Psychoeducational interventions in adolescent depression: A systematic review

Prevention Treatment

Thi s v e r sio n is b ei n g m a d e a v ail a bl e in a c c o r d a n c e wit h p u blis h e r p olici e s. S e e h t t p://o r c a . cf. a c. u k/ p olici e s. h t ml fo r u s a g e p olici e s. Co py ri g h t a n d m o r al ri g h t s fo r p u blic a tio n s m a d e a v ail a bl e in ORCA a r e r e t ai n e d by t h e c o py ri g h t h ol d e r s .

Introduction
Depression is common in adolescence, and leads to distress for the young person and their family/carer. It is associated with social and educational impairments. It also predicts suicide, deliberate self-harm and poor physical health, and can mark the beginning of long-term mental health difficulties [1]. Early treatment and prevention of adolescent depression is therefore a major public health concern [2]. However, depression is difficult to recognise and treat in this age group, and engaging young people in prevention and early intervention programmes is a challenge for health and other services [3].
Guidelines for depression in young people (e.g. National Institute for Health and Care Excellence (NICE) [4]; American Academy of Child and Adolescent Psychiatry (AACAP) [5]) stress the need for good information and evidence-based psychosocial interventions for the young person, family and carer. Psychosocial interventions are likely to be important in young people for promoting resilience and preventing relapse [1,6]. Whilst the risk factors and possible causes of adolescent depression are complex, individuals with a family history of depression and psychosocial stress are known to be at a higher risk, and could be targeted for such strategies, along with those with a history of depression [1].
Over recent years there has been growing interest in psychoeducational interventions (PIs); that is the delivery of accurate information to individuals, families and carers about mental health or a specific diagnosis (including possible causes and symptoms), management (including associated risks/side-effects) and prognosis, and how affected individuals can stay well [5,[7][8][9]. Much of the literature on PIs has been in relation to individuals with schizophrenia and bipolar disorder and their families/carers [5,7,10], although there has been increasing interest in depression. Findings from a recent systematic review concluded that PIs are effective in improving the clinical course, treatment adherence, and psychosocial functioning of adults with depression [11].
However, there is no published review on PIs in the prevention and management of adolescent depression. This is an important knowledge gap; depression is more common than bipolar disorder and schizophrenia, and the presentation and management of depression is different in young people compared to adults, as might be their response to PIs. Further investigation could have implications on clinical practice, by informing the way in which practitioners communicate with young people and families/carers regarding depression (and future resources, interventions and guidelines), and raising public awareness of adolescent depression.
A systematic review was conducted of the published literature on PIs for adolescents with (or at high risk of) depression. The aim of the review was to i) systematically search and review the literature investigating PIs in the context of adolescent depression; ii) describe the range of PI programmes; iii) summarise the evidence for the effectiveness of different programmes.

Selection criteria
Inclusion criteria were: studies of PIs (as defined earlier) targeting depression as part of prevention or management approaches in the adolescent age group (studies were included if at least some of the participants were between 12 and 18 years old); targeted programmes for individuals with depression/ depressive symptoms (which could include relapse prevention) OR those at high-risk, and/or their families/carers. Studies were included only if there was evaluation of the response of adolescents or families/carers (no other groups, e.g. teachers), with quantitative or qualitative methodology.
Articles were restricted to those published or translated into English. Articles were also considered if only elements of the published study were of relevance (e.g. if the control group in a trial was given a PI).
Exclusion criteria were as follows: only adults or young children, other mental disorders only (including bipolar disorder), non-psychiatric disorders, established therapeutic approaches alone (including cognitive behavioural therapy (CBT)) or no evaluation of the programme. Universal programmes or general health information/education (e.g. in printed leaflets) were not considered. Single case reports/studies were excluded, but otherwise there were no restrictions on the format of the PI, study design, presence of a comparison/control group, or length of follow-up. This inclusive approach to the search was taken, as the initial search for PI randomised controlled trials (RCTs) returned a small number of papers.

