Background
The need to focus on the mental health of adolescents is gaining increasing recognition as the global community looks to achieve the Sustainable Development Goals (SDGs), in particular SDG 3: “Ensure healthy lives and promote well-being for all at all ages” and SDG 10: “Reduce inequalities within and among countries” (1). With adolescents comprising 16% of the global population, it is vital to address the main threats to their health in order to achieve the SDG targets (2).
Mental health conditions account for a considerable proportion of the global disease burden during adolescence and are the leading cause of disability in young people. Up to half of all mental health conditions start before the age of 14 years. Suicide is one of the three leading causes of death among older adolescents (3). Poor mental health in adolescence portends a range of high-risk behaviours, including self-harm, tobacco, alcohol and other substance use, risky sexual behaviours and exposure to violence, the effects of which persist and have serious implications throughout the life-course (4, 5).
There are multiple opportunities for health promotion and disease prevention in adolescence, which could benefit young lives in the short and long term. This stage is deemed as one of the optimal timeframes for intervention, given the neuroplasticity evident in adolescence and the opportunity to step in at a time when the majority of mental health conditions and risky behaviours have their onset (3).
Aim, scope and target audience
These Guidelines on promotive and preventive mental health interventions for adolescents: helping adolescent thrive (HAT guidelines) provide evidence-informed recommendations on psychosocial interventions to promote positive mental health and prevent mental disorders among adolescents. These guidelines, the UNICEF/WHO HAT toolkit and other related implementation tools aim to support evidence-informed programming to achieve that goal. The HAT guidelines have been prioritized by WHO as one of its global public goods for health.
The guidelines are based on evidence from studies of interventions delivered to 10–19 year-olds, with particular attention to: (i) universal interventions delivered to unselected adolescents; (ii) targeted interventions delivered to adolescents who are known to be at increased risk of mental disorders or self-harm, because of exposure to specific adversities (violence, poverty and humanitarian emergencies), chronic illness (HIV/AIDS) and/or particular life circumstances (adolescent pregnancy and/or parenthood); and (iii) indicated interventions delivered to adolescents who present early signs and/or symptoms of emotional and/or behavioural problems but do not have a formal diagnosis of an emotional and/or behavioural disorder. In reviewing the evidence, the primary outcomes of interest were improved well-being and functioning, reduced symptoms and incidences of mental disorders, and reduction in self-harm among adolescents. Other outcomes of interest included reduced risky behaviours (substance use and aggression), improved school retention, and healthier sexual and reproductive behaviours.
The primary target audience of the guidelines includes national policy-makers, planners, and managers of government and nongovernmental health care programmes, along with people working in international health and development agencies.
Guidelines development methodology
The development of the guidelines conformed to standard WHO procedures for developing guidelines (6). The diagram below shows the seven steps involved in the development process.
Step 6 involved using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of the evidence, with reference to the study design, risk of bias, inconsistency, indirectness, imprecision and risk of reporting bias. The certainty of the evidence was accordingly characterized as high, moderate, low or very low. The GRADE profiler software (GRADEPro) was used to prepare summary tables. The final evidence review report was presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and the GRADE Evidence to Decision framework for each PICO question. During Step 7, the GDG followed the standard WHO procedure to develop recommendations based on the evidence review (6). Members considered the relevance of the recommendations for the various adolescent groups and the balance of benefit and harm of each intervention. They took into account values and preferences, costs and resource use, along with other practical issues of relevance to health care providers in low- and middle-income countries (LMICs).
In order to make a strong recommendation, the GDG members needed to be confident that the desirable effects of the intervention outweighed any undesirable effects. When the GDG was uncertain about the balance between the desirable and undesirable effects, the members issued a conditional recommendation. Strong recommendations imply that most adolescents would want the intervention and should receive it, while conditional recommendations imply that different choices may be appropriate.
Summary of recommendations
Based on the evidence synthesis and Evidence to Decision frameworks, the GDG developed five recommendations for mental health promotive and preventive interventions for adolescents, as follows.
Recommendation A
Universally delivered psychosocial interventions should be provided for all adolescents. These interventions promote positive mental health, as well as prevent and reduce suicidal behaviour, mental disorders (such as depression and anxiety), aggressive, disruptive and oppositional behaviours, and substance use.
Strength of recommendation: Strong.
Certainty of evidence: Low.
Important remarks: Based on available evidence, interventions should cover social and emotional learning, which may include components such as: emotional regulation, problem-solving, interpersonal skills, mindfulness, assertiveness and stress management (7).
Rationale: The certainty of the evidence was often downgraded because studies were subject to the risk of bias due to difficulty in blinding the interventions and to reliance on self-reported outcomes, both of which are common in these types of intervention studies. However, a strong recommendation was made despite the low certainty of evidence thanks to the relative consistency of the study results and the fact that significant benefits substantially outweighed potential harms. In addition, considerations about values, feasibility and cost-effectiveness further supported the recommendation. Universal interventions in schools may be easier to implement and less likely to cause stigmatization compared to interventions that require screening. When delivered in schools, interventions may help to reach a large proportion of adolescents and address a wide range of risk factors while providing basic skills to promote mental health and prevent risky behaviours.
