program for depression and generalized anxiety [19], one evaluated an online, school-based, indicated prevention program for social anxiety and test anxiety [21] and one evaluated an online treatment program for anxiety disorders in a clinical setting [20]. No treatment trials for depression alone were found. The trials identified delivered the interventions for a period ranging between 6 and 12 weeks, with all studies including a 6-month follow-up and two of the three studies including a 12-month follow-up. Participants in these studies were aged between 12 and 18 years with a mean age of 14 years. The majority of participants were female. In both of the school-based trials, more than half of the participants were in Grade 10 or below when recruited. The school-based trial for the prevention of depression and generalized anxiety used a universal sample of high-school students with no exclusion criteria based on symptoms or diagnosis [19]. No significant differences in depression and anxiety were found at preintervention between the control and intervention groups; although, when compared with male participants, a higher proportion of female participants reported elevated levels of anxiety (13 vs. 4%) and depression (15 vs. 7%). The school-based trial for social and test anxiety only included participants with self-reported social and test anxiety at baseline, with different cutoff scores used for male participants and female participants [21]. Eligible &
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participants were required to complete a clinical assessment and only those with low-level social and test anxiety were included in the final sample. Adolescents with DSM IV diagnoses other than anxiety and/or with severely interfering anxiety diagnoses and/or who expressed a need for regular treatment were excluded. The online treatment program for anxiety disorders [20] was conducted in a clinical setting and included only those with a primary clinical diagnosis of generalized anxiety disorder (48%), social phobia (35%), separation anxiety (13%) or a specific phobia (4%). Participants with a primary diagnosis of panic disorder, obsessive compulsive disorder or posttraumatic stress disorder were excluded. Adolescents reporting a mood disturbance rated as ‘moderately disturbing’ or greater were also excluded, as were those with a pervasive developmental, learning or behavioral disorder, substance abuse, suicidal ideation or current self-harm. Two out of the three internet interventions used cognitive behavior therapy (CBT) [19,20] with the other using cognitive bias modification (CBM) [21]. Internet-delivered CBT (MoodGYM) in the schoolbased prevention trial for depression and anxiety was found to be more effective in significantly reducing anxiety symptoms in both male participants and female participants, and depressive symptoms in male participants only, when compared with a wait-list control condition at postintervention and 6-month follow-up [19]. In terms of the prevention of anxiety, a larger percentage of participants in the wait-list control condition than in the intervention condition (2 vs. 1%) became a case at postintervention and 6-month follow-up, although these differences were not significant. In terms of the prevention of depression, a larger percentage of male participants in the wait-list control condition than in the intervention condition (9 vs. 2%) met criteria for caseness at postintervention and 6-month follow-up. These differences were significant at both time points. The treatment trial for anxiety disorders compared internet-delivered CBT (Brave-Online) with face-to-face CBT (Brave-Clinic) and a wait-list control condition [20]. Both of the active interventions significantly reduced anxiety symptoms more than the control condition. Clinical improvement was defined as the percentage of adolescents who were free of their primary diagnoses. At 12 weeks, 37% of those in the online condition no longer met the criteria for their primary diagnosis compared with 33% in the face-to-face condition and 4.2% in the control condition. Post-hoc tests revealed significant differences between the control and online conditions, the control and face-to-face conditions, 338
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but not between the online and face-to-face conditions. These improvements were maintained at 6-month and 12-month follow-up. The effect sizes between the face-to-face and online conditions were not significantly different indicating that the faceto-face treatment was equal in effectiveness to the online treatment. In the school-based trial for social and test anxiety [21], internet-delivered CBM was compared with face-to-face group CBT and a wait-list control condition. Participants in the face-to-face CBT condition showed a significantly larger reduction in social and test anxiety symptoms than those in the control condition, and a similar trend was evident in the CBM condition; although, this trend was not significant. The differences between CBT and CBM were not replicated at 12-month follow-up, as the control condition showed similar reductions in anxiety symptoms. However, the CBM condition had a significantly stronger decrease in negative automatic associations than both the CBT and control group at 12-month follow-up. The provision of support varied within these interventions. The treatment trial for anxiety disorders provided remote therapist support via E-mail and telephone from a trained psychologist for the online CBT condition [20]. The universal prevention program for depression and anxiety [19] provided face-to-face nonclinical supervision from school teacher staff, and the school-based internet intervention for social and test anxiety [21] was completely self-directed.