Search strategy
Searches were conducted in PubMed, PsycINFO and EMBASE by two independent investigators (RBJ, ZS). Search terms included 'adolesc*' or 'young' or 'youth' or 'teen*' or 'famil*' or 'school' or 'college' AND 'psychoed*' AND 'depress*' in the title or abstract, with no restriction regarding publication dates (Fig. 1, flow diagram). These searches were performed up to January 2017.
Articles were also identified through reference lists and the authors' personal collections, including studies in a Cochrane review [12] , international guidelines [4,5], chapters in relevant textbooks [13], and educational material (e.g. Royal College of Psychiatrists (RCPsych), NICE, AACAP, Black Dog Institute, Orygen Youth Health). Key authors with expertise in adolescent depression interventions were contacted, and authors were contacted for details on studies (e.g. regarding participants and follow-up).

Study selection, data extraction
Data extracted from the studies was tabulated independently by the authors, with columns including mode of delivery of PIs, study design, participant characteristics, assessment/follow-up, and findings. RBJ and ZS independently reviewed all the abstracts and extracted data, and discussed the studies to be included in meetings following the independent searches. Where there was disagreement, both researchers reviewed the studies together before deciding on whether they were included. Other authors (SS, AT, DS, AKT, IJ) were consulted where there was uncertainty or disagreement.
The review was guided by the PRISMA statement [14], and the risk of bias by Cochrane Collaboration guidelines [15].

Description of PIs
The findings from the review suggested there are many ways in which PIs for adolescent depression can be delivered and categorised, broadly ranging from 'one-to-one' approaches to multi-group and family approaches. Programmes can vary according to the number of participants (individual, family, group), setting (community, school, service), and mode of communication (printed, online, game, lecture). Several formats and approaches can also be adopted by a single programme.
PIs have been described as passive or active [16]. However, the literature search suggested that programmes may be a mixture of both, for example online interventions could communicate information 'passively', but with interactive components and access to therapists or forums. A similar approach was used to categorise studies according to whether programmes were 'proximal'/'in person' or 'long distance' (e.g. online, mail-outs). They could also be described according to whose response was evaluatedyoung person, family/carer, other (e.g. teacher), or a combination.
Fifteen studies were identified that met the inclusion criteria. In the following sections, the studies are presented according to whether they targeted adolescents with a current diagnosis of depression or depressive symptoms, and/or their families (some included relapse prevention) (seven studies, Table 1), or whether they focused on adolescents 'at risk' (eight studies, Table 2), for example if there was a family history of depression. PIs were also subcategorised according to whether they took a predominantly   Intervention could help e.g. with feelings of isolation.  -improvement seen in children's prosocial behaviour -reduction in emotional symptoms and anxiety.

Control:
Changes noted sooner with FTI (baseline-4 months) than LT (4-10 months family/group (10 studies), individual (two studies), or online approach (three studies). All 'in person' studies in the review (12 studies) involved a professional as a facilitator, whilst the 'long distance' studies (three studies) did not. Within each subcategory, the studies are presented according to a hierarchy of evidence, with RCTs presented first and smalluncontrolled studies discussed last. Eight of the studies were RCTs, and the risk of bias is presented in Table 3 [15]. The outcomes of interest included understanding, attitude, behaviour change, (family) communication and support, and mental health outcomes (depression, anxiety, aggression). Table 1)

