beyondblue in Curriculum: A Preventive Measure for Depression and Related Disorders

Background
There is no health without mental health but mental and neurological disorders, such as depression, anxiety, schizophrenia and epilepsy, are common worldwide including substances abuse, alcohol and drugs use disorders. Estimates made by World Health Organisation (WHO) in 2004 showed that about 450 million people globally suffer from mental and behavioural disorders and one person in four will develop one or more of these disorders during their lifetime.1 Stigma about mental disorders and fear of discrimination increase suffering and vulnerability of the individuals and families affected by mental disorders and then suffering become intense and pervasive. Higher levels of stigma and fear of discrimination prevail more in urban areas and among people with higher levels of education. The myths and misconceptions associated with the disorders, such as a public survey in South Africa showed that most people thought mental illnesses are associated to stress or a lack of willpower than medical disorders (http://www.who.int/mental_health), make conditions worse.

About half of mental disorders begin before the age of 14. Table 1 shows rate of mental disorders in young people ranged from 8% in the Netherlands to 57% in service recipients in San Diego, California, USA.

Table 1 source: Patel Vikram, Flisher Alan J, Hetrick Sarah and McGorry Patrick. Mental health of young people: a global public-health challenge. Lancet 2007; 369: 1302-1313.

There is sufficient evidence that mental health problems are increasing worldwide. The report based on the work by WHO and the World Bank states that by the year 2020 depression will be the second largest cause of global disease burden. In addition to the affected people’s suffering, stigma and discrimination, mental disorders may influence overall society in terms of reduced or lost productivity, expenditure for treatment, support, education as well as criminal justice due to mental disorders. The global burden of mental disorders is well beyond the treatment capacities. The social and economic expenditure associated with this growing burden will not be reduced by the treatment of mental disorders alone.2 Many promotional, educational, awareness and preventive programs are needed; preventive interventions can be a cost-effective and an essential step to prevent or address mental disorders or problems.

Preventive Interventions
Several reviews and analysis have established that prevention programs produce significant benefit by reducing the rates of future social, behavioural and academic problems. Durlak and Wells3,4 found significant mean effects ranging from 0.24 to 0.93 according to program type and target population by reviewing about 177 universal prevention studies. One of the promising universal interventions is Zippy’s Friends program designed to help children in the first years of school and to develop the necessary skills for life-long emotional well-being.5

Neil and Christensen report a review of twenty four efficacy or effectiveness trials of nine Australian intervention programs.6 The FRIENDS program and Resourceful Adolescent Program (RAP) were effective with the strongest evidence. The six trials targeting anxiety for evaluating the FRIENDS program, an anxiety prevention program for children from 7 to 16 years of age, reported lower anxiety immediately or at follow-up. The ten of the seventeen universal trials for depression reported positive outcomes. For randomised controlled trials of universal programs, 50% of trials targeting depression and 57% of trials targeting anxiety produced positive outcomes.6 The FRIENDS is a cognitive-behavioural program of 10 sessions that teaches children skills to cope with anxiety more effectively and builds emotional resilience, problem-solving abilities and self-confidence.7 The evaluation of the RAP, a school-based resilience building program, showed a two thirds reduction in depressive symptoms.8 MindMatters takes an organisational approach and provides a strategy to promote children’s mental health and well-being through all dimensions of the school environment.

In Australia, several other initiatives, such as the beyondblue schools research initiative, the KidsMatter initiative and the Aussie Optimism Program, have been performed to address student mental health. The beyondblue schools research initiative was a universal intervention program designed to reduce depressive symptoms experienced by the students at secondary school. The initiative has been investigated by annual assessments during the three-year intervention program followed by a two-year follow-up. Twenty-five pairs of high schools were assigned to an intervention and a comparison group across Queensland, South Australia and Victoria. The classroom curriculum was a sequential thirty-session program delivered in three years during Year 8, 9 and 10. The curriculum was delivered by the teachers who completed one day's professional development program. Sawyer Michael et al.9,10 observe that the students experienced negligible changes in the levels of depressive symptoms. It is disappointing that the intervention failed to achieve significant change in the levels of depression despite of obvious strengths and benefits of the project. The assessments on quality parameters of delivery are hard to find as it is a most dependable factor for success of any teaching program. A trial of KidsMatter initiative was carried out in hundred and one primary schools. The analysis by Slee et al.11 revealed variations in the quality of implementation across schools and significant differences in the involvement and support of parents, staff and school leadership. The Aussie Optimism Program, a 20-week universal mental health promotion program based on cognitive–behavioural intervention procedures, was delivered to Year 8 students of three schools in Brisbane. The results show the program was beneficial to the students who were experiencing emotional and behavioural difficulties.12

A number of school-based intervention programs produce positive outcomes. WHO13 has published thirty five case studies of mental health promotion programs, initiatives and strategies from nineteen countries so that organisations can use in their own communities and countries. However, even highly regarded programs also need further evaluation considering local social, economic and environmental contexts before implementation.

