Development and evaluation of a universal prevention program for depressive symptoms in Chinese adolescents

Abstract

Background: Depressive symptoms are prevalent among Chinese adolescents and pose a significant risk to their academic and social functioning. However, there is a lack of effective prevention programs to reduce depression in the general population. Objectives: The thesis consists of three studies with the following objectives, respectively: 1) to perform a meta-analysis of risk factors for depressive symptoms in Chinese adolescents; 2) to develop a universal prevention program for this population and conduct a pilot trial; 3) to explore the feedback and experiences of participants in the prevention program. Methods: In Study 1, literature about the psychosocial and psychological factors of depressive symptoms in Chinese adolescents was systematically searched and coded, and the pooled correlation coefficients between all factors and depressive symptoms were computed. In Study 2, a universal prevention program was developed based on the strongest risk factors, and a pilot cluster randomized controlled trial was implemented in a sample of second-year students. Data were collected from a total of 279 students, including 148 in the intervention group and 131 in the control group. Participants in the intervention group received a 6-week prevention course, and the control group received a 6-week regular course focusing on career development. The primary outcomes were measured by The Short Mood and Feelings Questionnaire (SMFQ) and Depression Anxiety and Stress Scale (DASS-21). Dysfunctional attitudes, rumination, and negative life events were also measured as potential mediators. Data were collected at pretest, posttest, and 6-month follow-up. The intention-to-treat (ITT) principle was employed to analyze the data. Linear mixed models (LMMs) were used to examine the effect of the intervention on all outcomes. Effect size (Cohen's d) was also calculated to evaluate the effect of intervention compared to the control condition. The study also reported significance levels of .05 and .10. In Study 3, thirteen participants in the intervention group were interviewed to explore their perceptions about helpful techniques and the benefits and barriers to the intervention. Thematic analysis was chosen to analyze the qualitative materials. Results: In Study 1, fifteen psychosocial factors and twenty-one psychological factors were identified. Among the psychosocial factors, poor parent–child communication, negative life events, and academic pressure had the strongest associations with depressive symptoms. Among psychological factors, negative cognitions (i.e., automatic thoughts, negative self-evaluation, dysfunctional attitudes), personality factors (i.e., neuroticism, self-esteem, resilience), and coping strategies (i.e., rumination) had the strongest relationship with depressive symptoms. In Study 2, the LMMs show that the group × time interaction was significant in both measurements of depressive symptoms: the SMFQ (F(2, 549) = 2.41, p = .09) and DASS-21 (F(2, 550) = 5.72, p = .003), indicating the prevention program could significantly reduce the depressive symptoms. This finding was also supported by effect sizes: for SMFQ, the Cohen's d at posttest was 0.28 (95% CI 0.51, 0.04). In a 6-month follow-up, the effect of the intervention was maintained (d = 0.21, 90% CI 0.41, 0.01). Similar findings were also observed in anxiety and stress, revealing that the prevention program could also alleviate anxiety (group × time: F(2, 550) = 4.16, p = .02) and stress (group × time: F(2, 550) = 3.21, p = .04). Mediation analysis showed that family stressors could significantly mediate the effect of the prevention program on depressive symptoms (SMFQ) and anxiety. In addition, family stressors and academic stressors significantly mediate the effect of prevention on depressive symptoms (DASS) and stress. A significant serial mediation effect was also found in that the prevention program brought about a reduction in negative life events, which led to a decrease in depressive symptoms and finally enhanced help-seeking intentions. In Study 3, the helpful techniques as perceived by students were cognitive restructuring, mindful breathing, and communication strategies. The participants experienced significant improvements in negative emotions, relaxation and good sleep, and interpersonal relationships. Barriers to the implementation of the program included maladaptive beliefs and coping strategies regarding negative emotions (e.g., avoidance strategies or a wish for a quick fix to deal with negative emotions), the complexity of the techniques and a lack of proficiency, and the limitations of psychological courses (e.g., preferring entertainment requiring no cognitive effort, a lack of in-depth exploration of emotion and thoughts). Discussion: Results have shown that the universal prevention program can significantly reduce depressive symptoms, anxiety, and stress in Chinese adolescents. The effect appears to have been maintained at a 6-month follow-up. The program failed to reduce psychological risk factors such as dysfunctional attitudes and rumination. Instead, family and academic stressors decreased significantly, which in turn significantly mediated the intervention’s effect on the outcomes. This result might indicate that psychosocial factors, rather than psychological factors, are easier for universal prevention programs to modify. The qualitative findings showed that the participants received benefits and learned helpful techniques. However, several barriers to the implementation of the program arose. The main barriers were students' lack of scientific understanding of emotional regulation, the lack of credibility of psychotherapeutic treatment in Chinese society, the complexity of the techniques, and the intervention’s classroom-based format. Conclusion: This pilot study showed that a universal prevention program is promising in reducing adolescent depressive symptoms. The prevention manual was refined based on the feedback of the participants. A full randomized controlled trial is needed to provide a more reliable evaluation of the intervention effect. (873 words)