Family PI
Sanford et al. [17] carried out a pilot RCT of a programme, comparing the effectiveness of twelve structured sessions conducted at home, with usual treatment for adolescents meeting DSM-IV criteria for major depressive disorder. Sessions aimed to increase family knowledge about depression, understand effects and improve communication and coping strategies. Sixteen adolescents (aged 13-18 years) and their families participated in the intervention group, and 15 in the control (individual or group counselling). Assessments were done at baseline and threemonthly intervals up to nine months. The programme improved adolescent social functioning, family relationships, depressive symptoms (effect size >0.5 for all, 0.64 for depressive symptoms (RADS scale) on follow-up) and duration of remission, and participants reported greater satisfaction compared to counselling.
The 'Children's Medication Algorithm Project' targeted young people with depressive disorder, ADHD or both (diagnosed by the treating psychiatrist) -to improve compliance with medication (and self-monitoring) and coping strategies [18]. The information was general at first, but then tailored to families' needs and developmental age, and available in different formats. There was no fixed number of sessions (median = 6). Ninety participants (aged 6-17 years) were recruited from community clinics, and asked to complete surveys at baseline and after four months. The majority of caregivers (63%) and children (60%) were happy with the amount of information and found it helpful. The authors reported (in personal communication) that the programme was completed, but follow-up results were not analysed.
Brent et al. [19] described a feasibility study of a programme for parents of adolescents with depression, cited in AACAP parameters. This consisted of a session on diagnosis (depression as a  chronic, recurrent illness), course and treatment, and methods of coping with a family member with depression. Sixty-two parents and 34 adolescents participated. There was an improvement in their knowledge, and modification of dysfunctional beliefs about depression and treatment. Almost all participants (97%) described this as useful and interesting.

Individual PI
PI was provided to a control group in a factorial RCT to evaluate low-intensity interventions in young people, with mild-moderate depression and/or anxiety [20]. The mean age of participants was 17.6 years (range 15-25 years). The group was delivered 'lifestyle' PI, particularly on physical activity, sleep and substance use, by psychologists in six manualised weekly sessions. Eighty-six young people participated in this group, whilst 88 received the 'intervention', behavioural activation physical activity (BAPA). Depressive symptoms reduced in both groups, but BAPA was more effective (effect size: BDI-II d = 0.41, MADRS d = 0.48), although there was no reported follow-up.

Computerised/Online PI
A school-based RCT included a 'psychoeducation computer programme' (CPE) in the control arm, versus the main intervention, a computer 'fantasy game' with CBT content, 'The Journey' [21]. The latter comprised seven modules, including ones on problem solving, conflict resolution, challenging unhelpful thoughts and relaxation techniques. CPE had a similar structure, but was more 'instructional' than therapeutic, and covered depression, 'mental health hygiene' and stress reduction. Seventeen adolescents (aged 13-18 years) with low mood participated in each group, referred from school counsellors. These were assessed at baseline, post-intervention and one month. Reductions in depression scores (CDRS-R scale) were seen in both groups, but greater in the CBT group (effect size between groups: 1.7). Participants reported the CPE had been helpful and favourable feedback on the computer-based format.
The 'Depression Experience Journal' website served as a platform for children/adolescents, families and professionals to share their personal experiences of living/working with mental illness [22]. This aimed to "facilitate healthy coping", and could be used individually or with others. A feasibility trial included 38 primary caregivers, each with a child aged 8-19 who had been admitted to hospital because of mental health difficulties. Assessments were done at baseline and 2-4 weeks after use. Parents were satisfied overall with the way information was presented, and personal stories were most helpful. They suggested increasing the number/range of narratives, and making the site more interactive.
Stjernswärd and Hansson [23] conducted an exploratory trial of a web-based supportive intervention for relatives of those with depression. This included a psychoeducation module, diary and forum. One of the discussion themes was the youth to adult transitions. The 25 participants included parents and other relatives of young people with depression, or those who had suffered from a young age, although the authors noted (in personal communication) it was unclear how many were adolescents. The tool was generally well-received, and highlighted how web-based support could help with feelings of social isolation.

Adolescents at risk of depression: PIs for adolescents and families/ carers (eight studies, Table 2)
A family history of depression is one of the best-known risk factors for adolescent depression [24]. Children of depressed parents are therefore a potential target group for depression prevention programmes. Another major risk factor for depression in young people is psychosocial stress, which is another consideration when developing prevention programmes [25].

