Social isolation is a major cause of depression onset and relapse in young people, yet this is not directly targeted in treatment for depression. To address this disconnect, our project will conduct a randomised controlled trial (RCT) to assess the efficacy of an novel intervention that targets social isolation in young people with depression (the Connecting Adolescents to Reduce Relapse [CARR] trial).
GROUPS 4 HEALTH (G4H) is an intervention founded on social identity principles that has been found to be effective in reducing depression in our published pilot work and a recently completed wait−list control RCT. In addition to reducing depression symptoms, G4H works by targeting a primary cause — social isolation — in a way that is cost−effective, accessible, and destigmatising. This program offers a new approach to treatment and relapse prevention of the leading cause of disability among young people in Australia.
The CARR trial will compare the effectiveness of G4H to another effective treatment, group Cognitive Behaviour Therapy (CBT) at program completion and one−year follow up. Participants will be 200 young people with depression recruited from two sites, Headspace (Metro South, Brisbane) and the University of Queensland Psychology Clinic. We hypothesise that both interventions will be effective in reducing depression symptoms, but that G4H will be superior in reducing the social isolation that causes depression. This trial will therefore test the capacity for G4H to function not only as a treatment, but also as relapse prevention for young people at risk of depression recurrence.
Depression is currently ranked by the World Health Organization as the single greatest cause of disability in young people (aged 15−25) in Australia. Although both psychotherapy and pharmacological treatments are effective in reducing acute symptoms in young people, they come with notable downsides. The cost of both psychological interventions can be prohibitive, particularly as depression is more common among disadvantaged communities. There is also a shortage of mental health professionals with the level of training needed to deliver these treatments. This shortage is most pronounced in areas of greatest need.
There are other barriers to the effective treatment of depression. Previous research has suggested that only a minority of young people with depression present to a health professional, and only a minority of those who do present receive treatment. For instance, one of the most common pathways to treatment is a consultation with a General Practitioner and prescription for antidepressant medication. However, the most common antidepressants prescribed for adults are not suitable for young people due to elevated suicide risk'. Even for those medications that are safe for adolescents, compliance rates are as low as 45 percent, partly due to common side effects such as drowsiness and weight gain.
While most young people prefer non−drug treatment, the stigma associated with therapy often leads to treatment avoidance. For these reasons, there is a need for the development of treatment alternatives for young people with depression that are cost−effective, non−stigmatising, and widely accessible.
Research has demonstrated that social isolation both precipitates and maintains depression. Several large−scale studies have shown that social isolation is a powerful longitudinal predictor of depression risk, even after controlling for other candidate variables, such as depression history. Social isolation also reduces responsiveness to treatment and is a well−established risk factor for relapse. Our research has shown that when a person with depression joins a group, they reduce their risk of relapse four years later by approximately 24 percent after controlling for gender, age, ethnicity, relationship status, socioeconomic status, subjective health, initial number of group memberships, and severity of depression. However, to date, there have been no formal evidence−based treatment programs that specifically target social isolation. Thus, for health professionals, community workers, and policy makers who are convinced by this evidence, there is, as yet, limited direction about how best to put this evidence−base into practice to improve health outcomes for young people.
Young people experience some of the highest levels of mental illness in Australia. In fact, depression is the leading cause of disability for those aged 15−25 years3. Despite strong epidemiological evidence showing that social isolation is a major determinant of mental health, particularly depression4, this is not targeted in any standard interventions. This gap can be filled by GROUPS 4 HEALTH (G4H) which is an evidence−based program that treats social disconnection by empowering young people to strengthen their existing social group ties and foster new ones.
This project will directly compare the effectiveness of G4H to the dominant framework for psychological intervention, cognitive behaviour therapy (CBT), in young people aged 15−25 experiencing clinically significant depression. For this purpose, a two−site Phase III Randomised Control Trial (RCT) with 200 participants will be conducted to test the following specific hypotheses:
- H1. At program completion, G4H will be superior to CBT in reducing social isolation (a major risk factor for relapse in depression).
- H2. At program completion, G4H will be as effective as CBT in reducing depression symptoms (i.e., non−inferior5).
- H3. The benefits of G4H for social isolation and depression will be sustained at one−year follow−up.
GROUPS 4 HEALTH (G4H) is a new theory−derived intervention that offers the possibility of preventing and treating mental illness by targeting a primary cause of depression social isolation. This is significant for at least five reasons:
- G4H is effective. Both our published pilot and our recently completed wait−list control RCT show that it reduces depression symptoms and increases social connectedness in young people.
- G4H is cost−effective. It can be administered by facilitators without advanced training in mental health, is brief, and it is far cheaper than either class of current evidence−based treatments (antidepressants and psychotherapy).
- G4H is de−stigmatising. It does not require participants to be given a diagnostic label, nor does it provide a biomedical or genetic explanation for mental illness. This is important as such explanations contribute to increased stigma from health providers and sufferers, as well as increased pessimism about prognosis.
- G4H offers a low risk intervention for depression. Some current treatment options for adolescents have safety concerns (specifically, fluoxetine can increase suicide risk under some circumstances') or negative side effects (e.g., drowsiness, weight gain). By contrast, the "side effects" of reduced social isolation (e.g., enhanced cognitive function and quality of life9) are positive, and thus if this trial is successful G4H may ultimately be offered as a broad−based intervention for individuals at risk of depression (e.g., when undergoing stressful life transitions).
- G4H may prevent relapse. G4H targets one of the primary factors associated with depression relapse. This is critical because existing approaches to relapse prevention are only minimally effective. About 80% of individuals with a history of depression are expected to relapse, experiencing an average of four episodes in a lifetime". Even among those receiving evidence−based treatment, approximately one−third relapse within 18 months.
Translating Research Findings into Practice
This research project is firmly translational, involving a program (G4H) already found to be efficacious in a pilot trial. However, the CARR trial aims for the first time to establish the relative benefit of G4H over practice as usual (in this case, CBT), at two sites (the UQ Psychology Clinic and Headspace Metro South) which together provide community mental health care to over 1500 young people per year.
Our research team has a strong track record of industry partnership to evaluate and improve service provision13'14'1'. CARR involves a partnership with Headspace, including two co−investigators from the service (one on the Headspace board), which offers opportunities to expand our program into other Headspace centers if the trial is successful. Headspace provides care to over 50,000 young Australians annually. In addition, facilitators will be provisional psychologists, whose training and supervision through this trial will prepare them for implementing G4H in their future practice, thereby building capacity in the public and private sectors.
We will disseminate our findings through traditional means such as (open−access) journal articles, conference presentations, and media releases. However, the primary dissemination strategy will be through offering (at cost) professional development at practitioner−oriented conferences, where mental health practitioners from around Australia can receive training in G4H in order to integrate these techniques into their practice.
This project ‘Connecting Adolescents to Reduce Relapse (the CARR trial): An RCT to assess whether a social identity intervention reduces social isolation more effectively than cognitive behaviour therapy’ is funded by the Australian Rotary Health.
The Principal Investigator on this project is Senior Lecturer Dr Tegan Cruwys, at the Research School of Psychology ANU. Learn more about Tegan Cruwys.
Research School of Psychology
The Australian National University
Canberra ACT 2601