Online, self-help Single Session Interventions could expand current provision, improving early access to help for young people with depression symptoms, including minority groups

Abstract

Current mental health service provision for young people was primarily designed based on an assumption of repeat attendance to enable access to interventions. This applies to in-person therapy, and in recent years, digitally provided apps and programmes. Yet, discontinuation after only one or two attendances or uses is a common problem. However, there is a different model, which is intentionally designing provision without assuming repeat attendance, i.e., single session interventions. Evidence from the USA, where a suite of digital, self-help single session interventions, accessible anonymously, have been designed, indicates that these are helpful to young people with reductions in depression symptoms at up to 9 months later. These interventions also have had better reach into currently under-served populations (e.g. LGBTQ+ and ethnic minority adolescents). Therefore, these may be a potentially helpful way to expand existing provision at scale, enabling all young people to access evidence based help quickly.

Background

One in three adolescents has elevated depression symptoms and even sub-diagnostic depression has substantial consequences. Prompt treatment can reduce the burden of depression symptoms, yet it is difficult to access, particularly for those who are beginning to struggle as traditional Child and Adolescent Mental Health provision has prioritised those who are most severely unwell or risky. This needs-access gap is disproportionately large for minority adolescents (e.g., ethnic minorities, LGBTQ+) who are particularly vulnerable to depression (Deighton et al., 2019) and also less likely to access traditional mental health service provision. Yet, adolescents want to be able to access help when they start to experience difficulties, before they become significantly impaired. Therefore, we need timely, scalable, effective interventions with better reach into under-served populations.

The potential of digitally provided evidence based treatment

Digital technology offers an effective way to deliver evidence-based treatment at scale as on demand self-help and can overcome many help-seeking barriers, including stigma. However, currently available digital treatments like internet-based cognitive behaviour therapy (iCBT) assume repeat use, but suffer from significant drop out and frequently, are only used once or twice. The few mental health apps that have been rigorously evaluated also assume repeat use, and may have a cost to the user, as well as a requirement to have a specific compatible device on which to download and use them. Indeed, even when provision is in person, many adolescents disengage before completing all the sessions available to them, and those from minority backgrounds are disproportionately more likely to attend only once (Edbrooke-Childs et al., 2021).

Why single session interventions may be a useful way to expand on current provision

Single session interventions (SSIs) are one-off therapeutic interventions by design. Thus, they do not assume repeat use, although they do not preclude this either. A meta-analysis of SSIs (n = 10,508 adolescents with mental health problems) found a pooled mean pre-post intervention effect size of g = 0.32 (Schleider & Weisz, 2017). Although this effect size is relatively small, it is impressive given how small the treatment dose is. And more extensive therapy does not perform that much better; for comparison, a meta-analysis of psychological treatments targeting subthreshold adolescent depression has an effect size g = 0.38 (Cuijpers et al., 2021). And, even more persuasive is that the evidence showed that self-help SSIs were as effective as therapist-delivered SSIs (Schleider & Weisz, 2017).

Online self-help SSIs can be accessed anonymously, which is particularly important for those who are already stigmatised and excluded. Several brief (<30 minutes) online SSIs have been developed for adolescents and trialled in the USA by the Lab for Scalable Mental Health. These SSIs include psychoeducational materials in written and visual form, brief videos, vignettes, and self-reflexive exercises. There is some personalisation within each SSI using branching logic. Content is based on four elements, B: Brain science - to normalize concepts in the programme, E: Empower adolescent to a “helper” or “expert” role, S: Saying-is-believing exercises to consolidate learning, and T: Testimonials and evidence from valued others.

The two SSIs with the best existing evidence for reducing depression symptom severity in American adolescents are a cognitive and a behavioural SSI. The cognitive SSI (OSF | Schleider + Weisz 2019 - Project Personality.pdf) teaches how and why people’s traits or habits are malleable rather than fixed (i.e. growth mindset). The behavioural SSI (OSF | The ABC Project: Action Brings Change) teaches that engaging in valued activities can increase positive mood (i.e., behavioural activation). Three randomised controlled trials (RCTs) have found that these SSIs reduce depression symptoms in American adolescents at up to 9-month follow-up compared with a supportive (placebo) control SSI. In the largest of these trials, conducted mid-pandemic, almost 2500 adolescents with at least some symptoms of depression (aged 13–16), were recruited via social media (mainly Instagram) within just 3 weeks. Those randomly allocated to one of the two active SSIs (vs. control) had reduced depressive symptoms (Cohen’s d = 0.18) 3 months later (Schleider et al., 2021). The participants recruited to the trial were a population-congruent representation of ethnic minorities and an over-representation of sexual minorities, and outcomes were just as good for minority adolescents.

The Lab for Scalable Mental Health has also shown that in the USA, these online SSIs could be useful as openly accessible resources in practice beyond their use in trials. Specifically, their evaluation supported the acceptability and utility of the SSIs for young people experiencing psychological distress outside of a trial and importantly, those accessing this platform were diverse on several dimensions including > 50% non-White, and > 40% sexual minorities (Schleider et al., 2020). Through an academic-community partnership in San Antonio, Texas, they have also shown that it is possible to translate, culturally adapt and disseminate these resources specifically for low-resourced and minoritized communities with evidence of good uptake, acceptability and utility (Shroff et al., 2023).

It is important to consider potential unanticipated adverse consequences of any therapeutic provision. Based on the existing work in the USA and two feasibility studies in the UK, the risk of adverse events/harms is low. However, there could be unintended consequences of offering SSIs, including assuming that SSIs will be accessible, appropriate, and sufficient for all young people, and the risk that they may be used in the place of, rather than as an expansion to current provision. More large-scale work is needed to determine safety, uptake and reach, as well as experience of SSIs within minority adolescents specifically.

Conclusion

Online, single session interventions could be an addition to existing provision which enables all adolescents to access evidence-based help in a timely manner. Because they are intentionally designed to be used in a single sitting, from any device with an internet connection, they overcome the persistent problem many more extensive interventions face of drop-out. And because they can be offered anonymously, they also overcome stigma as a potential barrier to participation, increasing their potential reach into under-served communities who may otherwise not access help.

Key Practitioner Message.

Young people want to access help that works when they first start to struggle with their mental health. Online, self-help single session interventions could be a way to expand on current provision, ensuring that all young people can access evidence-based help when they want it and anonymously. In the USA, several single session interventions have been developed and evaluated, showing better uptake and reach into currently under-served communities, and effectiveness in reducing depression symptoms with very low risk of harm.