Family PI where there is parental depression
Five studies focused on adolescents at risk because they had a parent with depression. Beardslee et al. [26] described an intervention targeting parents with depression and their asymptomatic child. It consisted of 6-10 sessions facilitated by clinicians, and the main concepts were increased familial understanding of the disorder, and appreciation of children's experience of parental illness. The pilot study included 19 families in the intervention group, 18 in the control (lectures on depression, its effects and warning signs), each with an 8-15 year-old child. Assessments were done at baseline and after eight weeks. Adults in the intervention group were happier with the information received, and reported greater understanding of their feelings about mood disorders and increased marital support. There was also improved communication with their children about their illness because of increased understanding in both parent and child.
The authors established sustained positive effects on these outcomes 1.5 years after enrolment [27], and identified specific 'healing principles' that contributed to the changes in family behaviour and attitudes, which enhanced resilience in children [28]. These principles were based on findings from the first 12 families to complete the intervention, and included demystification of the illness, modulation of shame/guilt, increase in the capacity for perspective taking, development of a hopeful perspective and a belief in one's own competence.
AACAP parameters referred to a RCT by Beardslee et al. [29] with the same recruitment criteria. The study design was updated with telephone contacts/refresher meetings carried out at 6-9 month intervals. There was focus on linking the educational material to a family's individual experience, reducing feelings of guilt/blame, and helping children learn to build relationships within and outside the home. Fifty-three families participated in the intervention arm, and 40 in the 'lecture' control group. Assessments were made at baseline, post-intervention, after 1 and 2 years. There were long-term effects on how families address problems regarding parental mental illness. Parents reported that the intervention was more beneficial than the lecture in changing child-related behaviour and attitudes. Children reported increased understanding of parental illness and reduced depressive symptomatology (x 2 1 = 7.3) after the intervention over two years. PI was a substantial component of the 'Family Talk Intervention' (FTI) [30]. This consisted of a minimum of six sessions, and guidebooks were provided to participants. Two parent sessions were followed by one with each child. Parents were taught about depression, and how to talk about it with family members, cope with family problems and answer children's questions. In an RCT, 53 parents treated for a mood disorder (and partners) participated in FTI, and 56 (controls) underwent 'Let's Talk about the Children (LT)', a brief PI parent discussion to assess/support the child (aged 8-16). They completed questionnaires at baseline and 4, 10 and 18 months post-intervention. An improvement was seen in children's prosocial behaviour and reduction in their emotional symptoms and anxiety in both groups, although they were noted earlier in the group who received FTI.

Other family PI
Two family studies targeted adolescents at elevated risk of depression due to psychosocial stress exposure. Jordans et al. [31] conducted a controlled (pilot) trial of a parenting group PI. This was part of a larger mental health package for low and middle-income countries (LMIC), and targeted families reporting high levels of psychosocial stress due to political violence. Sessions focused on communication, problems affecting children and how to manage them. Fifty-eight children aged 10-14 years (and their parents) were recruited from the 'treatment school', and 62 from the 'control school' (waiting list for intervention). Assessments were made at baseline and three weeks post-intervention. No improvement was seen in child depressive symptoms or perceived family support, although parents in the intervention arm saw an improvement in their child's aggression (effect size d = 0.6), especially in boys. The majority of parents reported they were satisfied and had learned to be 'better parents'.
A controlled (exploratory) trial of 'Egokitzen', a post-divorce intervention for parents and their children, comprised 11 weekly sessions on divorce, interparental conflict, and parenting styles/ discipline [32]. Thirty-four parents and 51 children (aged 2-23 years) participated, and six parents and nine children were in a comparison group (waiting list). They did not state how many adolescents participated, although eight were over 13 years old. There was some effect of the intervention on the children's mental health symptoms (anxiety/depression: d = 0.57, aggression: d = 0.65), particularly in the 6-month follow-up.

Individual PI
Barnet et al. [33] described a RCT of a community-based homevisiting programme for adolescent mothers. The authors noted how this group was at risk of becoming pregnant again, depression, school dropout, and poor parenting. Home visitors were paired with each adolescent through the child's second birthday, and delivered a parenting curriculum, encouraged contraceptive use, connected the adolescent with primary care, and promoted school continuation. Forty-four adolescents (aged 12-18 years) were in the home-visited group, and 40 in a control group (usual care), predominantly with low incomes and of African-American origin. Structured interviews were done at baseline and 1 and 2 years' follow-up. This programme improved adolescent mothers' parenting attitudes and school continuation, but it did not reduce their odds of depression or repeat pregnancy, or achieve coordination with primary care.

