The number of adolescents seeking help for their mental health is higher than it has ever been before, with one in five surveyed young people meeting the criteria for a probable mental health disorder (NHS England, 2023). This trend is met by significantly reduced Child and Adolescent Mental Health Services capacity struggling to respond to increased service demands. This perfect storm, along with the ongoing perceived stigma around mental health, leads to many help-seeking adolescents struggling to access evidence-based and cost-effective interventions.
One evidence-based intervention that has demonstrated its effectiveness in improving the wellbeing of young people is Cognitive Behavioural Therapy (CBT). However, we need to make this more accessible to young people, beyond its traditional format of clinic-based delivery and implementation. A recent review suggested that developing more accessible CBT treatment modalities may help break down perceived stigma and improve its utility. Similarly, this review suggests that a group-based approach might help improve access without requiring more resources for those involved.
A ‘self-referral’ process, by which young people could ask for mental health support, is an important component of the CBT-based “stress management” workshop Brown et al. (2024) designed to address some of the existing barriers and improve self-efficacy to help improve the overall wellbeing of adolescents in schools. This blog summarises the BESST study published today in The Lancet Psychiatry, which evaluated the efficacy and cost of implementing these workshops in schools across England.
Brown et al. (2024) designed a group-based CBT workshop which adolescents in schools across England could self-refer themselves to in order promote mental wellbeing.
Methods
Brown and colleagues (2024) conducted a cluster randomised controlled trial with state-funded schools, over a period of two academic years in England (2021-2022 and 2022-2023). Participants were students between 16-18 years who self-referred, seeking help for stress, anxiety, worry or low mood. After enrolment, participants were allocated in a ratio of 1:1 to the DISCOVER cognitive behavioural therapy workshop (CBT-based) or Treatment as Usual (TAU).
Participants completed the primary outcome, the Mood and Feelings Questionnaire (MFQ) at Baseline and were followed up after 3-months and 6 months. Statistical analyses included mixed-effect, multi-level linear modelling predicting 6-month post-baseline MFQ scores. All analyses included intention-to-treat population. Economic analyses followed a cost-utility analysis in terms of quality-adjusted life year measures EQ-5D-3L.
Results
This study included 900 students from 15 localities across four regions of England; all participants were assigned to treatment-as-usual (n = 457) or to the DISCOVER workshop programme (n=443). The proportion of participants who identified as female (71%) was higher than those who identified as male, per group allocation and in the overall sample. This should perhaps be viewed in the context of 2023 NHS England survey data, which showed that “for 17 to 25 year olds, rates [of probable mental disorder] were twice as high for young women than young men”.
The trial successfully recruited an ethnically diverse population. 52% of the study population were White, 17% Asian, 16% Black, 7% mixed, 2% Chinese. 14% of the participants did not have English as their first language.
Overall implementation
80% of those who took part in the trial had never considered seeking help from their GP for their mental health and 70% had never had counselling before, suggesting that the format of this workshop may have made it more accessible to those who were struggling, but had not actively sought help yet.
Generally, the workshops were well attended, with 88% of those in that group attending at least 75% or more of the workshop.
Effect on measures of mood and wellbeing
Those randomised to the workshop programme demonstrated a significant but small effect of a reduction in MFQ scores 6-months post-baseline compared to the Treatment as Usual group.
When looking more specifically at subgroups in the workshop group, results showed a significant medium effect of reduction of MFQ scores in participants who reported clinically relevant depressive symptomatology, assessed as MFQ > 27.
In terms of the authors’ secondary outcomes, in comparison to those who were in the TAU group, young people who attended the workshop also demonstrated a significant but small effect size in reductions in anxiety scores, and improvements on scores of wellbeing and resilience 6-months post-baseline.
No improvement was found in terms of sleep.
Cost-effectiveness
The authors estimated the DISCOVER workshop intervention to be cost-effective, based on the NICE Quality Adjusted Life Years Threshold.