Epilogue
There is sufficient evidence that ecological interventions programs in schools, for enhancing cognitive, problem-solving and social-emotional skills of children and adolescents, can influence positive mental health and reduce emotional and behavioural problems. However, an intervention program alone is insufficient; schools, teachers and parents have to pay more attention to giving children the skills they need not only to pass the exams but also to live balance, happy, proactive, productive and fulfilled lives. It is clear that schools remain central to impart life skills including planning, opting for alternative right paths, conflict resolution, time management, anger management, stress management and grief and bereavement management. However, life skills have to conceal in side entire school-based curriculum, co-curricular and extra-curricular activities so that each child by default acquire minimum skills to live balance, happy and fulfilled lives. The programs with positive psychology approach can be incorporated in school curriculum for the development of resilience, such as adaptive thoughts, behaviours and problem-solving.

References

1. World Health Organization. Prevention of mental disorders: effective interventions and policy options, a report of the World Health Organization Department of Mental Health and Substance Abuse in collaboration with the Prevention Research Centre of the Universities of Nijmegen and Maastricht. 2004.
2. World Health Organization. Promoting mental health: concepts, emerging evidence, practice, a report of the World Health Organization, Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion Foundation and the University of Melbourne. Editors: Helen Herrman, Shekhar Saxena, Rob Moodie. 2005.
3. Durlak JA and Wells AM. Primary prevention mental health programs for children and adoelscents: a meta-analytic review. Am J Community Psychology 1997; 25: 115-152.
4. Durlak JA and Wells AM. Evaluation of indicated preventive intervention (secondary intervention) mental health programs for children and adolescents. Am J Community Psychology 1998; 26: 775-802.
5. Mishara BL and Ystgaard M. Effectiveness of a mental health promotion program to improve coping skills in young children: Zippy’s Friends. Early Childhood Research Quarterly 2006; 21: 110-123.
6. Neil Alison L and Christensen Helen. Australian school-based prevention and early intervention programs for anxiety and depression: a systematic review. MJA 2007; 186: 305-308.
7. Barrett Paula M, Farrell Lara J, Ollendick Thomas H and Dadds Mark. Long-Term Outcomes of an Australian Universal Prevention Trial of Anxiety and Depression Symptoms in Children and Youth: An Evaluation of the Friends Program. Journal of Clinical Child and Adolescent Psychology 2006, 35: 403–411.
8. Shochet IM, Dadds MR, Holland D, Whitefield K, Harnett PH and Osgarby SM. The efficacy of a universal school-based program to prevent adolescent depression. Journal of Clinical Child and Adolescent Psychology 2001; 30: 303-315.
9. Sawyer Michael G, Harchak Taylor F, Spence Susan H, Bond Lyndal, Graetz Brian, Kay Debra, Patton George and Sheffield Jeanie. School-based Prevention of Depression: A 2-Year Follow-up of a Randomized Controlled Trial of the beyondblue Schools Research Initiative. Journal of Adolescent Health 2010.
10. Sawyer Michael G, Pfeiffer Sara, Spence Susan H, Bond Lyndal, Graetz Brian, Kay Debra, Patton George and Sheffield Jeanie. School-based prevention of depression: a randomised controlled study of the beyondblue schools research initiative. Journal of Child Psychology and Psychiatry 2009; 51: 199-209.
11. Slee PT, Lawson MJ, Russell A, Askell-Williams H, Dix KL, Owens L, Skrzypiec G and Spears B. KidsMatter Primary Evaluation Final Report. Centre for Analysis of Educational Futures, Flinders University of South Australia. 2009.
12. Swannell Sarah, Hand Matthew and Martin Graham. The Effects of a Universal Mental Health Promotion Programme on Depressive Symptoms and Other Difficulties in Year Eight High School Students in Queensland, Australia. Journal School Mental Health 2009; 1: 229-239.
13. World Health Organization. Mental health promotion: case studies from countries, A Joint Publication of the World Federation for Mental Health and the World Health Organization. Editors: Shekhar Saxena and Preston J. Garrison. 2004.