Main findings
This is the first systematic review of PIs in the prevention and management of adolescent depression. The main objective was to identify studies on PIs for adolescents with, or at high risk of, depression, by rigorous methods, to explore the content and design of existing programmes and to evaluate their effectiveness. This could help inform clinical practice and the development of future programmes and guidelines, and increase awareness of adolescent depression.
Fifteen PI studies for adolescent depression were identified in this review. The studies showed a range of approaches to PI, and the vast majority were 'in person' ('proximal') and 'active', and most involved content presented to families/groups facilitated by a professional. NICE [4] and AACAP parameters [5] state that the involvement of the family is important in the management of adolescent depression, the motivation for treatment often comes from parents, and any parental and child mental health difficulties should be treated in parallel.
Whilst only a few studies in the review were categorised as 'individual' or 'group' PI, many of the studies in other categories, such as 'family' or 'computerised' PI, embraced one-to-one or group approaches. This demonstrated how programmes could incorporate a range of formats to engage/communicate information, consistent with 'blended learning' approaches [34].
There is emerging literature on computerised and online interventions, although many were not included in the review because there was no evidence they had been evaluated [e.g. 35,36].
Some of the studies in the review [e.g. 21,31], recruited adolescents via schools. Most school-based programmes found, however, were universal mental health programmes [e.g. 37,38], and were not included in the review. There were also programmes developed for teachers only [39], and assessments of mental health literacy [40], but not in association with PI.
PIs for mental health difficulties other than depression were not included in the final review, but could help inform future programmes. For example, elements of PIs for bipolar disorder [10,41], anxiety and suicide [42], could be examined, particularly where dealing with depressive symptoms. There were also case studies of depression programmes [e.g. 43], which could be explored with more participants.

Effectiveness of PI
In general terms, PIs aim to inform and empower users to make decisions about their welfare and care, and promote resilience. In the current review, studies showed PIs may have a beneficial effect on a range of measures, including knowledge/understanding of depression and its effects, behaviour and attitudes, treatment adherence, and depression and other mental health and wellbeing outcomes. Increased parental and child understanding which may be facilitated by PIs, can lead to improved communication, conflict resolution and problem-solving, and this appears to be important in managing/preventing depressive symptoms in adolescence [29].
Evidence for the effectiveness of PIs is limited, but based on the evidence to date PIs in adolescent depression show some promise, although further well-designed multi-centre trials are needed. All this is consistent with a review of PIs for depression in adults, which concluded that whilst few studies have been published in this field, PIs can help improve the clinical course, treatment adherence and psychosocial functioning in adults, and family PI is seen as part of its 'optimal treatment' [11].
As with all interventions, it is important to consider possible side-effects of PIs. Adolescents with depression can experience difficulties with concentration, energy levels and motivation [44]. Some studies included in the review noted that research participants stated there was too much information in the programmes [e.g. 18] . Detailed health information could make the individual, family and carers anxious and distressed, or lead to excessive 'self-checking' and rumination. There may also be a risk of dependence on, or over-compliance with, the PI facilitator, or at the other extreme, an over-reliance on self-management strategies.
At this time it is not possible to conclude that PIs are effective in adolescent depression given the small number of studies and the variable methodological quality. For example, there was potentially a high risk of performance and detection bias in many of the studies (Table 3). There was also little consideration of the costeffectiveness in the studies in this review. A roll-out of a PI would need to be evaluated, for example with regards to time and costeffectiveness, particularly where services/resources are limited.