Randomized controlled trials published in the last 12 months &
Two RCTs were identified [22 ,23] as being published in the last 12 months. One of these studies [23] was a universal school-based prevention trial examining the efficacy of two online CBT programs (This Way Up Combatting Depression and This Way Up Overcoming Anxiety) for lowering depressive and anxiety symptoms in high school students in Grades 9 and 10, with no symptom exclusion criteria. Only pretest and posttest measures were taken and clinical improvement was not reported. Participants were aged between 14 and 16 years and 68% were female. No significant differences in symptoms were found between the conditions at baseline. The internet programs were delivered in class time, with teacher supervision, as part of the school curriculum. Both of the internet interventions were compared with a control condition, which was attending personal development, health, and physical education classes as usual. When compared with the control condition, the online intervention for depression was found to Volume 28 Number 4 July 2015
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significantly reduce both depressive and anxiety symptoms, whereas the online anxiety intervention was found to only significantly reduce anxiety symptoms. The second study [22 ] compared the effectiveness of a positive psychology website with an attention-control website for lowering depression and anxiety symptoms in a nonclinical youth sample aged 12–18 years, over a period of 6 consecutive weeks. Only pretest and posttest measures were taken. This study was conducted in a nonclinical sample recruited via schools and youth centers. The active intervention website (Bite Back) consisted of interactive exercises and information across a variety of positive psychology domains. The control condition consisted of two neutral entertainmentbased youth websites that contained no psychology information, but equal levels of interactivity. Participants in the active intervention reported significantly lower depression scores at posttest compared with the control condition. At posttest, participants were divided into two groups based on the frequency of their site visits and the amount of time they spent on their assigned website during the study. Participants who visited the active intervention website three or more times a week reported significantly greater reductions in depression and anxiety scores than those who visited the site less than three times per week. No such differences were found in the control condition. Participants in the active intervention who visited the site for 30 min or more per week also reported significantly greater reductions in depression compared with those who visited the site for less than 30 min. Those in the control condition who reported less than 30 min of time per week using their site reported a significant increase in anxiety levels at posttest. &
Noteworthy themes and issues Efficacy There is growing evidence for the effectiveness of online CBT interventions for reducing the level of anxiety and depressive symptoms in adolescents aged between 12 and 18 years, when delivered in school and clinical settings, with some level of supervision [19,20,24 ]. Where available, the effect sizes for the internet interventions aimed at reducing depression and anxiety symptoms ranged from 0.1 to 0.3. The effectiveness of online CBT for the treatment of anxiety disorders [20] was similar to that of face-to-face treatment, with particularly large effect sizes reported for each of the five outcome measures (d ¼ 0.3–2.0) [20]. There is some evidence supporting the efficacy of a positive psychology website for lowering symptom levels of depression; &
although the decrease in symptoms was related to the frequency and duration of site usage. In terms of disorder prevention, one school-based trial found that, when compared with the wait-list control condition, online CBT significantly lowered the risk of developing clinical levels of depression, but only in male participants [19]. No significant results were found for preventing the onset of clinical levels of anxiety. Self-directed CBM showed a statistically nonsignificant trend for lowering social and test anxiety [21]. None of the studies examined the treatment efficacy of internet interventions for depressive disorders. More research using RCTs to directly compare online treatments with face-toface psychosocial treatments, and psychotropic medication, particularly for depression, is needed to further validate these findings. Therapeutic approaches All of the online interventions identified in this review were based on adaptations of evidence-based therapies including CBT, CBM and positive psychology. Internet-delivered CBT currently has the most research evidence supporting its effectiveness [25–27]. This review included three studies that utilized online CBT for lowering both depression and anxiety symptoms [19,24 ], or treating anxiety disorders [20]. In all studies, online CBT was found to be significantly more effective than the control conditions for lowering symptoms. However, because of the heterogeneity across studies, it is currently not possible to determine which of the specific online CBT modules resulted in the greatest positive outcomes on depression and anxiety. Only one study evaluated an online, self-directed positive psychology resource [22 ]. Given that the efficacy for the online delivery of other therapies (CBM and positive psychology) remains limited, adapting and testing additional evidence-based therapies for online delivery, such as Acceptance and Commitment Therapy and Interpersonal Therapy, will help to expand the number and types of psychological therapies offered by the internet, ultimately increasing access. &
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Support and supervision Only one study provided clinical support alongside the internet intervention [20]. Two of the three school-based studies [19,23] provided nonclinical support and supervision for the internet interventions delivered via the classroom teachers. Although both of these trials found significant positive effects for the internet intervention compared with the control, the level of supervision and the nature of support were not manipulated, so no firm conclusions can be made about the unique effect of
