Prevention of depression and anxiety in adolescents with a high familial risk

Depression and anxiety disorders are a major concern of public health. In the
Netherlands, approximately 37.000 adolescents suffer from depression yearly.
The prevalence of depression in Dutch adolescents is approximately 3.8%
(Verhulst, 1997), and one third of all adolescents show significant depressed
moods. In addition, anxiety disorders are the most common psychological
disorders and often already occur during childhood. The lifetime prevalence of
anxiety disorders is 28.8%, and childhood and adolescence is the core risk
phase for the development of anxiety symptoms. Previous research has shown that
anxiety and depression are highly co-morbid disorders and seem to reflect
maladaptive forms of emotion regulation.
Prevention and care on depression and anxiety in adolescence is undervalued.
Often depression and anxiety are not identified and therefore not treated. This
lack in identification and indicated prevention of adolescent depression and
anxiety is particularly concerning because of the possible consequences of both
pathologies during adolescence. Firstly, adolescent depression is associated
with depression and anxiety disorders later in life, poor psychosocial and
academic outcome, an increased risk for substance abuse and it is the most
frequently reported risk factor associated with adolescent suicide. Secondly,
anxiety disorders are associated with additional psychological problems, poor
academic performance, impairment in peer relations and low self esteem. Given
the prevalence, the recurrence and the negative outcomes of adolescent
depression and anxiety, it is crucial to implement prevention programs for
high-risk adolescents.

This study proposes to bridge the gap between prevention and treatment, and
between adult and youth mental health care by screening the children of
depressed and anxious parent(s) for depressive and anxiety symptoms and
offering them a prevention program to prevent the onset or maintenance of
depression and anxiety.

Primary Objective: The primary goal is to evaluate the effectiveness of a
prevention program for adolescents. These adolescents are children of parents
who receive treatment at a mental health care institution for their
internalizing problems (anxiety and/or depression), and therefore these
adolescent are at risk to develop anxiety or depression themselves.
Secondary Objective(s): The secondary goal is to define parent and child
factors which possibly relate to the effectiveness of the prevention program.

The present study involves a randomized controlled trial (RCT) with two
conditions (intervention versus control) in which the effectiveness of the
prevention program will be examined.

The intervention that is evaluated is called 'Een Sprong Vooruit'. It consists
of 6 lessons of each 90 minutes. In the first lesson, the participants learn
about emotions, about anxiety and depression and how they experience their
parent's mental health problem. The adolescents learn which emotions they
experience and how they can recognize them. During this program, they will use
a schedule to find out that activating events (gebeurtenis), beliefs
(gedachte), emotional consequences (gevoel) and behavioral consequences
(gedrag) are related. In the second lesson, the adolescent learn about the
relationship between activating events, beliefs and emotional consequences.
Beliefs can be optimistic or pessimistic and play a major role in the emotional
consequences. The adolescents learn how they can recognize pessimistic beliefs.
In the third lesson, several strategies are taught to replace the pessimistic
beliefs by optimistic beliefs. Adolescents learn how they can recognize the
pattern of their beliefs, how they can replace them and how they can prove the
alternative belief is true. In the fourth lesson, adolescent learn that
behavior is not always a consequence. In some situations the beliefs cannot be
replaced or changed, but they have to change their behavior to influence the
emotional consequences. Therefore assignments are aimed at pleasant and less
pleasant activities. Furthermore, they learn to organize large tasks. In the
fifth lesson, the adolescents learn what anxiety is and how fear develops over
time. They learn how to divide a fearful task in small steps, to practice those
steps and experience the decrease in anxiety. In the sixth and last lesson, the
fearful tasks are evaluated and practiced again. Furthermore, the adolescents
learn that social support sometimes makes things easier. They practice on how
they can ask people in their social environment for help. Finally, they look
how the future will be for them.

The potential value of the study is that we can offer children of parents with
a depression or anxiety disorder a prevention program that is proven to be
effective. In order to achieve this goal we need to evaluate the effectiveness
of this prevention program in the right population, and that is the population
of adolescents between 12 and 16 years old, with one of their parents receiving
mental health care for anxiety or depression, are screened on their depressive
and anxiety symptoms. We cannot evaluate the effect in a population that is not
related to the adolescents the prevention program is aimed at.
We are of opinion, however, that the risks associated with participation can be
considered negligible. This form of prevention is often used in children of
parents with a mental illness. The new aspect of this prevention program is
that it is specifically aimed at internalizing problems, such as depression and
anxiety disorder.