The DISCOVER workshop was a moderately effective short-term intervention for reducing symptoms of anxiety and depression in adolescents.
Conclusions
The authors concluded that the DISCOVER workshop was mildly effective for demonstrating small effects in reducing symptoms of depression and anxiety in this group of 16-18 year olds.
In comparison to TAU, this short CBT-based intervention is likely to be a cost-effective approach to providing early-intervention mental health care to young people in schools and a further implementation and scalability study is warranted.
The self-referral pathway improved accessibility for young people who had not engaged in formal help-seeking behaviour for their mental health prior to taking part in the study, however there is a need for further investigation as to why less male students participated than females, and also for whom a self-referral pathway may be less suitable.
This study suggests that the DISCOVER workshop was cost-effective.
Strengths and limitations
Strengths
The key strengths of the BESST study included collaboration, attention to diversity, and accessibility within the recruitment strategies. The authors collaborated with a teenage advisory group which supported its acceptability across ethnic groups and genders. Additionally, the researchers consulted a PPI group to support the design of their recruitment strategies and recruitment materials.
Other strengths of the study included using non-diagnostic terms to make the study more accessible. For example, the researchers allowed participants to identify with terms such as ‘stress’ or ‘stress management’ when self-identifying for participation in the workshop. The research team made this decision due to research stating that such self-referral processes lead to higher engagement from both those who have previously not sought out help, as well as those from ethnic minority groups.
Limitations
Reporting of the DISCOVER workshop and adaptions made from the original workshop designed for adults within this paper or the referenced protocol paper (Lisk et al. 2022) is lacking detail beyond a summary of the theoretical model. This lack of detail potentially limits replicability and further investigation of this intervention.
Whilst there is good identification of treatment fidelity and engagement in the experimental group, the authors do not report in the paper the level of engagement with the variety of supports for the control group. [Editor’s note: This detail is available in the supplementary information, which was not available at the time of writing this blog]. This limits the analysis and our ability to draw clear conclusions for the effectiveness of the DISCOVER workshop in comparison to an active or inactive control condition.
Further due to the randomisation design, young people who consented to the study and were then allocated to the control condition already had their help-seeking trajectory altered by taking part in the research study, and may not be described as a true TAU comparison condition. This lack of specification of the control is not unusual for these designs.
Including a Lived Experience Advisory Group and a Public Patient Involvement group in the design of this study are recognised as strengths in this study, however the lack of reporting on the content of the DISCOVER workshop limits replicability of the intervention.
Implications for practice
Given the increasing rates of young people seeking help for mental health related difficulties, Brown et al. (2024) suggest that a very brief, one-day school-based intervention could have the potential to effectively support young people’s mental health, whilst offsetting the need for using more specialist services. Indeed, by focusing on coping strategies to improve resilience in the face of low mood and perceived stress, the DISCOVER workshops seem to offer a mainstream solution that emphasises functioning over medicalisation and pathologisation of the complex experiences that young people navigate.
That being said, since the DISCOVER intervention only demonstrated a very small clinical effect, it is possible that it may not be sufficient to address some of the more complex context-specific needs of young people. The lack of specification and interest in the control condition further doesn’t allow us to draw a true comparison with the mental health supports available to pupils in schools. We suggest that implementing short-term interventions, such as DISCOVER, alongside improving the existing school support system, might be better suited to provide context-specific mental health support for young people in mainstream settings (see Ariadna Albajara Saenz’s blog post on Fazel et al., 2023).