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these on the effectiveness of the interventions. Studies in adults have generally found that support, regardless of its clinical or nonclinical nature, increases the effect of internet interventions [28]. Little research exists in adolescents. As the positive psychology website had significant effects without any supervision or support [22 ], future research that compares the type and intensity of support or supervision will help to determine the minimum level of resources and input required for maximum clinical efficacy. &
Program adherence, study retention, and user satisfaction Adherence among those allocated to the modular CBT internet programs was low with only 32–39% of participants completing all modules [19,20]. These findings suggest that despite the greater accessibility afforded by internet interventions, adherence is problematic, although the one study that compared the completion of internet therapy with the completion of face-to-face therapy found no difference in completion rates [20]. It is unclear from the studies reviewed here, how many completed modules are needed for a significant decrease in symptoms, and it is likely that this would be partially dependent on the nature of the intervention itself. The relationship between baseline symptom severity and adherence also remains unclear. One study found that those with lower anxiety at baseline were less likely to complete modules [21]. A secondary analysis of adherence to an online intervention for anxiety and depression in adolescents [29] found that greater adherence to the online intervention was correlated with better clinical outcomes: school grade, location (rural) and higher symptoms of depression or self-esteem at baseline were predictive of greater adherence. All but one of the studies examined here [23] retained more than 60% of the sample at posttest, which is similar to the rates reported by face-to-face studies [30], suggesting that internet trials do not result in higher drop-out; however, one of the school-based trials did report a 63% drop-out rate, which is surprising given the purported advantage of school-based interventions having a captive audience. Only one study examined participants’ perceptions of treatment credibility and satisfaction [20]. In this study, adolescents reported moderateto-high satisfaction with the internet treatment and these scores were not significantly different from those in the face-to-face condition. The limited nature of program acceptance data precludes clear conclusions being drawn about the broad acceptability of internet interventions in youth; however, it highlights the importance of further 340
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research investigating the interactions between adherence, acceptability, and clinical outcomes. Internet medium All interventions included in this review were delivered using an internet web browser. The development and rigorous evaluation of mobile phone or tablet interventions for adolescents should be examined due to the portability of such devices [31], as well as the increasing rates of app development [32] and tablet usage [33], particularly in lowmiddle income counties [34]. Sample bias Most studies included in this review relied on school-based recruitment [19,21,23]. Two studies used community recruitment methods such as advertisements. Only one of the school-based studies reported the locality of students, of which only 16% were living in a rural location [19]. Neither of the community samples indicated the locality of participants. Only two studies reported the ethnicity of participants [19,20] and neither of these samples were particularly diverse with over 90% born in Australia or speaking English as their first language. As such, the cultural sensitivity of the included internet interventions remains unknown. All included studies were conducted in high-income countries. Given that most of the world’s young people live in low-middle income countries [35], inclusion of such youth in effectiveness trials needs to occur for broader generalization of results. In future studies, investigators should attempt to have a more diverse range of participants, including those from rural areas, different cultural backgrounds and other minority youth, such as those who do not attend mainstream schools. Cost-effectiveness None of the studies examined cost-effectiveness. In future studies, investigators should endeavor to include a measure of cost-effectiveness to confirm the reduced economic burden associated with internet treatment for youth [36].
CONCLUSION There is growing evidence for the effectiveness of online CBT interventions for reducing the level of anxiety and depressive symptoms in adolescents aged between 12 and 18 years, when delivered in school and clinical settings, with some level of supervision. However, a number of gaps in knowledge remain. The heterogeneity in sample sizes, randomization procedures, and outcome measures made it difficult to compare trial results and the study designs did not attempt to identify the specific Volume 28 Number 4 July 2015
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aspects of the internet interventions responsible for success. These factors, alongside the lack of cost effectiveness data, mean that the likelihood of internet interventions being adopted by governments and healthcare providers in their current form remains limited. If internet interventions are to adequately address the shortfalls in the current healthcare systems, future research needs to include larger RCTs, more diverse samples, longer follow-up periods, assessments of clinically significant change and user satisfaction, comparisons of internet-based programs with face-to-face interventions and other online programs, and examination of the role of clinical and nonclinical support and supervision in maintaining adherence and increasing effectiveness. Despite these issues, the evidence is clear that some internet interventions, mainly online CBT, are effective for lowering symptoms of depression and anxiety in youth and have the potential to fill the gap for some mental health service providers. However, for this potential to be realized, rigorous implementation trials need to be conducted which attempt to integrate e-health interventions into existing and future healthcare services for adolescents, as well as school settings. To date, this has been a largely neglected field of research and represents a significant opportunity for the future. Acknowledgements We acknowledge the editorial support of the journal staff as they conducted the MEDLINE and PyschInfo literature searches. Financial support and sponsorship None. Conflicts of interest All authors declare that there are no conflicts of interest. A.L.C. is supported by a NHMRC Early Career Fellowship (1013199).