Active components
There were difficulties in analysing and comparing PIs (see 'limitations'), and deconstructing their components was challenging, particularly when evaluating the elements associated with beneficial effects. As with the review of PIs in adult depression, the mechanism of action was difficult to assess on the basis of the current evidence. Also, for those who are currently depressed and even those at risk, PIs might well be used as an adjunct to established approaches such as CBT, interpersonal therapy (IPT) and/or antidepressant medication. When developing/evaluating PIs, it would be helpful if authors developed a programme theory or logic model which described the mechanism of effect of their intervention, and evaluated this using methods like mediation analyses and/or through the study process evaluation [45].
Personalising the content and taking a person-centred approach might be important in the success of programmes [46]. Beardslee et al. [29] stated that combining a PI with a family's individual experiences ensured lasting improvements. Parents in some interventions preferred to have the amount/level of information tailored to their needs, so that it was relevant to them. Incorporating personal stories might be particularly helpful [22].
With regards to the specific content of programmes, learning to identify symptoms and plan activities could be important, and information on lifestyle approaches such as exercise. In their RCT of low-level interventions, Parker et al. [20] found that physical activity was most effective in reducing depressive symptoms. In adults, Tursi et al. [11] hypothesised that 'teaching lifestyle regularity' may help with the prevention of depression, whereas early detection of prodromal symptoms may be important for preventing relapses.
It is also likely that the success of a programme is related to the way it is delivered. The skills of the facilitator and therapeutic relationship could be key factors [47]. This review showed that facilitated PI could be delivered by a range of professionals, including nurses, psychiatrists, psychologists and health visitors. Colom [9], a pioneer of PIs in mood disorders, particularly in adults, noted that interpersonal skills and 'common sense' were especially important facilitator characteristics, and that those delivering PIs need to be an expert on the 'disorder', not the 'technique'. This would avoid the 'complex training' and associated funding required, for example for CBT. Furthermore, such skilled approaches are not always available; not only in LMIC, but also in higher income countries, and PIs could help address this need.
The mode of communication, such as the use of multimedia, can also accommodate personal learning styles and preferences [48], and make it more engaging and accessible [21]. Repeating key themes and messages in various ways might also help [29]. Therefore, it might be important that there is a range of formats (modalities, materials, activities) available to deliver PIs.

Strengths, limitations
This review has a number of important strengths; it is the first of its kind exclusively on PIs in adolescent depression, it was conducted rigorously, and efforts were taken to minimise bias, for example through two people completing independent searches and data extraction. However, the findings should be interpreted bearing in mind a number of considerations and limitations.

Heterogeneity, methodological quality
There was a diversity of approaches in the research design and PI approaches in the papers selected, which made it difficult to compare programmes directly and measure the overall effectiveness, and therefore no meta-analysis was attempted. The lack of consensus and diverse approaches were difficulties encountered by other reviewers when comparing programmes and studies [11].
The studies targeted a range of participantsyoung people with depression, those at high-risk, and parents/families. The programmes ranged in format, number and duration of sessions and the use of facilitators. PIs were also not always tested in isolation, and often were incorporated, for example with or versus CBT, and the use of control groups varied. The outcomes related to the individuals or parents/carers, or both, and a range of instruments was applied. Some papers did not describe these elements. All this made comparative analysis difficult.
The studies included were at various stages, from early development/evaluation to efficacy trials. Many had small sample sizes and short-term follow up. It was unclear how many of the programmes were developed using relevant theory, following extensive mixed-methods approaches with user input, and for a wide range of settings or services, in line with recognised frameworks [45]. The review included only published studies, and some studies/programmes might not have been documented or accepted for publication. This review might have been scientifically more robust had it included only RCTs. However, this approach would have yielded few studies, and excluded a number of relevant and interesting programmes, which could help inform work in this field.
The lack of large scale RCTs might be related to the lack of PIs available for adolescent depression in services in general, and the difficulty in setting up large multi-centre experimental designs, because of the time/funding investment required (e.g. to recruit, train practitioners, ensure similar delivery across centres). It might also be related to the 'branding problem' of PIs (noted below), and how PIs may be regarded as some as a low-level approach (e.g. compared to 'skilled' approaches such as CBT), and perceived as better suited to control groups, rather than the main intervention.
Furthermore, most studies were conducted in high-income countries, and few in less economically developed countries. The more advanced packages were developed in North America, Scandinavia and Australasia À especially e-health interventions. There are differences in each country, for example in service structure, culture and language, and there might be difficulties in implementing them elsewhere. Those in the adolescent age group might be particularly sensitive to such differences. Only Englishlanguage studies were selected, and so this may also have introduced bias.