Our research group currently engages with young people attending secondary schools who are in receipt of mental health care from CAMHS. Similarly to Brown et al. (2024), we have implemented a self-referral system for young people to participate in our studies. We have also observed that the proportion of self-referred young people who self-identified as female is always higher in comparison to those who self-identified as male. Locally, this trend aligns with recent statistics from the Scottish Government that show a higher proportion of girls engage with mental health related activities (e.g. accessing school counsellors) in comparison to boys (Scottish Parliament Information Centre, 2022). This gender difference in help-seeking behaviour posits a question regarding our practices when engaging young people in research – specifically early intervention programs. It is undeniable that invisible structural barriers related to gender influence boys’ self-efficacy. We are curious if the format in which the DISCOVER intervention was offered might have hindered gender-balanced participation in this study. Although Brown et al. (2024) do not directly address this concern, we suggest that offering the intervention as a group workshop might have deterred certain youth groups from participating. In this regard, alternative formats, such as digital interventions, could be more effective in engaging a diverse audience in school settings.
It may be important to consider the wider system context when designing and implementing preventative interventions in mainstream educational or community settings. School curricula, teacher participation and limited education for families and carers may be helpful facilitators and catalysts to maintain change. Conversations around mental health and wellbeing should be further centred on destigmatization, emphasising the resilience and resources young people already have and are capable of building up as they grow and navigate the challenges of late adolescence and early adulthood. We want to emphasise the importance of considering the overall functioning of young people and the way they adapt or cope with such challenges with their own strengths and skills. By adopting this view, we hope to stress the importance of keeping a distance from the purely diagnosis-based systems in mental health services, which may too readily pathologise young people’s experience in a normative and transient stage of their development. This view appears cogent with the approaches in this study by its use of non-medical and non-diagnostic terms and the emphasis on wellbeing and resilience.
Digital interventions could be a more effective alternative for engaging a more diverse audience in school settings.
Statement of interests
The authors of this blog also conduct youth mental health workshops in schools + SMILE which is a short-term school-based prevention.
However, they do not have any conflict of interests with respect to this study or the reviewed paper.
Links
Primary paper
Brown, J., James, K., Lisk, S., Shearer, J., Byford, S., Stallard, P., Deighton, J., Saunders, D., Yarrum, J., Fonagy, P., Weaver, T., Sclare, I., Day, C., Evans, C. & Carter, B. (2024). Clinical and cost-effectiveness of a brief accessible cognitive behavioural therapy programme for stress in school-aged adolescents: a cluster randomised controlled trial in the UK (Brief Educational Workshops in Secondary Schools Trial). The Lancet Psychiatry. https://doi.org/10.1016/S2215-0366(24)00101-9
PDF supplement to: Brown J, James K, Lisk S, et al. Clinical effectiveness and cost- effectiveness of a brief accessible cognitive behavioural therapy programme for stress in school-aged adolescents (BESST): a cluster randomised controlled trial in the UK. Lancet Psychiatry 2024; published online May 14.
Other references
Albajara Saenz, A. (2023). Building bridges between schools and mental health services to improve youth mental health support. National Elf Service. https://www.nationalelfservice.net/populations-and-settings/schools/building-bridges-between-schools-and-mental-health-services-to-improve-youth-mental-health-support/
Bouliou, E. Improving access to CBT for people with anxiety: a review of solutions? National Elf Service. Improving access to CBT for people with anxiety disorder (nationalelfservice.net)
Lisk S, Carter B, James K, Stallard P, Deighton J, Yarrum J, Fonagy P, Day C, Byford S, Shearer J, Weaver T, Sclare I, Evans C, Farrelly M, Ho PC, Brown J; BESST Study Collaborators. Brief Educational Workshops in Secondary Schools Trial (BESST): protocol for a school-based cluster randomised controlled trial of open-access psychological workshop programme for 16-18-year-olds. Trials. 2022 Nov 9;23(1):935. doi: 10.1186/s13063-022-06830-8.
Mental Health of Children and Young People in England, 2023 – wave 4 follow up to the 2017 survey (2023). NHS England. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2023-wave-4-follow-up
Scottish Parliament Information Centre. (2022). Children and young people’s mental health in Scotland.https://bprcdn.parliament.scot/published/2022/5/24/aa290f5c-f12a-4077-81ea-4cc5c6151e34/SB%2022-29.pdf
Photo credits
Photo by Julie Ricard on Unsplash