Recommendation B
Psychosocial interventions should be provided for adolescents affected by humanitarian emergencies. These interventions are particularly beneficial for preventing mental disorders (depression, anxiety and disorders related specifically to stress) and may be considered for reducing substance use in these populations.
These interventions are particularly beneficial for preventing mental disorders (depression, anxiety and disorders related specifically to stress) and may be considered for reducing substance use in these populations.
Strength of recommendation: Strong for reducing symptoms of and/or preventing mental disorders (depression, anxiety and disorders related specifically to stress). Conditional for substance use.
Certainty of evidence: Low.
Important remarks: Past and continuing support to adolescents exposed to humanitarian emergencies includes a broad range of psychosocial interventions. This reflects the heterogeneous nature of experiences involving emergency events. It is therefore important to interpret study findings with caution. Available evidence indicates that stress management, relaxation strategies and care for the implementer’s well-being are the intervention components most associated with effectiveness. For adolescents with high levels of trauma exposure, trauma-focused cognitive-behavioural therapy (CBT) has shown positive effects on reducing symptoms of depression, anxiety and stress (8, 9). Group-based CBT interventions have shown positive effects on the symptoms of other adolescents exposed to stressful events (10).
Rationale: The certainty of the evidence was often downgraded because studies were subject to the risk of bias due to difficulty in blinding the interventions and to reliance on self-reported outcomes, both of which are common in these types of intervention studies. However, a strong recommendation was made for psychosocial interventions to reduce symptoms of mental disorders, in spite of the low certainty of evidence. The reason was that the clinically relevant anticipated benefits outweigh potential harms. Furthermore, important values, equity and feasibility considerations suggest that programmes to prevent mental illness should give priority to adolescents exposed to humanitarian emergencies. The evidence supports the notion that all adolescents should benefit from universally delivered psychosocial interventions. The high prevalence of mental disorders among adolescents exposed to humanitarian emergencies, and the huge treatment gap in those settings, make the case for implementing psychosocial interventions with this population even more compelling. However, it is important to consider the adolescents’ profile and exposures, given the heterogeneity of experiences and circumstances.
Most of the studies were conducted in LMICs, and a third of the studies investigated interventions delivered by non-specialists. As such, the findings are directly relevant to the settings where most of the adolescents exposed to humanitarian emergencies live.
Recommendation C
Psychosocial interventions should be considered for pregnant adolescents and adolescent parents, particularly to promote positive mental health (mental functioning and mental well-being) and improve school attendance.
Strength of recommendation: Conditional.
Certainty of evidence: Low.
Important remarks: Based on available evidence, cognitive behavioural skills-building programmes may be considered for pregnant adolescents and adolescent mothers (11).
Recommendation D
Indicated psychosocial interventions should be provided for adolescents with emotional symptoms.
Strength of recommendation: Strong for reducing symptoms of depression/anxiety and/or preventing mental disorders (depression and anxiety) and promoting positive mental health. Conditional for improving school attendance.
Certainty of evidence: Very low.
Important remarks: Based on the available evidence, group-based CBT may be considered for adolescents with emotional symptoms (12).
Rationale: The certainty of the evidence was often downgraded because studies were subject to the risk of bias due to difficulty in blinding the interventions and to reliance on self-reported outcomes, both of which are common in these types of intervention studies. However, a strong recommendation was made to reduce symptoms of depression and/or anxiety and/or prevent mental disorders (depression and anxiety), as well as to promote positive mental health in adolescents with emotional problems. This was in spite of the very low certainty of evidence. The reason is that the benefits outweigh potential harms. Additionally, considerations about important values, equity and cost-effectiveness justify investing in interventions for this at-risk group. Poor mental health among adolescents is a key risk factor for physical and mental health issues later in life. Early intervention with adolescents who are already displaying emotional problems has proved crucial in preventing the progression of mental health problems and optimizing health and life trajectories.
Recommendation E
Indicated psychosocial interventions should be provided for adolescents with disruptive/oppositional behaviours. These interventions reduce aggressive, disruptive and oppositional behaviours, prevent mental disorders (depression and anxiety) and promote positive mental health. The interventions should be delivered with caution to avoid increasing substance use among adolescents with disruptive and oppositional behaviours.
Strength of recommendation: Conditional.
Certainty of evidence: Very low.
Important remarks: According to available evidence, effective psychosocial interventions for adolescents at risk of, or diagnosed with, conduct disorder often include: training for parents, based on social learning approaches; and social-cognitive problem-solving and interpersonal skills training for the adolescents. They may also include multimodal interventions for adolescents and their parents, based on a social learning model (13).