Defining PI
The approach to the definition of psychoeducation was variable in the programmes and studies in the review. There was a lack of clarity on the difference between 'psychological', 'psychoeducational', and 'educational', and the terms were used inter-changeably in some publications [12]. Many programmes reviewed had elements of psychological therapies such as CBT or IPT, and it was difficult at times to separate the psychological and educational componentsalthough there might be some overlap and similarities between the approaches. This was consistent with the description of the 'blurry' boundaries between 'simple' interventions (e.g. PI) and 'skilled' approaches (e.g. CBT) [9].
The distinction between general health information and psychoeducation was also unclear at times, for example in relation to the many printed (leaflets/books) or online resources for young people (e.g. RCPsych, Headspace). Trials have used printed literature with a control group [49]. However, there was little literature on the development and evaluation of such resources. It is possible that the term 'psychoeducation' should be reserved for 'active' intervention programmes with individualised/tailored information for young people and families, to help prevent and manage difficulties, as opposed to general 'passive' resources.
Another limitation of this review was that the searches were for articles with 'psychoeducation' (or psychoed*) in the title/abstract. This meant that relevant studies described as 'educational' programmes, might have been missed, although the searches went beyond the use of databases. Furthermore, given there are many possible psychosocial risk factors for adolescent depression, PIs that targeted such factors may have been missed.

Conclusions, practice implications
A limited number of PIs were developed and evaluated in line with recognised research frameworks and using rigorous methods of evaluation, and the large variation in approaches made it difficult to evaluate the overall effectiveness of PIs for adolescent depression. However, the findings to date for PIs in adolescent depression show some promise. Although evidence is limited, a range of potential benefits have been reported, from increased understanding and change in behaviour and attitudes, to improved family communication and effects on mood symptoms and wellbeing.
Whilst the evidence for the effectiveness of electronic PI (or e-PI) is limited thus far, many packages are in development [e.g. 35], and online PI in adults has been shown to reduce depressive symptoms and improve understanding of treatments [50]. There is evidence to support the use of CBT-based and other online packages [51,52]. The use of social media, technology (e.g. smartphones), and online material has been identified as a key area of future practice/research in adolescent depression [8]. However, there are also challenges, related to data protection, privacy and security, and the 'digital divide' between those who have access to the internet and those who do not, although this gap is narrowing [53].
Future work should include defining 'psychoeducation' in international guidelines, to help remedy the 'branding problem' referred to by Colom [9]. This would not only help with future research (including reviews) in the field, but also help to clarify to individuals, families/carers and professionals what PIs might entail, how PIs might help them, and how they compare with other approaches. However, the definition should not be too restrictive, and acknowledge there may be some overlap and similarities with other approaches/therapies, and embrace the range of possible formats of PIs.
Programmes should also be developed/evaluated according to recognised research frameworks [45]. Further research is required testing PIs in adequately powered (possibly multi-centre) RCTs, possibly alongside other therapies such as CBT, with process and economic evaluations included as part of the trial. There needs to be more emphasis on the theory, content and design of interventions, and an exploration of the active components of PIs, and potential mechanisms of PIs through process evaluation and investigations such as mediation analyses.
Further research is also needed to understand how to personalise the information and design, and incorporate multimodal approaches, given the variety of experiences of depression. Programmes need to accommodate and engage with a range of ages, backgrounds and abilitiesparticularly when motivation and concentration is impaired during depressive episodes. Future studies could explore how PIs could be integrated into the daily lives of young people and families/carers, and into health, social, education and youth services.