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This study was not included in the current review as it was not an RCT. 17. Reyes-Portillo JA, Mufson L, Greenhill LL, et al. Web-based interventions for & youth internalizing problems: a systematic review. J Am Acad Child Adolesc Psychiatry 2014; 53:1254–1270. A review on web-based treatment and prevention programs for depression, anxiety and suicide prevention in children, adolescents and emerging adults. Of the 17 trials identified, 10 found significant posintervention reductions in symptoms of depression and/or anxiety or improvements in diagnostic ratings, with small to large effect sizes. Many of these studies found that the significant improvements were sustained at follow-up. However, the authors argue that additional research and program development are needed to confirm the effectiveness of web-based interventions for youth depression and anxiety. 18. Ye X, Bapuji SB, Winters SE, et al. 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These findings suggest that online psychology websites may assist in lowering depression and anxiety in youth.
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Provision of services to people with mental illness 23. Li TM, Chau M, Yip PS, Wong PW. Temporal and computerized psycholinguistic analysis of the blog of a Chinese adolescent suicide. Crisis 2014; 35:168–175. 24. Wong N, Kady L, Mewtown L, et al. Preventing anxiety and depression in & adolescents: a randomised controlled trial of two school based internetdelivered cognitive behavioural therapy programmes. Internet Interventions 2014; 1:90–94. An RCT examining the efficacy of two, 7-week internet prevention programs aimed to reduce anxiety and depressive symptoms in adolescents. Participants who received the online interventions had significant improvements in symptom levels when compared with the control group. The depression intervention was found to reduce both anxiety and depressive symptoms, whereas the anxiety program only reduced anxiety. The study was limited by attrition and data corruption, thus findings can only be considered tentative. 25. Andersson G. Using the internet to provide cognitive behaviour therapy. Behav Res Ther 2009; 47:175–180. 26. Andrews G, Cuijpers P, Craske MG, et al. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical healthcare: a meta-analysis. PLoS One 2010; 5:. doi: 10.1371/journal.pone. 0013196. 27. Griffiths KM, Farrer L, Christensen H. The efficacy of internet interventions for depression and anxiety disorders: a review of randomised controlled trials. Med J Aust 2010; 192 (11 Suppl):S4–S11.
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28. Palmqvist B, Carlbring P, Andersson G. Internet-delivered treatments with or without therapist input: does the therapist factor have implications for efficacy and cost? Exp Rev Pharm Out Res 2007; 7:291–297. 29. Calear AL, Christensen H, Mackinnon A, Griffiths KM. Adherence to the MoodGYM program: outcomes and predictors for an adolescent schoolbased population. J Affect Disord 2013; 147:338–344. 30. Bados A, Balaguer G, Saldan˜a C. The efficacy of cognitive–behavioral therapy and the problem of drop-out. J Clin Psychol 2007; 63:585–592. 31. Proudfoot J. The future is in our hands: the role of mobile phones in the prevention and management of mental disorders. Austr and New Zealand J Psychiatry 2013; 47:111–113. 32. Madden M, Lenhart A, Cortesi S, Gasser U. Teens and mobile apps privacy. United States. Pew Research Centre 2013; pp. 1–20. 33. Zickhuhr K. Tablet ownership 2013. Washington, United States. Pew Internet Research Center 2013; pp. 1–11. 34. Wike R, Oates R. Emerging nations embrace internet, mobile technoloy. Washington, United States: Pew Research Center 2014; pp. 1–43. 35. United Nations Children’s Fund (UNICEF). Progress for Children: A report card on adolescents. New York: United Nations Children’s Fund, 2012. 36. Stikkelbroek Y, Bodden DH, Dekovic M, van Baar AL. Effectiveness and cost effectiveness of cognitive behavioral therapy (CBT) in clinically depressed adolescents: individual CBT versus treatment as usual (TAU). BMC Psychiatry 2013; 13:314.
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